How to Practice ERP - Stairsteps Model
I’m not sure if the “Stairsteps Model” is an officially recognized term used by therapists when it comes to practicing Exposure Response Prevention (ERP), but it’s how I like to term the process of gradual overload - that is, over time, gradually exposing yourself to heavier and more stressful triggers so your brain can learn to better handle OCD triggers and improve your mental capacity.
I believe that when OCD sufferers first start out with ERP, they often believe two major fallacies:
1) ERP MUST be an all-or-nothing approach - either I do 0 compulsions (SUCCESS) or I do compulsions (FAIL)
2) I have to tackle my biggest, worst triggers and fears first - if I’m not practicing ERP on a trigger that is a 10/10 on my anxiety scale, then I’m not doing ERP right
Both of these assumptions are FALSE and will actually harm your ERP progression (and hence, OCD recovery) more than they will help. Let’s explore, shall we?
The first fallacy - the idea that you “succeed” at ERP only if you do 0 compulsions, and “fail” if you do even just 1 compulsion, is quite counterproductive to successful OCD recovery, especially when you are just starting out. This perfectionist mindset only sets us up to fail, because like with anything in life, when you are first starting out at something new, you are bound to make mistakes. This is especially true when practicing ERP. You may have spent months, years, or (in my case) decades living with OCD and acting on compulsions… this behavior is so ingrained in your brain that it’s impossible to just “switch it off” overnight. When you first start out doing ERP, it’s natural that you may slip up and give in to some compulsions when the anxiety gets too overwhelming to handle. This is normal and you need to be kind to yourself - don’t beat yourself up for not being perfect!
The second fallacy - the idea that you MUST tackle your absolute worst fears and anxieties first - will also set you up for failure in OCD recovery. When it comes to effective ERP, there is a “sweet spot” in terms of the anxiety level of the triggers which you choose to practice on. Let’s say you have an obsessive fear of contracting a virus or disease. You may have three triggers: touching a sink in a public bathroom (let’s say this gives you an anxiety level of 2/10, which means it causes you some anxiety but nothing too bad), eating a meal without washing your hands first (let’s say this is a 5/10 on the anxiety scale), and then cleaning your home toilet (let’s say this is a 9/10 on the anxiety scale, which is close to having a panic attack). When it comes to practicing ERP, you want to choose a trigger that is between the 5-7 range on the anxiety scale. Any lower (like a level 2) and it’s too easy to refuse the compulsion. Any higher (like a level 9 or 10) and you’re having too much of an anxiety attack to effectively practice ERP or function when you cut out the compulsion. Practicing on triggers that are around the levels 5-7 range gives you a decently challenging exposure exercise where you may feel a decent amount of anxiety when you cut out the compulsion, but it’s not so overwhelming that you eventually cave and do the compulsion anyways.
So, when it comes to tackling ERP and addressing these two fallacies, I like to implement the Stairsteps model. (this is just my own personal, unscientific term/approach. Maybe I should trademark it!) The idea of the Stairsteps model is to gradually expose yourself to heavier and heavier triggers, while also expanding your capacity to eliminate compulsions and “sit” with the resulting anxiety. Much like how weightlifters gradually increase their weights and reps to improve their physical fitness, we are taking a similar approach to our mental fitness.
So, let’s again use an example of someone who has an obsessive fear of contracting a virus or disease from touching contaminated objects. The process would first start out with identifying your triggers and assigning them an anxiety score, from a scale of 1-10 (with 1 being “low anxiety, easy to accept” and 10 being “PANIC ATTACK!”). This person may list their triggers thusly:
Touching a sink in a public bathroom (2/10)
Eating a meal without washing your hands (5/10)
Playing with someone else’s dog and then eating food without washing your hands (7/10)
Cleaning your own private bathroom (9/10)
Cleaning your friend’s bathroom (10/10)
If we follow the Stairsteps model, we want to practice on triggers/exposures in the levels 5-7 range to be the most effective. So:
Eating a meal without washing your hands (5/10)
Playing with someone else’s dog and then eating food without washing your hands (7/10)
Then, we would actually expose ourselves to one of the triggers and REFUSE the compulsion. So let’s say you prepare and eat a meal but you REFUSE the compulsion of washing your hands. You may notice that you feel anxiety (and if this is within the levels 5-7 range, it should be a decent amount of anxiety, yet not overwhelming). Try to sit with that anxiety as long as you can. Maybe you can finish your entire meal without having to wash your hands - great! Or maybe, you can only make it 5 minutes, and then the anxiety/compulsive urge becomes too strong and you have to wash your hands. That is totally fine. Make a mental note to yourself - “this time, I practiced X exposure and went 5 minutes before I gave in to the compulsion.” That is not a failure! It is a stepping stone. The next time you have a meal, try doing the same exposure and see if you can make it 7 minutes before you give in to the compulsion of washing your hands. Then at the next meal, see if you can last 10 minutes. Etc etc… until you can eventually face that exposure and eliminate that compulsion entirely. Once you are able to do so, move on to the next level in your exposure hierarchy (e.g. playing with someone’s dog and then eating without washing your hands, which is a level 7 on the anxiety scale). And repeat the process.
As you go through the process, you will gradually find that your ability to “sit with” anxiety and eliminate compulsions gets stronger, and the same triggers which you classified as a level 5 or a level 7 now may only be a level 2 or level 3. Additionally, a trigger which previously may have been a level 9 or 10 on your anxiety scale may now only feel like a level 7. This is how you make progress in OCD recovery and through practicing ERP. You gradually build up your capacity to handle bigger and heavier triggers through targeted exposure opportunities. You’re essentially habituating and re-training your brain to accept new baseline levels of anxiety when you refuse compulsions, and as you grow your ability to accept more and more anxiety without giving in to compulsions, the “fear” factor of your heaviest and worst triggers will decrease in comparison to your mental capacity.
That’s all there is to it! I believe the Stairsteps model is a great way to practice ERP and gradually improve your mental capacity to handle more anxiety when you eliminate compulsions. The Stairsteps model teaches you that you don’t need to be perfect to succeed at ERP, and it also teaches you how to smartly choose your exposure exercises so that you’re making the most out of the ERP process. Many people who are just getting in to ERP get frustrated when they can’t immediately eliminate their compulsions, and I believe this is because they are essentially “jumping into the deep end of the pool” too quickly. Instead, gradually build up your mental fitness and capacity. If you’re brand new to weightlifting, you wouldn’t expect to be able to deadlift 400 lbs right off the bat, would you? It’s something that takes months (or years) of gradual, consistent practice. The same is very true of ERP and OCD recovery, and the Stairsteps model is a great way to go about practicing your ERP exposure exercises.
Eric