ERP - Exposure Response Prevention
Pouring a drink-in order to stop drinking. Rolling a joint-to kick a pot habit. Laying out a few lines of cocaine-to overcome the desire to snort it. These aren't oxymorons or acts of a fool. They are examples of a new form of therapy for chemical addiction called ERP.
ERP, or exposure response prevention, is a proven behavioral technology applied in the 1980's to successfully treat obsessive-compulsive disorders and phobias. Our team of behavioral health care professionals applied ERP technology to the problem of chemical addiction and craving (Santoro, DeLetis and Bergman, 2001). Since 1990 they have successfully treated scores of chemically addicted patients with ERP.
ERP is based on principles of operant and respondent learning. Respondent learning takes place when we associate a new stimulus with one that already has an effect on us. For example, we experience respondent learning when we associate the name of a new restaurant with the already familiar experience of having a delicious meal.
Operant learning takes place when we associate rewards, punishments, success, and failure with individual patterns of behavior. Everyday we experience operant learning. It is the primary way in which we learn new behaviors and strengthen or weaken existing behaviors. When we meet a new person we use conversation that was operantly rewarded in the past. When we learn to serve a tennis ball we undergo an intense operant learning experience that will eventually (we hope) lead to a more effective serve.
Conventional wisdom advises people recovering from chemical addiction to avoid the people, places, and things they previously associated with their drug and alcohol abuse. This advice is based on the fact that the addict associates, through respondent learning, people places, and things with the preparation and use of their addicted substances. Respondent learning gives these stimuli the power to trigger strong desires to use drugs or alcohol.
For example, if a recovering addict meets a friend with whom they snorted cocaine in the past the addict will get the urge or impulse to use cocaine because of the respondent connection between their friend and cocaine use. Because of this connection conventional treatment advises that the recovering person avoid these stimuli completely.
Unfortunately, it is virtually impossible to avoid all former stimuli connected with drug and alcohol abuse (Chiauzzi & Liljegren, 1993). This fact partially explains why the relapse rate for recovering addicts is about 75% within one year. As Dr. Joe Santoro explains, "We realized that the conventional advice just didn't work for most addicted people. We needed to find a way to teach them how to cope with stimuli connected to their former addictions to give them a better chance of staying clean." Dr. Santoro went on to say, "So we applied exposure response prevention techniques to the problem. If we could simulate exposure to the most powerful forms of stimuli associated with chemical use, we could show the patient that after repeated therapeutic exposure to these stimuli their impulse to use would completely extinguish."
Studies completed by Dawe et al. (1993) and Powell et al. (1993) provide research data that supports the effectiveness of ERP for the treatment of opiate addiction. Blakely & Baker (1980) and Hodgson & Rankin (1982) documented the effectiveness of exposure therapy for alcohol use stimuli.
ERP kits are made up of simulated drugs, alcoholic beverages, drug use paraphernalia, and music and photographs that the user associates with their chemical abuse. The cocaine ERP kit includes a white powder, razor blade, rolled up money, mirror, small spoon etc. Each of these objects has the power to trigger a strong level of craving in an addicted individual. They have no effect on a non-addicted person. We also developed a photocard form of ERP for self-administered therapy. Each card set (see photos) depicts a hierarchical sequence of drug preparation and use scenes by substance. There are card sets available for crack, cocaine, alcohol, heroin and marijuana.
Robert DeLetis, a senior addiction specialist, developed the format for an ERP therapy session. He designed a special room for the therapy session that is decorated to remind the patient of their chemical use past. Patients need to learn that they can ride their craving wave (see illustration) without giving into a desire to use. Through repeated ERP therapy sessions the impulse to use triggered by the ERP stimuli becomes weaker and weaker. Eventually, the patient feels virtually no desire to use at all. It is at that point that the patient feels they have really accomplished something special.
The impulse to use rises upon exposure to a triggering stimulus (point B). If the person does not use, their craving will peak (point C) and then decline to zero (point D).
A typical ERP session starts with about five minutes of relaxation exercises. After relaxing the patient is asked to rate their craving level before being exposed to their triggering stimuli. They use a 10 point scale to do this where 10 represents a desire to use immediately. The patient's pulse is also measured (pulse rate generally increases as a patient's craving level rises). Once baseline ratings are secured exposure to the first level of stimulus begins. After looking, touching and smelling the object and answering a few questions the patient is again asked to rate their craving level. Their pulse is taken again as well. Generally, their craving level is up as is their pulse. If they have become over stimulated then the ERP stimuli are put away and they return to doing relaxation exercises. Otherwise, they continue to look at the objects while repeating their cognitive scripts. Cognitive scripts are motivating statements designed by therapist and patient. They are associated with the triggering stimulus and the impulse to use. Typical cognitive scripts include:
"Remember the pain and hurt I caused myself and my family."
"I will be able to feel better about myself if I walk away."
"Remember the physical pain and consequences of withdrawal."
The patient makes a respondent connection between these scripts and stimuli formerly associated with chemical abuse. So not only does the patient break the drink or drug connection with the triggering stimuli, he also connects the stimuli with his cognitive scripts. This new connection will help him to walk away from a tempting situation.
Once a patient has completed the first level of stimulus exposure he proceeds to the next level and repeats all of the steps. An ERP therapy session continues until the patient has completed all of the stimulus exposure levels or the session has to be stopped because of over stimulation.
The typical patient requires at least 30 ERP sessions to complete the entire stimulus hierarchy without experiencing any significant levels of cravings (as measured by the rating scale and pulse rate). Once a patient can view the ERP stimuli without experiencing an impulse to use they can end this part of their treatment.
ERP helps the patient to confront their worst fear: accidental exposure to a substance abuse triggers. It prepares them to handle these situations without making them cocky. After ERP therapy they will not experience an unmanageable level of craving if they are triggered by a situation. Instead the situation will trigger their cognitive scripts that will help them to think and talk their way out of the situation without using.
For some patients simulated ERP therapy is not sufficient. They need to experience ERP in real world situations. Some patients go to a bar (with their therapist) where they can experience triggers to drink and learn to cope with them without using. This step can only be taken after a patient has successfully completed simulated ERP sessions. Once this has been accomplished patient and therapist can set up a real world hierarchy of triggering situations that range from easy to difficult to handle. They then go together to these situations and follow a set of steps of that are similar to those used in office based ERP.
For example, one patient treated had a serious addiction to crack cocaine. Every two weeks on the day he got paid he would go on a several day crack binge. The patient responded well to office based ERP and wanted to handle his most difficult real world trigger: payday. His therapist describes how they did real world ERP as follows: "F and I went to pick up his paycheck together. I remember the first time very well. He was very nervous. He was sweating and twitching. He really wanted to get high. I helped him get through his cravings and after about five 'paycheck' sessions he was able to get his check on his own without being triggered to use." Real world ERP sessions can be very helpful when a patient must confront situations in his daily life that have become strongly associated with prior chemical abuse as was the case here. When avoidance is not possible ERP can save the day.
ERP therapy should never be used as the sole treatment for substance abuse problems. Substance abuse is a complex disorder that requires a comprehensive treatment approach. This approach should include group therapy, community based support meetings, individual psychotherapy to handle concurrent psychological problems and medication where appropriate to assist in the treatment of psychological disorders such as depression, anxiety, and mood swings.
ERP is a new therapy that can help people recover from drug and alcohol abuse when intelligently combined with other forms of treatment.
For more information about ERP therapy you can contact Blue Sky at 347-672-7199, explore this website or buy the book Kill The Craving (Santoro, DeLetis and Bergman, 2001). Addiction professionals can buy ERP therapy kits for use with their clients by calling 347-672-7199.
Blakely, R., & Baker, R. (1980), "An exposure approach to alcohol abuse", Behaviour Research and Therapy, 18, 319-325.
Chiauzzi, E. J., & Liljegren, S. (1993), "Taboo topics in addiction treatment: An empirical review of clinical folklore", Journal of Substance Abuse Treatment, 10, 303-316.
Dawe, S., Powell, J., Richards, D., Gossop, M., Marks, I., Strang, J., & Gray, J. (1993), "Does post-withdrawal cue exposure improve outcome in opiate addiction: A controlled trial", Addiction, 88, 1233-1245.
Hodgson, R. J., & Rankin, H. J. (1982), "Cue exposure and relapse prevention", In W. M. Hay & P. E. Nathan (Eds.), Clinical case studies in the behavioral treatment of alcoholism, (pp. 207-226). New York: Plenum.
Powell, J. H., Bradley, B., & Gray, J. A. (1993), "Subjective craving for opiates: evaluations of a cue exposure protocol for use with detoxified opiate addicts", British Journal of Clinical Psychology, 32, 39-53.
Santoro, J, DeLetis, R & Bergman, B. 2001. Kill The Craving. Oakland: New Harbinger Publications.
Santoro, J, DeLetis, R & Bergman, B. 2004. Kill The Craving. New York.