Exposure and Response Prevention (ERP) Therapy is a type of Cognitive Behavioral Therapy (CBT) considered the first line of psychotherapy forOCD(Hezel & Simpson, 2019).
ERP therapy has been found effective for 80% of people with OCD (Foa, 2010), making it one of the most effective mental health treatments available.
ERP therapy aims to gradually reduce the anxieties associated with OCD and interrupt the problematic obsession-compulsion cycle. ERP therapy is not about eliminating your distress but rather about learning how to accept and manage it without neutralizing it.
ERP therapy involves therapist-guided, systematic, repeated, and prolonged exposures to situations that provoke obsessional fears whilst abstaining from performing compulsive behaviors.
The objective of ERP treatment for OCD is for the patient to deliberately confront the feared situations and stimuli they usually avoid (e.g., public bathrooms or crowded spaces). This confrontation aims to induce the obsessional fears and urges that these individuals ritualized.
After exposure, the patients are also instructed to avoid performing their compulsions (e.g.,counting; arranging & ordering objects;washing;checking).
Over the last 30 years, several investigations of ERP for treating OCD have been conducted worldwide. These studies, with over 500 patients and numerous therapists, have affirmed the success and generalizability of ERP’s beneficial effects on OCD treatment (Abramowitz, 2006).
How Does ERP Therapy Work?
During ERP, patients gradually expose themselves to feared situations meant to set off their obsessions whilst resisting the urge to carry out their compulsive activity.
By staying in a feared situation and leaning into the discomfort and uncertainty, patients learn that they don’t need their compulsions to cope, and that their fearful thoughts have no power over them.
As their anxiety or distress naturally reduces, the strength between their obsessions and compulsions also reduces. Through ERP, patients learn to resist the urge to perform compulsive rituals and manage their OCD thoughts and actions independently.
This habituation process of repeatedly invoking anxiety and exposing the brain to a stimulus disrupts the neural circuit between the processing and action parts of the brain.
The compulsion to avoid anxiety is a powerful driver of OCD. Still, ERP is one of the most powerful tools available for treating OCD because it directs the patient to live with the anxiety and see that nothing bad will happen.
ERP is best undertaken with the support of a practitioner trained to work with OCD. They can help you devise a plan and support you in carrying it out safely.
How does someone actually do ERP Therapy?
People with OCD are often trying to seek 100% assurance or guarantee that their fear will not become a reality. But the problem with this is that we can never be 100% sure.
In ERP, patients will be taught to face their fears and then wait, instead of acting on them. Eventually, they will develop the ability to tolerate the uncertainty around their fears. Building this relationship with uncertainty is the only way to overcome OCD.
1. Assess the individual’s symptoms
Symptom monitoring can help patients see how much their OCD affects them on a daily basis and motivate them to engage in treatment.
The first step of ERP is working with a therapist to identify and assess your symptoms. A trained ERP professional will help you identify your obsessions, intrusive thoughts, images, urges, and compulsive rituals.
Then, they will work with you to create a list of triggers / feared stimuli and rank them in order from least to most distressing.
When making the graded ERP hierarchy, the patient will arrange the situations or sources of anxiety that trigger their fears in order of severity.
The anxiety is usually rated on a scale from 0% (completely relaxed) to 100% (the worst anxiety you can imagine feeling). This is known as the Subjective Units of Distress Scale, or SUDS scale.
2. Psychoeducation
Psychoeducation involves learning about OCD and its symptoms, treatments, treatment effectiveness, and other research.
This education is vital because patients often do not realize that struggling against their intrusive thoughts will only worsen them.
Psychoeducation can also help patients maintain their motivation through treatment. They might write a statement about why it’s worth recovering, write out the advantages/disadvantages of stopping compulsions, or discuss with their therapist their goals for treatment.
People report that learning more about OCD, especially how avoiding things and doing rituals keeps the OCD going, changes how they think about their symptoms. This knowledge can give them the push to start Exposure and Response Prevention (ERP) exercises.
“Even though I sometimes still feel guilty, I’m trying not to do my rituals because I know they don’t really help – it’s just the OCD controlling me.”
People report that understanding how and why ERP helps was encouraging. For example, learning that natural reactions, like fear, will fade over time if we face them.
This made some, like Helen, want to confront their OCD head-on: “… it made me eager to face it rather than just think about it.” Isabel felt empowered, saying, “I realized I can face something that scares me, and with time, it won’t be as scary anymore.”
3. Exposure
This is the action component of ERP. It involves purposely being exposed to triggers in a gradual, moderated way.
Exposure therapy can progress at different paces for different individuals depending on the severity of the OCD and the fear(s) associated with the patient’s OCD.
Graded Exposure
Graded means that you gradually face your fears, starting with something manageable and slowly building up to more challenging situations.
During ERP, your therapist will guide you through a graded fear hierarchy or ladder that serves as a roadmap to guide your progression through exposure therapy.
Once you’ve gone through the exposure and response-prevention process with a moderate-level fear, you’ll start to work your way up the anxiety ladder.
You and your therapist will work together to decide when it is time to move from one avoided situation to the next.
You begin with the things in your exposure hierarchy that give you at least 50-60% anxiety and move up to the more difficult things.
Each new goal will still be somewhat anxiety-inducing, but as you learn to manage your intrusive thoughts, this anxiety will start to arise less frequently and with less power.
When you have been repeating an exercise and it no longer gives you at least 40% anxiety at the start of the exercise, you are then ready to move up to the next item on your exposure hierarchy.
Exposure must be repeated, it is important that you practice facing your fears many times until you feel comfortable in that situation.
Repeated exposure involves repeatedly exposing yourself to each step on the hierarchy until the exercise no longer makes you feel anxious (i.e., it no longer goes above 40% anxiety at the start of the exercise).
Once you have repeated exposure until it is no longer anxiety-inducing, you will move up to the next exercise on your hierarchy ladder.
Prolonged Exposure
For example, if you were 85% anxious at the beginning of the exercise, you would stay in the situation until your anxiety drops to at least 35%. You would then repeat the exercise until it no longer gets above 40% at the start of the exercise.
4. Response prevention
Response Prevention is one of the main components of ERP therapy. This step refers to the intentional practice of refraining from engaging in compulsions or avoidance behaviors when exposed to a trigger.
Compulsions, or rituals, are behaviors that people with OCD perform in response to an obsession, or intrusive thought. People perform these compulsions to suppress their anxiety and neutralize their fears.
However, while compulsions might “help” in the short term, they only make the intrusive thoughts worse and serve to keep the OCD cycle going long-term.
ocd anxiety
Low tolerance to uncertaintyis a primary feature of the obsession-compulsion cycle. People who suffer from OCD believe that their distressing thoughts will become a reality, so they engage in compulsions to prevent this from happening.
Overtime, this will progress until a patient is resisting the compulsion altogether.
In addition to delaying their responses, patients will also be challenged to modify their rituals. That way, they can still act on their thoughts but not in the same ways that they are typically inclined to do.
This step involves avoiding doing things that serve to reduce your anxiety artificially or distract you from how you are feeling during your exposure exercises.
These temporary reliefs are only keeping you stuck in the vicious OCD cycle.
Each time you expose yourself to an exercise on your hierarchy, you need toresist the urge to carry out a compulsionto neutralize or reduce your distress. This final condition is critical to making your ERP effective.
Patients are encouraged to focus their attention on simply noticing what happens as they are exposed, while not performing a compulsion to cope (i.e., not seeking reassurance, neutralizing, or checking).
Types of ERP Therapy
In Vivo Exposure
In vivo exposure involves directly facing the feared object, situation, or object in real-time.
For example, someone withsocial anxietymight be instructed to give a speech in front of an audience or someone or someone with contamination OCD might be guided to refrain from washing their hands after going to the bathroom.
Imaginal Exposure
Because some feared consequences/situations can not be physically brought on, imaginal exposure involves vividly imagining the feared object, situation or activity.
For example, someone with Posttraumatic Stress Disorder might be asked to recall and describe their traumatic experience in detail in order to induce (and eventually reduce) feelings of fear.
The goal is to create a first-person, present tense, detailed narrative of the worst-case scenario occurring.
Interoceptive Exposure
Interoceptive exposure is the practice of strategically inducing the somatic symptoms associated with a threat appraisal and encouraging the patient to maintain contact with the feared sensations.
Examples of interoceptive exposures include spinning around on a swivel chair to simulate feelings of dizziness; breathing fast to recreate a racing heart; or running upstairs to simulate breathlessness.
This approach is particularly helpful in treating clients who fear the physical sensations accompanying their panic, anxiety, or phobia more than the event itself. It is generally employed when treating panic attacks.
Virtual Reality Exposure
Virtual reality exposureis a more novel approach that involves confronting your fears using virtual reality. For example, for a patient who has a fear of flying, this type of exposure can use virtual reality to simulate flying in an airplane.
Flooding
Floodingis another treatment approach that involves exposing a patient to the highest level of the hierarchy all at once.
Therapists tend to use flooding if a patient’s fear interferes with their ability to go about their daily life, and thus needs to be handled more aggressively.
Flooding can help a patient overcome their fear faster, but it can also be traumatic and overwhelming to experience.
FAQs
How effective is ERP therapy for OCD?Exposure with response prevention is the most effective and thegold standardfor first-line treatment of OCD. It has a 75 to 85 percent efficacy rate, making it one of the most effective mental health treatments available.How long does ERP therapy take?The length of treatment can vary based on the severity of symptoms and your therapy process.Some people experience benefits and changes in just a few weeks after starting ERP, whereas for others, it can take months to see an impact.On average, ERP will require around 12-16 weeks of treatment. Each session typically lasts from 90 to 120 min and they are typically carried out weekly.You will know you’re getting close to the end of ERP therapy when you can do exposures at the top of your hierarchy, manage the thoughts that arise, and allow your anxiety to naturally decrease.Can ERP therapy make OCD worse?During ERP, you will feel an initial increase in anxiety, uncertainty, and obsessional thoughts. However, this increase in symptoms is only short-term.Overtime, you will learn that while these feelings and thoughts are distressing, they can’t hurt you.Eventually, you will find that when you stop fighting the obsessions and anxiety, these feelings will begin to subside.
How effective is ERP therapy for OCD?Exposure with response prevention is the most effective and thegold standardfor first-line treatment of OCD. It has a 75 to 85 percent efficacy rate, making it one of the most effective mental health treatments available.
How effective is ERP therapy for OCD?
Exposure with response prevention is the most effective and thegold standardfor first-line treatment of OCD. It has a 75 to 85 percent efficacy rate, making it one of the most effective mental health treatments available.
How long does ERP therapy take?The length of treatment can vary based on the severity of symptoms and your therapy process.Some people experience benefits and changes in just a few weeks after starting ERP, whereas for others, it can take months to see an impact.On average, ERP will require around 12-16 weeks of treatment. Each session typically lasts from 90 to 120 min and they are typically carried out weekly.You will know you’re getting close to the end of ERP therapy when you can do exposures at the top of your hierarchy, manage the thoughts that arise, and allow your anxiety to naturally decrease.
How long does ERP therapy take?
The length of treatment can vary based on the severity of symptoms and your therapy process.Some people experience benefits and changes in just a few weeks after starting ERP, whereas for others, it can take months to see an impact.On average, ERP will require around 12-16 weeks of treatment. Each session typically lasts from 90 to 120 min and they are typically carried out weekly.You will know you’re getting close to the end of ERP therapy when you can do exposures at the top of your hierarchy, manage the thoughts that arise, and allow your anxiety to naturally decrease.
The length of treatment can vary based on the severity of symptoms and your therapy process.
Some people experience benefits and changes in just a few weeks after starting ERP, whereas for others, it can take months to see an impact.
On average, ERP will require around 12-16 weeks of treatment. Each session typically lasts from 90 to 120 min and they are typically carried out weekly.
You will know you’re getting close to the end of ERP therapy when you can do exposures at the top of your hierarchy, manage the thoughts that arise, and allow your anxiety to naturally decrease.
Can ERP therapy make OCD worse?During ERP, you will feel an initial increase in anxiety, uncertainty, and obsessional thoughts. However, this increase in symptoms is only short-term.Overtime, you will learn that while these feelings and thoughts are distressing, they can’t hurt you.Eventually, you will find that when you stop fighting the obsessions and anxiety, these feelings will begin to subside.
Can ERP therapy make OCD worse?
During ERP, you will feel an initial increase in anxiety, uncertainty, and obsessional thoughts. However, this increase in symptoms is only short-term.Overtime, you will learn that while these feelings and thoughts are distressing, they can’t hurt you.Eventually, you will find that when you stop fighting the obsessions and anxiety, these feelings will begin to subside.
During ERP, you will feel an initial increase in anxiety, uncertainty, and obsessional thoughts. However, this increase in symptoms is only short-term.
Overtime, you will learn that while these feelings and thoughts are distressing, they can’t hurt you.
Eventually, you will find that when you stop fighting the obsessions and anxiety, these feelings will begin to subside.
Sources
Abramowitz, J. S. (2006). The psychological treatment of obsessive—compulsive disorder.The Canadian Journal of Psychiatry,51(7), 407-416.
Foa, E. B., Yadin, E., & Lichner, T. K. (2012).Exposure and response (ritual) prevention for obsessive-compulsive disorder: Therapist guide. Oxford University Press.
Gellatly, J., Bower, P., McMillan, D., Roberts, C., Byford, S., Bee, P., … & Lovell, K. (2014). Obsessive Compulsive Treatment Efficacy Trial (OCTET) comparing the clinical and cost effectiveness of self-managed therapies: study protocol for a randomised controlled trial.Trials,15, 1-10.
Hezel, D. M., & Simpson, H. B. (2019). Exposure and response prevention for obsessive-compulsive disorder: A review and new directions.Indian journal of psychiatry,61(Suppl 1), S85.
Leeuwerik, T., Caradonna, G., Cavanagh, K., Forrester, E., Jones, A. M., Lea, L., … & Strauss, C. (2023).A thematic analysis of barriers and facilitators to participant engagement in group exposure and response prevention therapy for obsessive–compulsive disorder.Psychology and Psychotherapy: Theory, Research and Practice,96(1), 129-147.
Saul McLeod, PhD
BSc (Hons) Psychology, MRes, PhD, University of Manchester
Saul McLeod, PhD., is a qualified psychology teacher with over 18 years of experience in further and higher education. He has been published in peer-reviewed journals, including the Journal of Clinical Psychology.
Julia Simkus
BA (Hons) Psychology, Princeton University
Julia Simkus is a graduate of Princeton University with a Bachelor of Arts in Psychology. She is currently studying for a Master’s Degree in Counseling for Mental Health and Wellness in September 2023. Julia’s research has been published in peer reviewed journals.
