What is Exposure and Response Prevention Therapy (ERP) for Obsessive-Compulsive Disorder (OCD)?

Obsessive-Compulsive Disorder (OCD) is a mental health condition characterized by persistent, unwanted, and extremely distressing thoughts (obsessions) which are responded to with repetitive behaviors (compulsions) or avoidance strategies. Compulsions and avoidance strategies serve to reduce the overwhelming anxiety and/or distress triggered by the presence of obsessions.

While I’m usually one to argue that many forms of therapy can be helpful for treating the same mental health issues (for example- EMDR is not the only effective form of therapy for trauma), Exposure and Response Prevention (ERP) therapy is actually the ONLY form of therapy that will successfully treat OCD. All other forms of therapy will make OCD worse.

So, what is ERP?

Exposure and Response Prevention (ERP) is a type of Cognitive Behavioral Therapy (CBT). It involves a structured and systematic approach that helps individuals confront their fears and reduce the compulsive behaviors associated with OCD. The therapy involves two key components: exposure and response prevention.

1. Exposure involves gradual and repeated intentional exposure to the thoughts, images, objects, or situations that trigger obsessions and associated anxiety or discomfort. The idea is to face these triggers without engaging in compulsive behaviors. Exposure can be direct (in vivo) or imagined (imaginal). For example, a person with contamination obsessions might be encouraged to touch a doorknob they perceive as dirty.

2. Response Prevention involves refraining from engaging in the compulsive (or avoidance) behaviors typically performed to alleviate the anxiety triggered by the obsessions. In the example above, the individual would resist the urge to wash their hands, seek reassurance from others, or create a mental plan to calm themselves immediately after touching the doorknob. Instead, they would intentionally sit with the distressing feelings that were triggered by touching the doorknob.

How Does ERP Help OCD?

ERP is highly effective in treating OCD and essentially focuses on three different things:

1. Mastery: Throughout ERP your brain learns that you are capable of coping with upsetting situations and tolerating distressing emotions.

2. Disconfirmation: ERP demonstrates that the obsessions you fear are either not going to play out how OCD tells you they will, or if they do, that you are capable of navigating those situations.

3. Habituation: This is the element that we hope for in treatment, but does not always happen. Habituation is the process by which the body and mind become desensitized to something over time. By consistently facing an anxiety-provoking situation without performing compulsive actions, your brain learns that anxiety will naturally diminish without the need for compulsions or avoidance. Habituation feels great when it happens (ERP is successful regardless of whether or not it happens) and helps to break the cycle of obsessions and compulsions that maintain OCD. 

Here’s a simplified breakdown of the ERP process:

1. Assessment and Planning: an assessment is followed by treatment planning which includes building out an exposure hierarchy. An exposure hierarchy identifies and ranks situations that will intentionally trigger obsessions in order to elicit feelings of distress without responding with either avoidance or compulsive behaviors in order from least to most distressing.

2. Repetition: repetition is key to successful treatment. We practice an exposure multiple times together in session, then you go home and repeat the exact same exposure daily for homework. Repetition is a huge component of ERP (not the most exciting I know- but it’s super effective!)

3. Gradual Exposure: during ERP we usually begin with the least distressing items on the hierarchy, and then gradually increase the difficulty. However, this does not always have to be the case. There are times when we may jump around in the hierarchy depending on the progress of treatment and situations coming up in your day-to-day life. ERP allows for the ability to adapt and readjust the plan as needed throughout treatment.

4. Response Prevention: During and after the exposure, you will resist performing any compulsive or avoidance behaviors. This is challenging, but with practice and support, it becomes more manageable. Practicing exposures in session is extremely helpful with this as it allows me to help guide you through the process.

5. Building Tolerance: Over time, you can expect your tolerance for anxiety to increase, and the need to perform compulsions to decrease. You will learn that if you do not interfere through avoidance and compulsions, feelings of anxiety and distress will naturally resolve on their own.

Benefits of ERP

ERP is considered the gold standard treatment for OCD because of its effectiveness. Research has shown that about 70% of individuals with OCD experience significant improvement with ERP. Some key benefits include:

• Reduced Anxiety: By facing their fears, people with OCD learn that their anxiety can decrease without the need for compulsions.

• Increased Control: ERP empowers people with OCD by helping them take control over their actions rather than being controlled by their OCD.

• Improved Quality of Life: As obsessions and compulsions decrease, people typically experience improved daily functioning and overall quality of life.

While ERP is highly effective, it can be challenging. People with OCD don’t love to sit with distressing emotions and yet that’s what is repeatedly practiced throughout the course of ERP. Working with a therapist who understands OCD, is trained in ERP, and you trust to guide you through the process is imperative. It’s something that you need to have a willingness to do and really mentally prepare to go all in (your therapist should help you with this).

Exposure and Response Prevention therapy has completely changed my life. My mind is quieter than I ever felt possible and while I still don’t love experiencing obsessions, I no longer fear them and know exactly what to do (and what not to do) when they come up. 

I continue to practice exposures to address my own OCD symptoms everyday and am so grateful to be able to help other people who are suffering with OCD learn to do the same. Although ERP is challenging, the rewards of ERP are life changing, and I could not recommend it enough.