Exposure and Response Prevention for OCD

Suraji Wagage, PhD, JD

What is ERP, and How Does it Work?

Exposure and Response Prevention (ERP) is a cognitive behavioral therapy that is the gold-standard treatment for obsessive-compulsive disorder (OCD).

ERP works by identifying how OCD becomes reinforced and reversing the process. OCD involves having persistent thoughts (obsessions) that cause anxiety, which we then seek to reduce by completing certain actions (compulsions).

For example, I might have the thought that since I touched a pen that fell on the floor, my hands are dirty or contaminated and I will get sick. This thought causes anxiety, which I address by washing my hands repeatedly for several minutes. When I wash my hands thoroughly, I feel relief and temporarily feel less anxiety, which means that I’m much more likely to do this in the future, because it “worked” (reduced my anxiety and made me feel better).

However, I am also reinforcing my belief that I was in danger and completing the compulsion kept me safe, which means that I’m likely to develop more and more compulsions over time and to become more and more vigilant for “dangerous” situations in which I need to complete compulsions to feel safe, which means that over time I will actually become much more anxious.

With ERP, you learn to identify these thoughts as obsessions and the actions as compulsions, and to let the thoughts exist without completing the actions. You do this by doing exposures in which you gradually approach the feared situations without doing compulsions. For example, you might purposely touch something “dirty” (like the floor or something that touched the floor) and then refrain from washing your hands.

You will start at a level of difficulty that feels manageable, complete exposures repeatedly with your therapist’s help and guidance, and work up to more and more challenging situations. By doing this, you learn that the situations that feel unsafe aren’t actually unsafe (you will never do an exposure that is actually unsafe), and compulsions do not keep you safe. You learn to manage anxiety without doing compulsions. Over time, these situations cause much less anxiety and you no longer need to do compulsions at all.

What are ERP Sessions like?

Early on in ERP, you will create a hierarchy of feared situations. You will monitor the situations in which obsessions and compulsions come up and rate them for how distressing they are, and then rank them. You can start to do exposures at the most challenging level that you can manage. You will also rate your level of distress during exposures on a personalized scale from 1-10.

A typical session (after the preliminary sessions) involves reviewing exposures completed during the preceding week, discussing an exposure for the session, and completing the exposure. You will then debrief after the exposure and plan goals for the following week. Sessions can vary if issues or other questions arise.

What is the Goal of ERP?

The goal of ERP is to ultimately be free from compulsions. You may still have obsessions as passing thoughts, but you will be able to identify them and choose not to complete compulsions in response to them. You may still complete compulsions from time to time, but you will recognize them and be able to change the pattern. You will regain freedom and the ability to choose what to do with your time, rather than having OCD decide for you.

How Should I Choose an ERP Therapist?

You want to choose a therapist who is an expert in ERP. Don’t be afraid to ask questions about any potential therapist’s experience treating OCD. You can ask them to explain how the treatment works and what you can expect. You will also likely want a therapist who focuses on cognitive behavioral therapies or evidence-based practices.

This may seem like it goes without saying, but choose a therapist who is, above all, compassionate and supportive. ERP involves doing things that are stressful and frightening and may seem counterintuitive. You want someone who will explain everything carefully, be understanding and patient, and serve as an encouraging guide. You want someone who will celebrate your successes with you and instill hope when the going gets tough.

Also, if you choose a therapist who can provide video sessions through teletherapy, you can do exposures wherever your obsessions and compulsions actually arise (such as your home, rather than a therapy office), with your therapist’s help.