Exposure and Response Prevention (ERP) for OCD: What to Expect

Exposure and Response Prevention (ERP) is an evidence based therapeutic intervention that helps people to confront their fears head on in a safe and paced way. ERP is the gold standard treatment for Obsessive Compulsive Disorder (OCD) and is a behavioral therapy that helps people to decouple obsessive thoughts from subsequent compulsions. It involves immersing into feared environments and practicing tolerating the discomfort that may arise without avoidance or reliance on rituals or safety behaviors. Continued practice of ERP eventually retrains the brain to treat the feared stimuli as neutral, or at least vastly reduces the adverse reaction to them, leaving the individual better able to manage their anxiety without relying on compulsions. 

People with OCD live with intrusive thoughts that are distressing and significantly interfere with their daily functioning, otherwise known as obsessions. When they arise, people engage in behaviors that aim to temporarily reduce the discomfort the obsessions cause them, called compulsions. However, the relief the compulsions bring is short lived and actually ends up causing more long term distress, as it creates a pattern of reinforcement between the obsessions and compulsions that becomes stronger and harder to break over time. ERP helps to break this vicious cycle by forcing intentional exposure to feared stimuli and limiting the compulsive response. 

ERP treatment begins with psychoeducation about the modality and then will gather information about the client’s individual intrusive thoughts, obsessions and compulsions in order to craft a treatment plan specific to them and their very own hierarchy of exposures. As treatment progresses, the client will gradually become more exposed to their triggers and work on resisting the urge to act on their compulsions. Exposures can come in two forms: imaginal and in vivo. Imagine exposure asks clients to imagine a situation that evokes their obsessions, for example picturing a messy row of objects and resisting the urge to organize it. In vivo exposure involves confronting feared situations in real time, such as touching a doorknob without washing your hands. Following each exposure time will be dedicated to processing the exposure and how it felt. Since ERP is a member of the larger group of Cognitive Behavioral Therapies, clients will receive “homework” after each session to do throughout the week in order to reinforce the skills taught and rehearsed in therapy. These practices will mimic what was done during the session and utilize the non-avoidance techniques rather than compulsions to overcome the anxiety induced by triggers. 

It is important to remember that ERP can be a slow process and baked into its structure is the ability to debrief how skills are working and to troubleshoot and adjust when things don’t feel right. ERP is not meant to be a linear process and bumps in the road are pretty much a given. Coping skills are often needed to tolerate the distress of sitting with anxiety when it is too high, inducing stimuli and if the exposures are not paced gradually enough, they can become too overwhelming. However, they can also be contraindicated when they serve to distract from the distress. ERP is a highly collaborative treatment, and it is important to communicate to your therapist when something feels too intense and the treatment plan can be easily adjusted.