What is Exposure and Response Prevention Therapy for OCD?

Ally Bremer
1 day ago
4 min read

Introduction

Before we discuss what Exposure and Response Prevention Therapy (ERP) is, it may be helpful to discuss what it treats. ERP is the first line of treatment for Obsessive and Compulsive Disorder (OCD).

OCD is characterized by the presence of intrusive thoughts (obsessions) and repeated behaviors or mental rituals (compulsions). These compulsions are attempts to reduce anxiety or prevent a feared event but they actually reinforce the OCD cycle.

Here are a few examples of what OCD can look like:

- Having intense worry about being sick, so you wash your hands excessively

- Being worried about missing a question on a test so you re-read each word over and over again

- Being afraid that you hit someone with your car so you drive around the block repeatedly to check

For more examples of how OCD can present, please see other blog posts on OCD.

Evidence Based Treatment: What is ERP?

So what is ERP? Let’s break it down.

Exposures: ERP starts with exposures. This means that you will systematically expose yourself to anxiety producing stimuli.

Response Prevention: Response prevention means that you will stop yourself from engaging in compulsive behaviors.

Together these steps help retrain your brain to tolerate discomfort and break the connection between obsessions and compulsions. Over time, anxiety decreases without the need for rituals.

Here are some examples:

Obsession: “I’m afraid that I will get my entire family sick”

Compulsion: Repeatedly washing hands

ERP: Intentionally touching “contaminated” surfaces and not washing hands

Obsession: “I’m afraid that someone will break into the house when I’m gone”

Compulsion: Checking the locks excessively before leaving the house.

ERP: Leaving the house without checking the locks

Steps of ERP:

1.) Assessment:

The first step in ERP is determining what obsessions and compulsions you experience. OCD is often categorized into subtypes. Through assessment with your therapist, you can determine which subtypes you struggle with most. During this phase your therapist will”

- Ask questions to understand how often you have obsessive thoughts and how often you engage in compulsions

- Explore how difficult it is for you to resist compulsions

- IDentify triggers and patterns

- Assess how friends and family may reinforce OCD

In this stage, a good therapist will explain OCD, the treatment process, and your role in ERP. You should never feel forced to complete an exposure that you are not ready for. ERP is most effective when you are informed and willing to engage in the process.

2.) Exposure Hierarchy

After the assessment, you and your therapist will create an exposure hierarchy. This is a list of triggering stimuli that is ranked from least triggering to most triggering. You and your therapist will discuss what to put on this list.

Example of an Exposure Hierarchy if you struggle with contamination fears:

Least Distressing: Touching a doorknob and waiting a minute before washing hands

Moderate Distress: touching the floor and waiting 10 minutes before washing hands

Severe Distress: Shaking hands with someone and not washing hands.

3.) Exposure Practice and Homework

Once you have created the hierarchy, you and your therapist will practice completing exposures and recording data. You will be assigned homework to complete at home. In session, you and your therapist will review your progress and practice more exposures.

Homework is a key part of ERP. Between sessions, you will practice exposures and record the data on your own. The more consistent you are, the faster you will notice improvement.

Other treatments for OCD

Talk therapy:

Traditional talk therapy is not a first line of treatment for OCD. In fact, talk therapy may even serve as reassurance seeking. A professional who is not trained in OCD, they may unknowingly be reinforcing the connection between your thoughts and actions, which ultimately increases your anxiety. That said, talk therapy can still be beneficial for processing emotions, learning coping skills, and addressing and co-occurring issues.

ACT

Acceptance and commitment therapy (ACT) is often involved in OCD treatment. It involves the client noticing their thoughts and letting them pass without judgement. This treatment can be great when combined with ERP.

Medication:

Medication is another first line of treatment. It can help to manage symptoms. If you have questions about medication, please reach out to your psychiatrist or ask your therapist for a referral.

Commonly asked questions:

What if the exposures are too hard?

ERP is always a collaborative process. Your therapist will discuss your distress ratings with you before you are exposed. If you think that an exposure is too difficult… Talk to your therapist! You and your therapist can always adjust your exposure hierarchy and discuss barriers to success.

Will my obsessions ever go away?

This answer is complicated. Your obsessive thoughts may lessen, but OCD often takes many forms. Your thoughts will shift and change over time and may not disappear completely. The good news is that with ERP, you will build the skills to manage your response to intrusive thoughts and challenge them, causing them to be less consuming and distressing.

How long does it take for me to see progress?

Again, this is a complicated answer that depends on each individual person, the environment that they live in, and their dedication to treatment. Typically, progress is seen within 8-12 sessions. However, this is subject to change between people.

Will you scare me with a big exposure before I’m ready?

Never! The only time in which this may happen is if you and your therapist have previously discussed this as a possibility. ERP is gradual and collaborative. You will be informed of the process the entire way.