Whether you have tried therapy to treat obsessive-compulsive disorder (OCD) in the past, you’re considering it for the first time, or you’re just beginning to think that you might have OCD, understanding what effective treatment looks like—and doesn’t—is crucial to ensuring you get the care you need.
Exposure and response prevention (ERP) therapy is a specialized form of cognitive behavioral therapy (CBT) that is proven to be the most effective way of treating OCD. It teaches you to tolerate the distress of your intrusive thoughts and urges while resisting the drive to engage in compulsions. You may have heard that ERP will push you straight into your worst fears and force you to immediately resist every behavior that you rely on to feel safe—and this might all sound a little bit scary. It might also make you afraid that ERP is going to pull you away from the things you care about in life, like the relationships you’re holding tight to or the daily rituals that feel sacred to you.
The truth is most people with OCD engage in a lot of seemingly urgent or necessary behaviors that are actually doing the opposite of keeping them safe. ERP will gradually encourage you to break those patterns, but only once you and your therapist have first determined what your true beliefs and life goals are—so you can use ERP to live more in accordance with your values. Contrary to what some people believe, ERP will never mean abandoning the things that you care about. It’s actually a way to get closer to those things, without letting OCD get in the way.
Let’s take a look at how that works, through three very personal stories.
How ERP helped Alix Behar reclaim important rituals
OCD is ego-dystonic, which means it often latches onto the things you care about most and stirs up doubts and fears around them. This can change your relationship to the hobbies, interests, people, and communities you love—though that may not always be obvious at first. For example, if like Alix Behar, your OCD has seized on your religion, you may initially believe that the intensification of fears and rituals simply means you’ve become more devout. Even once it becomes clear that OCD is twisting your relationship to the things you care about in ways that can be time-consuming, alienating, and deeply painful, it’s common to feel afraid to deviate from your OCD-driven behaviors—or continually question if it’s really OCD. And as you learn about OCD treatment, you may find yourself further questioning whether ERP can really help with this.
If you know that ERP is meant to disrupt the OCD cycle—and will teach you how to resist compulsive behaviors like excessive prayer or repetitive confession, you might fear that ERP therapy will take you away from the things you love entirely. But that’s not the case. If your OCD has seized on something you care about, the problem is OCD, not that thing. In fact, ERP will help you gain a better understanding of your true values and sense of what matters to you—crucial tools for both managing your OCD and engaging more fully and earnestly in the activities that you care about.
Take Alix’s story for example. Soon after she found faith in Christianity, she was beset by a barrage of intrusive thoughts and images that hijacked her beliefs and made her terrified she would go to hell. She began compulsively seeking opportunities to confess and pursue reassurance, including in prayer.
Reassurance seeking is an extremely common compulsion in OCD, and while it can feel good in the moment—Alix says it brought her only temporary relief—it ultimately taught her brain that it must keep compulsively pursuing reassurance in order to feel safe (this is part of the OCD cycle). It was only when Alix tried ERP that she was able to let go of the need to respond to, counter, or atone for her intrusive thoughts. Then, she was able to reclaim the act of prayer in a way that was no longer compulsive, and connect with her faith from a place of peace rather than fear.
How ERP taught Tracie Ibrahim to trust herself over her OCD
OCD often tries to convince you that you’re a bad person—by convincing you that you must constantly prove your sense of morality, that you’re responsible for all the world’s problems, that anything less than perfectionism could result in serious harm to others, or a number of other beliefs that feel awful and daunting. And once you are terrified that you might really be a bad person, OCD tells you that only by performing compulsions are you able to stave off your true nature.
Because OCD craves certainty, addressing this dynamic in ERP means confronting the fact that you can’t be absolutely sure about whether you’re a “good enough” person. To work towards this goal, your therapist might have you repeat a phrase like, “Maybe I’m a terrible person, maybe I’m not.” They might have you engage with activities or objects you’ve been avoiding—like the knives you’ve locked in a kitchen drawer out of fear that you’ll use them to harm someone, the car you never drive out of concern that you’ll run someone over, or the children’s birthday parties you’ve been avoiding attending out of concern that you’ll do something wildly inappropriate or violent.
And as you sit with these possible ERP exercises, you might find yourself feeling very uncomfortable. After all, if you’re accepting the possibility that you might be a terrible person instead of actively trying as hard as you can to prove that you’re good, that probably means you’re a bad person, right? If OCD compulsions like hiding your knives, avoiding driving, and staying away from kids are the only thing keeping you in check, then surely learning to resist these behaviors will cause you to act on every thought you’ve been terrified of, right?
Wrong! This is just something OCD wants you to believe so that you keep engaging in compulsions to “protect” yourself. NOCD Chief Compliance Officer and therapist Tracie Ibrahim says that decades of experience with both treating OCD and dealing with her own has shown her that OCD is not a moral compass, it’s a broken alarm system. “Never in the history of me treating people with OCD, which is well over 20 years, have I ever seen somebody where I was like, ‘Wow, this OCD’s really keeping you safe, I highly recommend that you don’t treat it,’” she says.
When Tracie’s own harm OCD and suicidal OCD caused her to experience unwanted thoughts of harming herself and others, she was afraid that treating the OCD and stopping the compulsions would cause her to act on these urges. Instead, ERP helped her identify that these urges were not a reflection of what she wanted. Coming to understand your values through ERP can help you act in accordance with them—not as evidence of goodness, or as resistance against intrusive thoughts that OCD labels “true desires,” but as an extension of how you actually want to show up in the world.
How ERP taught Paige DeAngelo that OCD wasn’t behind her success
Just like OCD can convince you that it’s the only thing stopping you from behaving badly, it can also insist that it’s the reason for all of your success. If you’ve achieved things you’re proud of while also dealing with compulsions, the two can begin to seem linked. Your compulsive urge to check and re-check your work might feel like fastidiousness that ensures you avoid mistakes. Seeking “feedback” (reassurance) on every decision you make at work might feel like being diplomatic and thorough.
But in reality, OCD is just putting stumbling blocks in your path. The energy you spend engaging in compulsions could be channeled into the projects and goals you actually care about. Without the constant doubt and uncertainty that are the calling cards of OCD, you can move with more confidence and act more decisively.
Professional dancer and makeup company founder Paige DeAngelo says her OCD made her feel like she had “magical powers”—as long as she engaged in compulsions like touching a staircase and pacing back and forth a certain number of times, she felt like she could achieve her goals. But over time, she realized that OCD was actually holding her back from the goals she cared most about by eating up the time she could have otherwise spent learning, improving, and growing. Through ERP, Paige was able to separate her ambition from her compulsions and trust herself.
Putting values over fear
Every person’s ERP experience looks different, because every person has different needs, goals, and values. A trained OCD specialist will work with you to assess your challenges and aspirations, teach you more about the treatment process, and then personalize your exercises according to a hierarchy you design together that progresses from confronting your least distressing fears to how to safely overcome your most distressing ones. Then you’ll work your way up through exercises tailored to your precise goals.
For example, if OCD has made you believe that you need to check and re-check everything you write for errors—seizing on your career ambitions but permeating every part of your life—your ERP therapist might have you start by writing out your weekly grocery list, and not re-checking it before leaving for the market. From there, you might move on to sending a text message to a friend, an email to a co-worker, and finally working on a written proposal for your boss that you only re-read once. This process can feel uncomfortable and difficult, but it will never actually be unsafe. And you’ll come out the other end feeling more confident in your ability to engage in the things and people that truly matter to you, with more time and attention to dedicate to them.
Across the board, ERP helps you by connecting you with your true sense of purpose, increasing your tolerance for uncertainty and anxiety by reminding you that they are simply passing states, and training you to recognize when the feverish churn of OCD is trying to pass itself off as your own judgement or ambition. And throughout it all, compassion should be a throughline, both from your therapist and for yourself.
Ultimately, ERP works by first helping you identify your values, and then strengthening your ability to make decisions based on those values rather than based on the fears OCD creates. Far from stopping you from engaging in the hobbies, interests, and communities you cherish, it reconnects you with them. When OCD tries to latch onto and twist something you hold dear, ERP hones your ability to recognize when it’s actually pushing you further from what you care about and the choices you want to make.
