In the 1970s, exposure and response prevention therapy (ERP) was specifically created to help millions with Obsessive-Compulsive Disorder (OCD) manage their symptoms and regain control of their lives. In the subsequent decades, this approach has been found effective for up to 80% of OCD patients, with most patients’ ability to manage their symptoms significantly improved within 12-20 sessions.
While ERP is a type of cognitive behavioral therapy (CBT), it profoundly differs from CBT’s other forms—so much so, in fact, that other types of CBT are often ineffective in treating OCD. In this article, we’ll explore general CBT’s limitations in treating OCD, highlight why ERP is considered the gold standard treatment for this disorder, and show you how you can play a crucial role in more people receiving this life-changing, specialized care.
Understanding OCD and its unique treatment needs
To understand why many forms of CBT are often ineffective in treating OCD, we first need to look at the unique characteristics that set the condition apart from mental disorders that other types of CBT do effectively treat.
A complex disorder that goes beyond simple anxiety, OCD involves recurring and distressing thoughts that people with OCD cannot easily dismiss (obsessions). To alleviate anxiety caused by these thoughts, they engage in repetitive behaviors or mental acts (compulsions). Compulsions do tend to reduce anxiety, but only temporarily, and they end up reinforcing this sequence, often called the “OCD cycle.”
The diagnostic criteria for OCD include the presence of obsessions and compulsions that take up more than an hour a day, cause distress, and impair everyday functioning.
Unlike other anxiety disorders, OCD is distinct in that it most often focuses on specific themes. The most well-known of these are contamination, symmetry, or order, but many people’s obsessions can be violent, sexual, and even pedophilic in nature. It’s these more taboo OCD subtypes that are most often misdiagnosed by physicians and mental healthcare professionals who have limited familiarity with OCD.
General CBT and its limitations in OCD treatment
Many CBT techniques aim to modify thoughts and behaviors associated with various mental health conditions and can be helpful in the treatment of depression, anxiety, eating disorders, and substance abuse issues, among others.
While common techniques like cognitive restructuring and relaxation exercises may provide some relief in people with OCD, they fail to target the condition’s core symptoms. In fact, the application of other types of CBT, such as acceptance and commitment therapy (ACT), rational emotive behavior therapy (REBT), mindfulness-based cognitive therapy (MBCT), and others, may sometimes accommodate compulsive responses like rumination or reassurance-seeking, making OCD symptoms worse.
“Let’s say someone with OCD shares their obsessions around harming their child in a session with a CBT therapist who specializes in something other than ERP,” explains Dr. Patrick McGrath, Chief Clinical Officer at NOCD. “The therapist might encourage that patient to think or say something contrary to their ego dystonic thought. Something like: ‘I’m a good person, I love my children, and I would never harm them.’ While this sort of self-assurance can help treat other disorders, for people with OCD, it will become a compulsion. A CBT therapist might also tell the patient to do some diaphragmatic breathing or muscle relaxation when their anxiety becomes uncomfortable. Again, this just becomes another safety-seeking behavior, and every time they use it, the patient unwittingly strengthens the cycle they’re trying to escape.”
McGrath adds that other forms of CBT don’t typically provide specific strategies for managing exposure to feared situations or preventing compulsive responses.
Exposure and response prevention (ERP) therapy
In contrast with most other forms of CBT, ERP is based on the principle of confronting obsessions and preventing compulsive responses. It involves exposing patients to their obsessive fears or triggers while preventing them from engaging in the corresponding compulsions. By repeatedly facing their fears without resorting to rituals, people with OCD can learn that their anxiety diminishes over time, and that they don’t need to rely on the false sense of security that their compulsions provide.
“The biggest difference between ERP and many other forms of CBT is that ERP therapists are not in the business of convincing somebody that their thoughts are right or wrong, whether they’re valid or not,” says McGrath. “We’re here to get people to sit with their anxiety instead of being ruled by it, and recognize they’re making a fundamental mistake in trying to be 100% certain about anything that randomly pops into their head. None of us can have that level of certainty, whether we have OCD or not.”
ERP-trained therapists work collaboratively with patients to create a hierarchy of anxiety-provoking situations tailored specifically to their symptoms, starting with less distressing fears and gradually progressing to more challenging ones. Through this process people learn to tolerate the discomfort their obsessions trigger and develop healthier coping mechanisms that free them from the vicious cycle of OCD.
ERP vs. other types of CBT in OCD treatment
ERP is, along with certain medications, the first-line treatment for OCD. It should be noted, however, that while SSRIs and others can be effective in reducing the symptoms of OCD in some people, they don’t address the condition’s underlying causes. The implication here is that the symptoms will likely resume when a patient stops taking medication if it’s the only form of treatment used. That said, certain medications can be an invaluable tool in a full treatment plan, helping those with more severe OCD to tolerate the discomfort exposures can provoke.
In clinical research however, the effectiveness of ERP over other forms of CBT is often difficult to observe, because results have frequently been confounded by ERP being lumped in with CBT more generally. This is the conclusion reached by the authors of a systematic review and meta analysis published in 2021. Researchers identified 24 studies published between 1997 and 2018 that included a cumulative total of 1134 OCD patients. Their review found a significant difference in OCD symptom reduction between ERP therapy versus other groups of CBT intervention.
Still, more research with a clear delineation of various CBT modalities is needed to back up what therapists have observed—and patients have experienced—over the past four decades: ERP is the best means of achieving sustainable optimal outcomes for people with OCD.
It’s important to note that ERP has been shown to be effective across various subtypes of OCD—its tailored approach allowing patients to confront their specific fears and develop personalized strategies for managing their symptoms.
How you can help
To effectively treat OCD, mental health providers need specialized training and supervision in ERP therapy. Understanding the nuances of exposure techniques, developing effective treatment plans, and providing ongoing support is crucial for optimal outcomes.
To that end, we invite all therapists who are interested in making a difference for the underserved population of people with OCD to explore NOCD Academy. It’s a continuing education (CE) portal for healthcare professionals, increasing the clinical community’s familiarity with this frequently misidentified condition and its most effective treatment.
NOCD Academy offers a wide range of free, accredited CE courses, developed and led by some of the world’s leading experts in OCD treatment. Therapists can gain CE credits by attending live webinars or completing home study courses that cover topics from using medication in OCD treatment to identifying the many different subtypes of OCD.