What is Exposure and Response Prevention Therapy?
Exposure and Response Prevention (ERP) therapy is a form of Cognitive Behavioral Therapy (CBT) that was developed specifically to treat obsessive-compulsive disorder (OCD).
OCD starts with obsessions: unwanted, intrusive thoughts, images, ideas, or urges. They can include doubts about one's identity, mental images about harm coming to loved ones, fears about one's health, and a wide range of others. What they all have in common is that they create distress—anxiety, fear, doubt, or worry.
This leads to compulsions: physical or mental behaviors done to reduce this distress or keep something unwanted from happening. Compulsions may provide short-term relief from the distress caused by obsessions, but they actually make obsessions worse by reinforcing the belief that the obsessions were a threat in the first place.
OCD often comes in waves. ERP will help dissipate distress over time.
Exposure and response prevention therapy, or ERP, was created specifically to treat OCD, and it works by interrupting the cycle of obsessions and compulsions. In ERP, you're encouraged to gradually and carefully confront your obsessions, sit with the discomfort you feel, and resist the urge to do compulsions. This might sound scary, but you'll start small—and your therapist will guide you every step of the way.
OCD wants you to believe that compulsions will make you feel better or keep obsessions from happening, but it doesn't work—obsessions always come back. In reality, compulsions teach you to run from obsessions, which only gives them more power. When you're guided by a trained therapist to stop doing compulsions, you learn to accept uncertainty and doubt, and you teach your brain that discomfort from obsessions will go away on its own. Eventually, you're able to simply acknowledge that you're having an unwanted thought, idea, image, or urge, and it won't feel nearly as distressing.
Throughout the ERP journey, you'll confront your obsessions both in and outside of therapy sessions through therapy exercises called exposures. Sometimes you and your therapist will plan these exercises, and other times they'll simply occur in everyday life. With proper practice and guidance, resisting compulsions when uncomfortable thoughts arise will become a habit, and you—not OCD—will be in control of your life.
Effectively building a hierarchy requires hands-on guidance from a therapist trained in ERP. To begin working with licensed therapist specialized in ERP, book a free 15-minute call with the NOCD team.
The Exposure Hierarchy
The first stage of the ERP process involves cataloging your obsessions—every intrusive thought, image, idea, and urge that causes you distress—and the situations that cause them to occur, known as your triggers. You'll also identify all your compulsions: all the physical or mental behaviors you do in an attempt to feel better or keep something “bad” from happening.
Identify repetitive and unwanted images, thoughts, or urges
List things or events in the environment that trigger unwanted thougths/fears
The next step is to organize your obsessions and triggers into a hierarchy based on how much distress they cause. They're ranked on a simple scale ranging from 1 (minimal distress) to 10 (extreme distress).
This step may seem simple, but it's necessary for creating your treatment plan. By starting with the triggers that cause the least distress, you and your therapist can gradually work your way up the hierarchy, gaining confidence and facing difficult feelings without becoming too overwhelmed at any point.
All along, you'll work with your therapist to make incremental progress, learning various response prevention skills to help you keep resisting compulsions in the long run. The hierarchy you create at the beginning of your journey helps you build a foundation of skill through easier exposures, helping you eventually overcome your most difficult challenges.
The hierarchy can also keep you motivated along the way. When you learn that you can tolerate your discomfort at a 3/10 distress level, you can aspire to the freedom and achievement you'll feel from conquering triggers that cause a 9/10 distress level later on.
People often refer to ERP as simply “exposure therapy,” but exposing yourself to obsessions and discomfort actually doesn't do anything on its own—the key to making progress in ERP is the second component: response prevention. By resisting compulsions, you break the vicious cycle of OCD and learn that you are able to tolerate distress and accept uncertainty.
The premise may be simple, but there's much more to response prevention than meets the eye—that's why it's so important to do ERP with a trained specialist, rather than trying it on your own. There are specific techniques that trained therapists use, and certain errors that they're careful to avoid.
One common response prevention technique is known as non-engagement response: using brief, simple words or phrases that emphasize the irrelevance of intrusive thoughts and help you lean into uncertainty—things like “Whatever,” “Maybe, maybe not,” “So what?” or “Okay, fine.”
What does response prevention look like?
Avoidance is a good example of a sneaky compulsion that may go unnoticed—when the fear of triggers prevents you from doing things you would normally do, avoiding them is actually compulsive and can be tough to notice, especially if it's an ingrained habit. Mental compulsions like rumination and mental checking can also be difficult to identify yourself, and the guidance of a therapist who specializes in OCD can be especially helpful in identifying them.
Trained therapists can also help you avoid replacing one compulsion with another, which is common for people who try ERP on their own. For instance, many people intentionally distract themselves from their discomfort when they attempt ERP on their own, and they end up doing things they wouldn't normally do. While it may feel as if they're coping with distress without relying on compulsions, they're actually engaging in new compulsions—and keeping OCD in control of their lives.
Habituation and Inhibitory Learning
Over decades of studying ERP, researchers have identified two main processes that make it so successful. One is called habituation: the reduction in distress that people experience when they confront triggers and resist compulsions. When you learn to tolerate the anxiety and discomfort brought on by your obsessions, the discomfort actually decreases over time.
Another process known as inhibitory learning can also help you conquer OCD. Essentially, this happens when you repeatedly prove your OCD fears and worries wrong. Let's say you're afraid that you'll get horribly sick unless you wash your hands for 3 minutes every time someone touches you. You and your therapist will gradually work on washing your hands less and less over time, without resorting to any other compulsions, like using excess hand sanitizer.
Eventually, you'll learn that excessively washing your hands wasn't actually preventing you from getting a deadly illness, and OCD can no longer use that fear to control your life.
There are also other things that can indicate that ERP is working: sometimes, something you worried about can actually happen, and you'll learn that you're capable of handling unexpected, uncomfortable experiences. You and your therapist might also work to focus on your own values and choices as a way to resist OCD's influence. In doing so, you can bring a new sense of confidence and courage to other areas of your life.
As virtual therapy services have increased dramatically in recent years, many assume that teletherapy is less effective than traditional, in-person therapy—for virtual ERP, that couldn't be further from the truth.
A recent study validated by the Journal of Medical Internet Research (JMIR) showed that ERP done in live, face-to-face teletherapy is just as effective as in-person ERP therapy, and it leads to significant reduction in OCD symptoms and improvements in overall quality of life, depression, anxiety, and stress, as well. Even more, virtual ERP brought these results over twice as quickly as in-person therapy.
The effectiveness of virtual ERP is due to the way OCD works. Your obsessions are often closely related to the environments you find yourself in throughout the day, so the best way to conduct exposure exercises is to work directly in those places, rather than a therapist's office. Virtual ERP can even involve other places outside the home in order to target specific fears and obsessions.
Whether it's done in person or virtually, the success of ERP therapy often depends on consistently practicing response prevention outside of therapy sessions. However, by practicing exposures first with the guidance of your therapist, directly in your everyday environment, you can quickly gain the skills you need to do exposures on your own between sessions.
FAQs about ERP
- What does a typical journey through ERP look like?
- Could virtual ERP be the new standard for OCD therapy?
- Does ERP therapy work for everybody?
- How does response prevention lead to recovery?
- Can ERP improve symptoms of depression?
- How long does OCD therapy take?
- Should I first try ERP on my own?
- Is ERP effective for all OCD subtypes?
- Can ERP treat phobias?
- Can virtual reality exposures be used to treat OCD?