ERP stands for
Exposure and Response Prevention (ERP) therapy is a form of Cognitive Behavioral Therapy (CBT) that was developed specifically to treat obsessive-compulsive disorder (OCD).
What is ERP?
One of the hallmark symptoms of OCD is obsessions, which are unwanted, intrusive thoughts, images, ideas, or urges that cause significant distress. These can include doubts about one’s own identity, intrusive thoughts about doing harm to others, unwanted fixation on physical sensations, and a wide range of countless others. OCD also includes compulsions, which are physical or mental behaviors done in an attempt to reduce this distress created by the obsessions. Compulsions are often done with the aim of detecting and neutralizing a perceived threat in order to prevent a feared outcome from occurring. Compulsions may provide short-term relief from the distress caused by obsessions, but it reinforces the belief that compulsions successfully dealt with a real danger or threat, allowing obsessions to return more frequently and causing more distress over time.
ERP therapy breaks this cycle by addressing both obsessions and compulsions. In ERP, an individual is encouraged to confront the stimuli that trigger distress related to their obsessions while also resisting the urge to perform compulsions in an attempt to reduce their distress.
Instead of responding with compulsions in order to resolve distress or avoid a feared outcome, someone in ERP therapy will learn to accept the uncertainty behind their obsessions and allow their distress to dissipate over time. Additionally, instead of avoiding their obsessions or distracting themselves from them, someone in ERP will simply acknowledge that they are having an unwanted thought, idea, image, or urge, without giving it any particular attention.
The success of ERP often depends on the patient consistently practicing exposures outside of their therapy sessions. This can occur in planned, structured activities, or other unplanned exposure opportunities that arise in daily life. Response prevention skills are built over time, eventually becoming “new habits” in daily life. At this stage, OCD symptoms are managed day to day, and even when intrusive thoughts occur, the distress they cause is often dramatically reduced or negligible.
The Exposure Hierarchy
The first stage of someone's ERP process involves cataloging their obsessions—every intrusive thought, image, idea, and urge they experience in relation to their OCD theme(s)—as well as all their compulsions—the behaviors they perform or avoid in an attempt to relieve distress or prevent a feared outcome in response to their obsessions. Included in this cataloging process are the scenarios that trigger the obsessional distress.
The next step is to organize these obsessions and triggers into a hierarchy based on the Subjective Units of Distress Scale (SUDS), or the level of distress these obsessions cause, which is measured on a scale ranging from 1 (minimal distress) to 10 (extreme distress). This hierarchy is used to plan the course of ERP treatment; the patient and their therapist will design exposures to trigger anxiety similar to each obsession on the hierarchy, starting with the ones that cause the least relative distress.
This is important to the ERP process. By starting with the obsessions that cause the least relative distress, the patient and therapist can work to make incremental progress, ensuring that the member learns response prevention skills without exposing themselves to too much distress. If a therapy member is exposed to high levels of distress too early, it can make them less receptive to ERP process, making it less effective.
The hierarchy of obsessions can also serve as a motivational tool. When people doing ERP learn that they can tolerate an exposure with a 3/10 SUDS level early in treatment, they can aspire to the freedom they might feel from conquering an obsession with a 9/10 SUDS level later in treatment.
You might note that compulsions are not organized into a hierarchy. That's because the structure of ERP is based on effectiveness and safety, so the process of learning to tolerate distress without engaging in compulsions is at the center of the treatment plan, and this is done by targeting specific obsessions and fears. While a patient and their therapist may choose to focus on eliminating especially burdensome compulsions at certain points on the hierarchy, the progression of exposures is based on the level of distress they cause.
Simply exposing oneself to obsessions and fears accomplishes nothing in itself—progress is only made in ERP through response prevention. This breaks OCD's vicious cycle and teaches someone going through ERP that they are able to tolerate distress and accept uncertainty without trying to get rid of it through compulsions, which reinforce those feelings and cause obsessions to return again and again.
Response prevention itself is not always as simple as not doing a specific compulsion, however. There are often specific techniques that may be employed and certain errors that need to be avoided.
Not all response prevention techniques involve simply “doing nothing,” for example. One such response prevention technique is known as non-engagement response, or brief, simple words or phrases used to emphasize the insignificance and irrelevance of intrusive thoughts. Non-engagement responses include phrases like “Whatever,” “Maybe, maybe not,” “So what?” or simply “Okay. Fine.”
It's also important to note that while response prevention can be done independently, working with a trained OCD specialist can help people avoid tricky compulsions going unnoticed or other compulsive behaviors simply being replaced by others. A trained specialist can also teach therapy members effective response prevention techniques so that they can manage OCD long-term.
Avoidance is a good example of a tricky compulsion that may go unnoticed—when the fear of OCD triggers prevents people from doing things they would normally do, their avoidance is compulsive and may be tough for them to notice. They may simply feel like they are staying safe and avoiding discomfort as usual, but when this discomfort is a result of OCD, they are only reinforcing the OCD cycle. Mental compulsions like rumination and mental checking can also be difficult to identify in oneself, and the guidance of a therapist who specializes in OCD may be especially helpful in identifying them.
Distraction is a good example of a compulsive behavior that may simply replace another when people attempt to do ERP without the help of a therapist. Without being guided in better ways of resisting compulsions, people may instead attempt to distract themselves from their thoughts or distress, doing things they would not normally do in an attempt to relieve anxiety. Compulsive behaviors like these may feel like proper methods of response prevention to people trying ERP on their own, which can interfere with their progress.
Habituation and Inhibitory Learning
One primary process by which people in ERP learn to manage OCD-related distress long-term is habituation, or the reduction in distress caused by obsessions through repeated exposure to them, along with response prevention. When patients experience habituation, they learn to tolerate the anxiety and discomfort brought on by their obsessions, and the discomfort itself decreases over time as a result.
While habituation is an important mechanism in OCD recovery, it is not the only sign of progress in ERP. A process known as inhibitory learning can also be involved, in which a fear or a belief based in fear is inhibited by additional knowledge and experience. For instance, if a person fears that they will get sick if they fail to sanitize their shoes every time they return home, by resisting this compulsion over time, they will come to understand that the compulsion was not necessary in order to keep them safe. Essentially, instead of erasing or reducing their fear, the ERP process simply adds a different source of knowledge and belief through experience. The new information acquired (i.e., “I do not get seriously sick from not sanitizing my shoes”) inhibits the person’s previous belief that sanitizing their shoes was absolutely necessary to prevent sickness.
There are also other things that can indicate that ERP is working and that a person is developing the skills they need to manage OCD in the long term. They may actually experience negative outcomes and learn that they aren’t as distressing as they had feared, developing an acceptance of uncertainty and unpredictability. In the process of ERP, someone might also strengthen their connection with their values and identity, providing motivation and confidence to continue resisting compulsions.
Furthermore, focusing only on habituation as a measure of progress can reinforce the idea that anxiety is an experience to be avoided at all times, which interferes in the process of ERP. Instead, progress can be seen in an increased willingness to enter into uncomfortable situations and a greater tolerance for anxiety, even if levels of anxiety remain the same or fluctuate.
When the COVID-19 pandemic caused office closures around the world, virtual therapy services increased dramatically. Many assumed that teletherapy, even live, face-to-face video sessions, were less effective than traditional, in-person therapy.
We now know that this is not the case when treating OCD with ERP. Recently the JMIR validated the largest study of OCD treatment ever recorded, conducted over 18 months,which showed that ERP done in live, face-to-face teletherapy is just as effective as traditional in-person ERP therapy, with a response rate of over 63% and an average reduction of over 43% in OCD symptoms, with significant improvements in other mental health measures, as well. Additionally, ERP delivered in live teletherapy sessions brought these results in under half the time, on average, of traditional outpatient ERP therapy.
The effectiveness of ERP in a virtual therapy model is due to the nature of OCD. People’s obsessions are often closely related to the environments they find themselves in throughout the day, so the most effective way to expose them to the resulting anxiety is by practicing exposures directly in those environments, rather than finding the closest approximation in a therapist’s office. A therapist can even conduct teletherapy sessions somewhere 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 the patient consistently practicing response prevention outside of their therapy sessions. However, by practicing exposures first with the guidance of a therapist, directly in the environments that trigger their obsessions, they can engage in response prevention techniques within the circumstances of day-to-day life, more quickly gaining the skills they need to do daily exposures independently.