Exposure and Response Prevention Therapy by Jon Abramowitz, PhD
BRIEF DESCRIPTION:
Exposure and response prevention (ERP) is a form of cognitive behavioral therapy (CBT) that is widely used in the treatment of OCD. It is considered the first-line psychological treatment due to its very strong evidence base and effectiveness in reducing symptoms and improving functioning in people with OCD.
ERP is a first-line treatment and is therefore recommended for most people with OCD. If you have tried other treatments for OCD that have not worked, it is worth considering ERP. You can do ERP while taking medication or while doing most other types of therapy as long as your ERP therapist is aware of these other treatments.
ERP typically begins with 2–3 sessions of education about OCD and a detailed assessment of your obsessions, compulsions, and avoidance patterns. Next, you and your therapist work together to develop an exposure list or “hierarchy” of selected situations, thoughts, and other stimuli that provoke obsessional fear.
Following these treatment planning sessions, the therapist coaches you through the process of gradually confronting the feared situations, objects or thoughts on the hierarchy (exposure therapy), without engaging in any compulsions or avoidance (response prevention). Exposure practices are planned ahead of time, and might involve directly confronting an actual situation or stimulus (situational exposure) or confronting thoughts and images (imaginal exposure). You are never forced or deceived into exposure — rather, therapists coach and encourage patients to gradually take more and more challenging steps. Response prevention entails helping you resist the urge to engage in compulsive behaviors during and after exposure. You would also be asked to complete additional ERP practice between sessions.
During ERP, your level of anxiety is expected to increase. This is an important part of therapy because it helps you learn that (a) anxiety, unwanted thoughts, and feelings of doubt and uncertainty are not dangerous and you can manage them better than you thought, (b) this increase in distress is only temporary, and (c) the negative consequences you’re afraid of are unlikely to happen. With consistent practice, ERP reduces the anxiety and avoidance associated with obsessions and compulsions and increases your ability to function in your various roles. Over time, these exercises often get easier.
A typical course of ERP therapy spans anywhere from 12 to 20 sessions but can be adjusted based on individual needs. Sessions typically last about one hour each. The format of ERP can vary, including individual therapy sessions (once per week or more), group sessions, intensive outpatient programs, or teletherapy options. Self-help resources can also complement the therapy.
ERP is typically administered by licensed mental health professionals, such as psychologists, psychiatrists, social workers, or counselors, who have specific training and expertise in ERP. To find a qualified provider, it is best to consult professional organizations specializing in OCD (like IOCDF) or seek referrals from other professionals. It's also important to verify the provider's credentials and experience with ERP.
WHY/HOW IT WORKS:
ERP works by allowing you to confront and habituate to your fears in a controlled environment, facilitated by a therapist. Habituation means staying in the situation long enough to see that anxiety naturally subsides even if you don’t perform rituals or fight the anxiety itself. Through repeated ERP, you also learn that your obsessions and anxiety are “false alarms,” and that your feared outcomes are unlikely and do not require compulsive rituals. Research shows that this leads to a rewiring of neural pathways in the brain. ERP also builds confidence and empowerment, enabling you to learn that you can effectively manage obsessional thoughts and anxiety without getting stuck.
SUMMARY OF THE RESEARCH SUPPORT:
Since the 1960s, hundreds of clinical trials have been conducted on the effects of ERP with thousands of adult, adolescent, and pediatric patients in countries around the world. This vast body of literature has consistently demonstrated that ERP can produce large OCD symptom reductions, which are often maintained in the long-term. On average, patients achieve a reduction of 60% of OCD symptoms, along with reductions in general anxiety, depression, interpersonal stress, and functional interference. Accordingly, ERP is recognized as a first-line, evidence-based treatment for OCD.
AGE CONSIDERATIONS
ERP has been shown to be effective in children as young as six years old, all the way through older adulthood.
OTHER IMPORTANT CONSIDERATIONS:
Importantly, ERP is not effective for everyone. We know that several factors can impact how well people respond. The most important factor is putting in the hard work — you get out of ERP what you put into it. Although it can be challenging to face your fears and resist rituals, with practice, you find that doing so is very much worth the effort and the temporary discomfort. Other factors that can interfere with treatment include severe depression, very poor insight into the senselessness of OCD symptoms, active bipolar disorder or psychosis, substance abuse, and extreme family or partner conflict or accommodation of OCD symptoms.
WHEN TO TRY THIS TREATMENT:
ERP is a first-line treatment and is therefore recommended for most people with OCD. If you have tried other treatments for OCD that have not worked, it is worth considering ERP. You can do ERP while taking medication or while doing most other types of therapy as long as your ERP therapist is aware of these other treatments.
An initial course of outpatient ERP is usually recommended first, but if that is not helpful, moving to a more intensive version, such as intensive outpatient or residential, can often be effective.
Importantly, ERP is not for everyone. It only works if you are on board and willing to give it a try. That doesn’t mean you have to be enthusiastic about facing your fears (very few people are!), but that you’re at least open to putting in an effort. If someone else is trying to coerce or force you to do ERP against your will, you are unlikely to see positive results. That is because this treatment requires hard work and lots of consistent practice. If you have to be “forced” into treatment, it probably means that you are not at a point where you’re ready to take these steps. In this case, it might help to work with a therapist to explore the pros and cons of ERP before you do it. There are alternatives to ERP, as you can read about on this website.