What Is Exposure and Response Prevention (ERP) Therapy?

Exposure and Response Prevention (ERP) Therapy is a type of Cognitive Behavioral Therapy (CBT) considered the first line of psychotherapy for OCD (Hezel & Simpson, 2019).

ERP therapy has been found effective for 80% of people with OCD (Foa, 2010), making it one of the most effective mental health treatments available. 

ERP therapy aims to gradually reduce the anxieties associated with OCD and interrupt the problematic obsession-compulsion cycle. ERP therapy is not about eliminating your distress but rather about learning how to accept and manage it without neutralizing it.

ERP therapy involves therapist-guided, systematic, repeated, and prolonged exposures to situations that provoke obsessional fears whilst abstaining from performing compulsive behaviors. 

The objective of ERP treatment for OCD is for the patient to deliberately confront the feared situations and stimuli they usually avoid (e.g., public bathrooms or crowded spaces). This confrontation aims to induce the obsessional fears and urges that these individuals ritualized.

After exposure, the patients are also instructed to avoid performing their compulsions (e.g., counting; arranging & ordering objects; washing; checking). 

Over the last 30 years, several investigations of ERP for treating OCD have been conducted worldwide. These studies, with over 500 patients and numerous therapists, have affirmed the success and generalizability of ERP’s beneficial effects on OCD treatment (Abramowitz, 2006).

How Does ERP Therapy Work?

ERP works by breaking the link between one’s obsessional thoughts, urges, or impulses and the compulsive things that one does to reduce any anxiety or distress that they might cause 

During ERP, patients gradually expose themselves to feared situations meant to set off their obsessions whilst resisting the urge to carry out their compulsive activity. 

By staying in a feared situation and leaning into the discomfort and uncertainty, patients learn that they don’t need their compulsions to cope, and that their fearful thoughts have no power over them.

This exposure therapy is intended to purposely invoke more anxiety in attempts to disrupt the neural circuit between the processing and action parts of the brain. Over time, a patient’s distress and anxiety will naturally reduce by remaining in the exercise without carrying out the compulsion.

As their anxiety or distress naturally reduces, the strength between their obsessions and compulsions also reduces. Through ERP, patients learn to resist the urge to perform compulsive rituals and manage their OCD thoughts and actions independently. 

This habituation process of repeatedly invoking anxiety and exposing the brain to a stimulus disrupts the neural circuit between the processing and action parts of the brain.

ERP takes time, effort, and practice, but patients learn to cope with their thoughts without relying on ritualistic behaviors. They start by confronting easier situations and gradually escalate to more difficult ones. Each time they carry out an ERP exercise, it becomes easier and easier as the anxiety or distress gradually subsides.

The compulsion to avoid anxiety is a powerful driver of OCD. Still, ERP is one of the most powerful tools available for treating OCD because it directs the patient to live with the anxiety and see that nothing bad will happen.

ERP is best undertaken with the support of a practitioner trained to work with OCD. They can help you devise a plan and support you in carrying it out safely.

How does someone actually do ERP Therapy?

People with OCD are often trying to seek 100% assurance or guarantee that their fear will not become a reality. But the problem with this is that we can never be 100% sure.

In ERP, patients will be taught to face their fears and then wait, instead of acting on them. Eventually, they will develop the ability to tolerate the uncertainty around their fears. Building this relationship with uncertainty is the only way to overcome OCD. 

1. Assess the individual’s symptoms

Symptom monitoring can help patients see how much their OCD affects them on a daily basis and motivate them to engage in treatment. 

The first step of ERP is working with a therapist to identify and assess your symptoms. A trained ERP professional will help you identify your obsessions, intrusive thoughts, images, urges, and compulsive rituals.

Then, they will work with you to create a list of triggers / feared stimuli and rank them in order from least to most distressing.

When making the graded ERP hierarchy, the patient will arrange the situations or sources of anxiety that trigger their fears in order of severity.

The anxiety is usually rated on a scale from 0% (completely relaxed) to 100% (the worst anxiety you can imagine feeling). This is known as the Subjective Units of Distress Scale, or SUDS scale.

Here is an example of an exposure hierarchy for a patient who fears contamination.

1. Handling money (SUDS rating: 50)
2. Pressing a button on a vending machine (SUDS rating: 55)
3. Touching the bottom of your shoe (SUDS rating: 60)
4. Shaking hands with a stranger (SUDS rating: 65)
5. Touching bathroom door handle (SUDS rating: 75)
6. Touching wall in toilet (SUDS rating: 80)
7. Handling raw poultry or hamburger meat (SUDS rating 85)
8. Touching floor beside toilet (SUDS rating: 90)
9. Touching toilet seat (SUDS rating: 95)
10. Putting hand in toilet bowl water (SUDS rating: 100)

2. Psychoeducation

Psychoeducation involves learning about OCD and its symptoms, treatments, treatment effectiveness, and other research.

This education is vital because patients often do not realize that struggling against their intrusive thoughts will only worsen them.

Psychoeducation can also help patients maintain their motivation through treatment. They might write a statement about why it’s worth recovering, write out the advantages/disadvantages of stopping compulsions, or discuss with their therapist their goals for treatment. 

Understanding OCD Better

People report that learning more about OCD, especially how avoiding things and doing rituals keeps the OCD going, changes how they think about their symptoms. This knowledge can give them the push to start Exposure and Response Prevention (ERP) exercises.

“Even though I sometimes still feel guilty, I’m trying not to do my rituals because I know they don’t really help – it’s just the OCD controlling me.”

Source: Leeuwerik, T., Caradonna, & Strauss, C. (2023). A thematic analysis of barriers and facilitators to participant engagement in group exposure and response prevention therapy for obsessive–compulsive disorder. Psychology and Psychotherapy: Theory, Research and Practice, 96(1), 129-147.

Why Treatment Works

People report that understanding how and why ERP helps was encouraging. For example, learning that natural reactions, like fear, will fade over time if we face them.

This made some, like Helen, want to confront their OCD head-on: “… it made me eager to face it rather than just think about it.” Isabel felt empowered, saying, “I realized I can face something that scares me, and with time, it won’t be as scary anymore.”

Source: Leeuwerik, T., Caradonna, & Strauss, C. (2023). A thematic analysis of barriers and facilitators to participant engagement in group exposure and response prevention therapy for obsessive–compulsive disorder. Psychology and Psychotherapy: Theory, Research and Practice, 96(1), 129-147.

3. Exposure

This is the action component of ERP. It involves purposely being exposed to triggers in a gradual, moderated way.

Exposure therapy can progress at different paces for different individuals depending on the severity of the OCD and the fear(s) associated with the patient’s OCD.

Graded Exposure

Graded means that you gradually face your fears, starting with something manageable and slowly building up to more challenging situations.

Graded exposure involves exposing yourself to the source of your fear gradually by going up the hierarchy one step at a time.

During ERP, your therapist will guide you through a graded fear hierarchy or ladder that serves as a roadmap to guide your progression through exposure therapy.

Once you’ve gone through the exposure and response-prevention process with a moderate-level fear, you’ll start to work your way up the anxiety ladder.

You and your therapist will work together to decide when it is time to move from one avoided situation to the next.

You begin with the things in your exposure hierarchy that give you at least 50-60% anxiety and move up to the more difficult things.

Each new goal will still be somewhat anxiety-inducing, but as you learn to manage your intrusive thoughts, this anxiety will start to arise less frequently and with less power.

When you have been repeating an exercise and it no longer gives you at least 40% anxiety at the start of the exercise, you are then ready to move up to the next item on your exposure hierarchy.

Repeated Exposure

Exposure must be repeated, it is important that you practice facing your fears many times until you feel comfortable in that situation.

Repeated exposure involves repeatedly exposing yourself to each step on the hierarchy until the exercise no longer makes you feel anxious (i.e., it no longer goes above 40% anxiety at the start of the exercise).

Once you have repeated exposure until it is no longer anxiety-inducing, you will move up to the next exercise on your hierarchy ladder.

Prolonged Exposure

Prolonged exposure involves staying in the exposed situation without carrying out a compulsive activity until your anxiety level drops by 50% from the rating at the start of the exercise. This usually takes between 45 and 90
minutes.

For example, if you were 85% anxious at the beginning of the exercise, you would stay in the situation until your anxiety drops to at least 35%. You would then repeat the exercise until it no longer gets above 40% at the start of the exercise.

4. Response prevention

Response Prevention is one of the main components of ERP therapy. This step refers to the intentional practice of refraining from engaging in compulsions or avoidance behaviors when exposed to a trigger. 

Compulsions, or rituals, are behaviors that people with OCD perform in response to an obsession, or intrusive thought. People perform these compulsions to suppress their anxiety and neutralize their fears.

However, while compulsions might “help” in the short term, they only make the intrusive thoughts worse and serve to keep the OCD cycle going long-term.

Tolerating uncertainty

Low tolerance to uncertainty is a primary feature of the obsession-compulsion cycle. People who suffer from OCD believe that their distressing thoughts will become a reality, so they engage in compulsions to prevent this from happening.

Delaying rituals

In ERP, a therapist might ask a patient to start by delaying their responses to triggers to increase the time between their obsessive thoughts and performing the compulsions they usually do.

Overtime, this will progress until a patient is resisting the compulsion altogether.

Modifying rituals

In addition to delaying their responses, patients will also be challenged to modify their rituals. That way, they can still act on their thoughts but not in the same ways that they are typically inclined to do.

Exposure Without Distraction

This step involves avoiding doing things that serve to reduce your anxiety artificially or distract you from how you are feeling during your exposure exercises.

These temporary reliefs are only keeping you stuck in the vicious OCD cycle.

Exposure Without Compulsion

Each time you expose yourself to an exercise on your hierarchy, you need to resist the urge to carry out a compulsion to neutralize or reduce your distress. This final condition is critical to making your ERP effective.

Patients are encouraged to focus their attention on simply noticing what happens as they are exposed, while not performing a compulsion to cope (i.e., not seeking reassurance, neutralizing, or checking).

Types of ERP Therapy

In Vivo Exposure

In vivo exposure involves directly facing the feared object, situation, or object in real-time.

For example, someone with social anxiety might be instructed to give a speech in front of an audience or someone or someone with contamination OCD might be guided to refrain from washing their hands after going to the bathroom. 

Imaginal Exposure

Because some feared consequences/situations can not be physically brought on, imaginal exposure involves vividly imagining the feared object, situation or activity.

For example, someone with Posttraumatic Stress Disorder might be asked to recall and describe their traumatic experience in detail in order to induce (and eventually reduce) feelings of fear.

Some people will use scripting where they practice writing out their worst fears and then exposing themselves to these scenarios in their minds by rereading or listening to the imagined script repeatedly.

The goal is to create a first-person, present tense, detailed narrative of the worst-case scenario occurring. 

Interoceptive Exposure

Interoceptive exposure is the practice of strategically inducing the somatic symptoms associated with a threat appraisal and encouraging the patient to maintain contact with the feared sensations.

Examples of interoceptive exposures include spinning around on a swivel chair to simulate feelings of dizziness; breathing fast to recreate a racing heart; or running upstairs to simulate breathlessness.

This approach is particularly helpful in treating clients who fear the physical sensations accompanying their panic, anxiety, or phobia more than the event itself. It is generally employed when treating panic attacks. 

Virtual Reality Exposure

Virtual reality exposure is a more novel approach that involves confronting your fears using virtual reality. For example, for a patient who has a fear of flying, this type of exposure can use virtual reality to simulate flying in an airplane. 

Flooding

Flooding is another treatment approach that involves exposing a patient to the highest level of the hierarchy all at once.

Therapists tend to use flooding if a patient’s fear interferes with their ability to go about their daily life, and thus needs to be handled more aggressively.

Flooding can help a patient overcome their fear faster, but it can also be traumatic and overwhelming to experience.

Flooding is the opposite of graded exposure, where a patient is exposed to their fears gradually by going up the hierarchy one step at a time. 

FAQs

Sources

Abramowitz, J. S. (2006). The psychological treatment of obsessive—compulsive disorder. The Canadian Journal of Psychiatry, 51(7), 407-416.

Foa, E. B., Yadin, E., & Lichner, T. K. (2012). Exposure and response (ritual) prevention for obsessive-compulsive disorder: Therapist guide. Oxford University Press.

Gellatly, J., Bower, P., McMillan, D., Roberts, C., Byford, S., Bee, P., … & Lovell, K. (2014). Obsessive Compulsive Treatment Efficacy Trial (OCTET) comparing the clinical and cost effectiveness of self-managed therapies: study protocol for a randomised controlled trial. Trials, 15, 1-10.

Hezel, D. M., & Simpson, H. B. (2019). Exposure and response prevention for obsessive-compulsive disorder: A review and new directions. Indian journal of psychiatry, 61(Suppl 1), S85.

Leeuwerik, T., Caradonna, G., Cavanagh, K., Forrester, E., Jones, A. M., Lea, L., … & Strauss, C. (2023). A thematic analysis of barriers and facilitators to participant engagement in group exposure and response prevention therapy for obsessive–compulsive disorder. Psychology and Psychotherapy: Theory, Research and Practice, 96(1), 129-147.