Exposure and response prevention (ERP) is the gold standard treatment for obsessive compulsive disorder (OCD). ERP treatment involves facing feared items, the causes of someone’s OCD obsessions, in real time or through imaginal work, and changing the response from compulsive to adaptive.
What is the best therapy for OCD?
Exposure And Response Prevention Therapy (ERP) – Do live video sessions with a therapist specialized in ERP, the gold standard treatment for OCD. Treatment from NOCD is covered by many insurance plans. Start With A Free 15 Minute Call
What Is Exposure and Response Prevention (ERP) Therapy?
Exposure and response prevention (ERP) involves facing a fear or fears (the exposure) while resisting compulsive behaviors (response prevention), neutralizing the components of OCD. Over time, the client learns that they can choose to respond differently in the face of fear and anxiety. They can choose to live by their values rather than living to avoid discomfort.
When someone completes an exposure, it builds distress tolerance and adaptive thinking. Prior to exposure, someone might expect a panic attack or a series of catastrophic events if they were to resist a compulsion. Through practice, they learn that the feared outcome doesn’t happen (or doesn’t happen nearly as often) and that anxiety is uncomfortable, but not dangerous.
ERP for OCD Is the Frontline Treatment Option
ERP is established as the first-line, evidence-based treatment for OCD, which has been ranked among the most debilitating disorders by the World Health Organization (WHO).1,2 Exposure and response prevention allows people to lead a value driven life on their terms, not by the rules their OCD creates.
The International OCD Foundation (IOCDF), an organization dedicated to helping those affected by OCD, states that ERP (with or without medication) is the gold standard treatment for OCD.3 The National Institute of Mental Health also states that ERP therapy for OCD can reduce compulsive behaviors, even in those who did not respond well to selective serotonin reuptake inhibitors (SSRIs).4
How Avoidance Reinforces Fear
People may mistakenly believe if something creates fear or anxiety, staying away from it will help. In reality, using avoidance coping may actually reinforce anxiety in an endless cycle. Each time a person avoids the anxiety-provoking situation, the perceived danger grows, which makes avoidance even more necessary. Then, with greater avoidance, there is a lower chance of exposure, so the situation feels even more threatening.
Typical Exposure Therapy Vs. Exposure & Response Prevention
Exposure therapy refers to a broad type of therapy that entails gradually exposing someone to a feared stimulus. This type of therapy can be beneficial for people with a variety of issues, including social anxiety, eating disorders, phobias, and more. Exposure and response prevention is a more nuanced form of exposure therapy specifically intended for treating OCD.
ERP Vs. CBT for OCD
CBT for OCD may broadly include interventions designed to challenge irrational thoughts and replace unwanted OCD responses for more proactive, desired responses. CBT can include techniques like cognitive restructuring, mindfulness, and changing thought records. ERP is a specific OCD protocol where patients are exposed to obsessions in safe, controlled environments without engaging in their typical compulsive behaviors.
ERP Vs. Traditional Talk Therapy for OCD
Traditional talk therapy is an umbrella term for sharing various feelings, thoughts, and needs with a therapist. Some talk therapies are highly structured, whereas others are more fluid and flexible. Some people with OCD can benefit from this approach, especially if they have other co-occurring issues. ERP is manualized and follows a specific set of instructions intended to treat OCD.
How Does ERP for OCD Work?
ERP treats OCD by interrupting the OCD cycle, in which obsessions (thoughts that elicit anxiety and distress) are reinforced by compulsions (acts that provide temporary relief from the distress). By engaging in ERP, someone can learn to tolerate discomfort, thereby stopping reinforcement of the OCD cycle. In short, exposure techniques create learning experiences where obsessional stimuli can be confronted without using rituals (response prevention).5
Psychoeducation
Psychoeducation refers to a therapist providing clinical information about a diagnosis, treatment, or intervention with a client. Psychoeducation can help demystify some of the therapeutic process, which can be important in cultivating trust and making a plan toward achieving change. A therapist will generally educate their client on what to expect during ERP and discuss potential treatment outcomes.
Creating an Exposure Hierarchy
When completing ERP therapy for OCD, the person will create a hierarchy of their triggers. These triggers (which will become exposures) will be ranked from least to most distressing. A Subjective Unit of Distress Scale (SUDS) is used to rank exposures, often in a 0-10 or a 0-100 format. This tool is also used in practice to build awareness around discomfort and the experience of exposure.
Models of Exposure Therapy
The two most common models of exposure for OCD are:
Habituation Model
The most well-researched model of ERP is the habituation model. Habituation leads to a natural decrease in anxiety without engaging in anxiety-reducing behavior (compulsions). When someone is actively engaging in compulsions, they don’t give themselves the chance to experience habituation. They engage in a compulsion before this happens, thus reinforcing the idea that anxiety would escalate to an unmanageable degree. By taking away the ritualization of the compulsion, an individual begins to trust their ability to cope with distress, anxiety, and uncertainty.6
Inhibitory Learning Model
A more recent, experimental model of ERP, the inhibitory learning model, acknowledges that habituation may not be so straightforward. Instead, ERP may be helpful by teaching people safety in such a way that it blocks, or inhibits, their feared stimulus.7 By engaging in ERP, someone learns that it is “safe” to experience uncomfortable emotions, even when OCD is triggering fear.
Tolerating Uncertainty
Tolerating uncertainty is an essential part of OCD treatment, and it can be one of the most challenging tasks. ERP specifically heightens feelings of uncertainty (presenting the feared or uncomfortable situation) and removes the normal coping response (engaging in compulsions). While this can be incredibly uncomfortable at first, the anxiety eventually subsides and may create a habituation effect.
Response Prevention
Response prevention refers to deliberately not engaging in a preferred compulsive behavior after experiencing an obsessive thought or exposure to a feared stimulus. Therapists will guide clients in doing this to start, then they will be expected to practice on their own as well. At first, flooding (feeling incredibly overwhelmed) is common, but this feeling dissipates over time. With practice, clients can learn how to implement response prevention into their own life.
Delaying Rituals
As part of ERP, therapists sometimes encourage clients to extend the time spent between noticing an obsession and engaging in a compulsion. This ‘pause’ effect can help people better sit with their distress and choose alternative coping methods. This can lead to an eventual reduction or elimination of compulsive reactions.
Modifying Rituals
Changing rituals can also break OCD patterns. For example, some people feel they must check the door four times before leaving the house. They might make a goal of checking it three times. This can create a sense of empowerment and also reestablish stronger feelings of control over the OCD itself.
What Does a Typical OCD ERP Session Look Like?
A typical OCD ERP treatment plan begins with a preliminary intake and assessment. You will spend a good amount of time discussing the history, intensity, and frequency of your OCD symptoms. You’ll also be asked about other important details about your medical and psychiatric history. This information will help your therapist establish a working treatment plan with set goals and objectives.
Early sessions tend to involve building initial rapport together, receiving psychoeducation about ERP, and creating a fear hierarchy. Your therapist may also assign homework for you to complete between sessions. You will then start engaging in gradual exposures in-session together. Over time, you will work up your fear hierarchy until OCD symptoms feel more manageable or reduced.
What is the best therapy for OCD?
Exposure And Response Prevention Therapy (ERP) – Do live video sessions with a therapist specialized in ERP, the gold standard treatment for OCD. Treatment from NOCD is covered by many insurance plans. Start With A Free 15 Minute Call
How Long Does OCD Exposure Therapy Take to Work?
Exposure therapy is one of the most reliable and rapid forms of therapy, and meaningful progress is possible after only one session. People may take part in a few extended sessions or weekly hour-long sessions. In either case, many people will see symptom reduction within eight weeks.9
Of course, it could take others many months to decrease and maintain symptom relief. No matter the timeline, people should try their best to remain patient and stay consistent with treatment.
How to Find a Therapist Skilled in ERP for OCD
If you feel you may be struggling with OCD, don’t hesitate to ask for help. When looking for a therapist for OCD, it is important to ask questions to ensure it’s an appropriate match.
Here are questions to ask any potential therapist you may want to work with:8
- What techniques do you use to treat OCD? (If the therapist does not mention exposure and response prevention, be cautious.)
- What is your training and background in treating OCD?
- What percentage of your caseload is treating OCD? (A good answer would be over 25%)
- Do you feel that you have been effective in your treatment of OCD?
For more information, visit the International OCD Foundation’s website. IOCDF provides valuable resources to individuals, parents, and families. Another great option for getting help is an online therapy directory where you can search for a therapist with specific qualifications, like someone who works specifically with people who have OCD.
Examples of OCD ERP Therapy
Every individual’s ERP plan will be unique to them. Even if two people share the same subtype of OCD, their exposures may vary widely. It depends on the core fear and overall presentation (triggers, obsessions, compulsions, and so forth).
Here are three case examples of how ERP can help with OCD:
1. ERP for Contamination OCD
Margot has experienced many subtypes of OCD for most of her life. In the last few years, contamination fears have taken over. Her main fear is spreading contamination to her loved ones and being responsible for their illness. A year ago, Margot had several rituals throughout the day. Now, her day contains four or more hours of completing OCD-related rituals.
After going through the psychoeducation portion of therapy, she begins her ERP for OCD.
Here is part of her exposure hierarchy (from most to least distressing):
- Use public restroom, go home, and resist changing clothes (sit on couch): 100
- Try makeup at a beauty store, give daughter a hug when you get home (1 minute hug): 90
- Throw away item in a public trash can, brush hand against the side: 80
- Pet a dog, eat a snack: 65
- Do family’s laundry without rituals (wiping down machine): 60
- Touch a public doorknob: 55
- Get a hot coffee at the store and drink using the lid: 40
- Use elevator and touch buttons: 40
- Use communal pen at doctor’s office: 30
Each of Margot’s exposures from this list provide her with valuable information. Her confidence grows and she sees that she doesn’t have to live her life on OCD’s terms. Her loved ones, who her OCD targeted with its threats, are able to spend quality time with Margot without OCD interfering.
2. ERP for Harm OCD
Indigo has lived with OCD for the last 15 years. Despite living a quiet life, their OCD threatens them with fear of causing harm to others. They have spent years mentally punishing themselves, thinking they were a “bad” person for having these thoughts. They avoid driving at all costs for fear of hitting a pedestrian, and only use plastic silverware for fear of losing control.
A therapist diagnoses Indigo with OCD and they begin working toward recovery together.
Here is part of Indigo’s exposure hierarchy:
- Sleep with steak knife on nightstand (when loved ones are home): 100
- Use steak knife at a restaurant during family during: 95
- Drive through a mall parking lot where people are walking (music is on): 85
- Drive next to bike lane (music is on): 85
- Put pocket knife in jacket; walk around mall: 80
- Use full-size scissors to cut paper snowflakes (15 minutes): 55
- Drive on highway in the evening (without music): 50
- Drive on highway in the daytime (without music): 40
- Write a script about worst fears; read five times a day: 30
Through their ERP journey, Indigo realizes that much of their treatment is resisting engaging in self-punishment. Indigo’s psychoeducation reminded them that intrusive thoughts do not say anything about the quality of the person. Letting themselves off the hook was a huge part of Indigo’s treatment success.
3. ERP for Real-Event OCD
Tallulah had mild OCD symptoms as a child, but she was able to manage without proper treatment until age 25. One day, she woke up with a memory of her first kiss and her OCD told her that it may not have been consensual, and she may have taken advantage of her friend, Jonah. The crippling anxiety and doubt prompted many rituals.
Now, Tallulah engages in countless compulsions led by sexually intrusive thoughts, including isolation. She reviews the memory over and over again, and even surveys friends for second opinions. Despite reassurance, the obsessional doubt prevails. Tallulah is seen by an OCD specialist and begins ERP.
Here is part of her hierarchy:
- Go on a date with someone new: 90
- Download a dating app, use it daily: 95
- Watch a movie about sexual assault: 85
- Write an imaginal script about Jonah confronting you: 85
- Read news stories about the #MeToo movement: 80
- Use social media without checking Jonah’s profile: 80
- Talk to a childhood friend for 20 minutes without seeking reassurance: 55
- Go out and meet three new people: 50
Tallulah’s success in treatment depends on her willingness to lean into uncertainty. Her OCD wants her to isolate, investigate, and self-punish. Instead, she embraces her ERP plan and lives life on her terms.
Is ERP the Only OCD Treatment Option?
Exposure therapy and imaginal exposure therapy are the cornerstones of OCD treatment, but some others have been effective, including:10
- Habit reversal training (HRT): HRT combines relaxation skills, social supports, positive reinforcement, and awareness training to build a new response that competes with the established compulsions.
- Cognitive therapy: Cognitive therapy aims to help a person understand the role and the root of OCD symptoms. Here, the goal is to reduce the unwanted symptoms by more fully understanding their source.
- Medication: For many, taking medication for OCD can help ease symptoms along with therapeutic treatment.
In My Experience
What is the best therapy for OCD?
Exposure And Response Prevention Therapy (ERP) – Do live video sessions with a therapist specialized in ERP, the gold standard treatment for OCD. Treatment from NOCD is covered by many insurance plans. Start With A Free 15 Minute Call
What to know when finding a therapist for OCD
With so much information out there regarding providers and treatment options for obsessive compulsive disorder, it can be hard to know exactly where to start—especially when you have to consider everything from the type of provider to the different treatment methods, as well as how you’ll fit it into your busy schedule.
Can OCD make it hard to make decisions?
From choosing what to wear in the morning to picking what to eat for dinner, decision-making is a part of everyone’s daily routine. But for millions of people with Obsessive-Compulsive Disorder (OCD), making any choice can feel like a daunting, sometimes impossible task.