ERP for OCD: How It Works, Examples & Effectiveness

How Does ERP Treat OCD?

Exposure and response prevention (ERP) was created specifically to treat OCD. It works by having individuals expose themselves to thoughts, images, objects, or situations that trigger their obsessive thoughts and prevent them from performing their compulsive rituals. By engaging in ERP for OCD, an individual learns to tolerate the discomfort of their intrusive thoughts without using compulsions to comfort themselves, thereby breaking the OCD cycle.¹

People may mistakenly believe if something creates fear or anxiety, staying away from it will help. In reality, using avoidance coping may actually reinforce the endless cycle of OCD. Each time a person avoids the triggering thoughts, images, objects, or situations, 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.

When someone repeatedly exposes themselves to what they fear, 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.

What to Expect During ERP for OCD Treatment

ERP for OCD begins with educating the client about the cycle of OCD and how avoidance worsens it. The therapist and client then work together to create an exposure hierarchy. The client will then start engaging in gradual exposures in sessions with the therapist. The therapist will act as a source of support and also provide coping skills for OCD that can help with the distress.

In addition to in-session exposures, the therapist may also assign homework for the client to complete between sessions. Over time, the therapist and client will work up the client’s exposure hierarchy until their OCD symptoms feel more manageable or reduced.

Here are six things to expect during the ERP for OCD treatment process:

1. 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 processes, 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 for OCD and discuss potential treatment outcomes.

2. Creating an Exposure Hierarchy

When completing ERP for OCD, the person creates a hierarchy of triggers. These triggers (which will become exposures) are 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.

3. Tolerating Uncertainty

OCD obsession inherently feeds off of uncertainty (i.e., “What if I end up hurting a loved one?” or “What if I catch a virus from touching the doorknob). Therefore, learning to tolerate uncertainty is an essential part of OCD treatment, and it can be one of the most challenging tasks.

By presenting the client with their feared or uncomfortable thought, item, or situation, ERP for OCD heightens feelings of uncertainty. The therapist then prevents the client from engaging in compulsions, removing their normal coping response. While this is incredibly uncomfortable at first, the anxiety eventually subsides and may create a habituation effect.

4. Response Prevention

Response prevention refers to deliberately preventing the client from engaging in a preferred compulsive behavior after experiencing an obsessive thought or exposure to a feared stimulus. Therapists will guide clients through exposure to start, but they will also be expected to practice exposure on their own. 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 lives.

5. Delaying Rituals

As part of ERP for OCD, 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.

6. 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.

How Effective Is ERP for OCD?

ERP is established as the gold standard treatment for OCD.² About 50–60% of individuals who complete ERP treatment experience clinically significant improvement in their OCD symptoms.^{3, 4} Additionally, ERP has been shown to be a significantly more effective treatment than medication alone, and the improvements that individuals experience are more long-term.^{5, 6} ERP can also treat individuals who do not respond well to SSRI medications.⁷

How Long Does it Take for OCD Exposure Therapy to Work?

ERP for OCD 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.⁸ Of course, it could take many months for others to decrease and maintain symptom relief. No matter the timeline, people should try their best to remain patient and stay consistent with treatment.

Examples of ERP for OCD

Every individual’s ERP for OCD 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 a public restroom, go home, and resist changing clothes (i.e., sit on the couch): 100
• Try makeup at a beauty store and give your daughter a hug when you get home (1 minute hug): 90
• Throw away an item in a public trash can and brush your hand against the side: 80
• Pet a dog and eat a snack: 65
• Do family’s laundry without rituals (i.e., 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 provides 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, whom 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 a steak knife on the nightstand when loved ones are home: 100
• Use a steak knife at the restaurant during family dinner: 95
• Drive next to the bike lane with the music on: 85
• Put a pocket knife in your jacket and walk around the mall: 80
• Use full-size scissors to cut paper snowflakes for 15 minutes: 55
• Drive on the highway in the evening without music: 50
• Drive on the highway in the daytime without music: 40
• Write a script about your worst fears and read five times a day: 30

Through their ERP for OCD 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 and 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 harm OCD wants her to isolate, investigate, and self-punish. Instead, she embraces her ERP for OCD plan and lives life on her terms.

How to Find an ERP Therapist for OCD

If you feel you may be struggling with OCD, don’t hesitate to ask for help. When looking for an ERP therapist, it is important to find someone who specializes in OCD. There are many online OCD resources, such as NOCD,  that provide targeted ERP for OCD care.

Is ERP the Only OCD Treatment Option?

Exposure and response prevention is considered the frontline treatment for OCD, but there are other treatments that have been proven to be effective. Every person is unique, and finding the right treatment can take time and patience. It is important not to give up; there is a treatment out there that will reduce your OCD symptoms.

Other effective treatment options for OCD include:⁹

• 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 behavioral therapy (CBT): CBT for OCD may broadly include interventions designed to challenge irrational thoughts and replace unwanted OCD responses with more proactive, desired responses. CBT can include techniques like cognitive restructuring, mindfulness, and changing thought records.
• Medication: For many, taking medication for OCD can help ease symptoms along with therapeutic treatment.
• Talk therapy: 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.