Exposure and Response Prevention Therapy: What It Is & How It Works

What Is ERP Therapy?

Exposure and response prevention therapy (ERP), also sometimes abbreviated as EX/RP, has two major components—exposure therapy and response prevention. The exposure process is gradual and progressive, starting with less anxiety-provoking exposures and gradually moving up towards exposures that trigger higher levels of anxiety. The second component of ERP is response prevention, and unlike general exposure therapy, is more specific to the treatment of specific disorders, most commonly OCD.

How Does Exposure and Response Prevention Work?

Exposure and response prevention works by combining exposure to an anxiety-causing stimulus with a prevention of someone’s automatic, compulsory response. Over time, pairing these techniques leads to habituation, or the simple concept that the more someone encounters something, the less anxiety-provoking it will become.

Exposure Therapy

The exposure component of treatment involves a process in which a therapist guides a person through imagined or real situations where they are exposed to anxiety triggers. While it might seem counterintuitive to intentionally expose people to situations that cause anxiety, exposure therapy is widely recognized as one of the most effective treatments for anxiety.¹ Clients do not immediately begin exposures when starting treatment. They are provided with information about the rationale behind the treatment and what it will entail, and then will work with the therapist to develop a plan to gradually begin exposure, and work through a hierarchy from least disturbing to most disturbing.

Response Prevention

Response prevention is a part of ERP treatment that helps people resist strong urges to engage in a certain behavior during times when they are anxious. Most frequently, response prevention is paired with exposure therapy to treat OCD. People with OCD cope with their anxiety and obsessive thoughts by engaging in compulsive and repetitive actions. Compulsions provide temporary relief from obsessive thoughts or anxiety, but typically worsen symptoms long-term. Response prevention aims to interrupt this sequenced reaction by encouraging people to avoid engaging in the compulsive behaviors during times when they are anxious or have obsessive thoughts or urges.

Habituation

It is believed that the success clients experience in ERP has to do with a process called habituation. Habituation describes the phenomenon of becoming less anxious about something the more you encounter it. For example, people who are afraid of public speaking would likely become less anxious about it if they had to do it on a weekly basis.

ERP Vs. CBT

ERP is considered to be a form of cognitive behavioral therapy (CBT), but is also viewed as its own separate treatment format. Standard CBT treatment focuses on changing unhelpful thought and behavior patterns in order to reduce symptoms and improve functioning. Standard CBT could focus on a wide range of problems, including negative or self-critical thoughts or behaviors like procrastinating or lashing out. It is used to treat a variety of mental disorders like depression, trauma, anxiety, and addiction.

ERP is focused on reducing specific fears and fear-based behaviors like those associated with OCD (e.g. checking, washing, counting, or avoiding). ERP primarily uses exposure techniques which focus on helping a person tolerate specific thoughts, feelings, and situations, while standard CBT might focus on helping a person modify or change them. The emphasis on response prevention is also unique to ERP and not a widely used technique in standard CBT treatment.

ERP Vs. Traditional Talk Therapy

While traditional talk therapy aims to help a client gain insight into their thoughts, feelings, behaviors, and experiences, ERP is a more structured protocol that is specifically used to treat OCD. It first helps you to confront the things that induce anxiety by exposing you to the thoughts, images, or situations that provoke your obsessions. Then, the therapist will work with you in the response prevention portion of the therapeutic process in which you choose not to engage in compulsions when triggered. While talk therapy might be a beneficial supplemental treatment down the line, when first diagnosed with OCD, ERP is the gold-standard of therapeutic interventions.²

What Can ERP Help With?

Exposure and response prevention is usually used to treat OCD. Until its development, OCD was largely considered an untreatable disorder, and ERP has offered hope to the millions of people diagnosed with this condition. Other forms of therapy have been used effectively with OCD, but ERP continues to have the strongest evidence.

In recent years, research has been conducted on other applications of ERP. The results of these studies have been promising, suggesting that ERP could be effective in treating other types of disorders, including:^3,4,5,6

• Hypochondriasis
• Tourette’s Syndrome
• Body Dysmorphic Disorder
• Anorexia Nervosa
• Bulimia Nervosa

Why Is ERP the Most Effective Treatment for OCD?

ERP for OCD is very effective as it helps people learn about why they have the obsessions they do and how that impacts their behaviors. It offers psychoeducation in addition to concrete tools to help people reframe in the moment to stop acting on OCD compulsions.

Common ERP Techniques

Therapists who use exposure and response prevention utilize a variety of techniques and activities to help clients at different stages of treatment, including teaching a client about their diagnosis, creating a fear hierarchy, and practicing exposures.

Some of the techniques and activities used in ERP include:

Psychoeducation

Psychoeducation involves providing detailed information to a client about their diagnosis and symptoms. This information can help people understand and monitor their symptoms and can also reduce shame and stigma about symptoms. Psychoeducation also includes information about ERP treatment, including information about the efficacy of this treatment and helping clients know what to expect as treatment progresses.

Creating a Fear Hierarchy

Early in ERP treatment, therapists work with clients to develop a fear hierarchy. A fear hierarchy is a list of anxiety triggers that begins with triggers that cause low levels of anxiety and moves up to the most anxiety-provoking triggers. These triggers could include specific thoughts, situations, objects, or behaviors that induce anxiety.

Practicing Exposures

Eventually, ERP therapists will guide clients through an exposure, where they are asked to intentionally confront one of the lower-level triggers on their fear hierarchy. This exposure could include exposing themselves to an object or situation or even just thinking about these fears. Over time, the exposures become longer or move to higher-level fears.

Tolerating Uncertainty

ERP helps with tolerating uncertainty through mindfully responding instead of reacting to the stimulus. It takes intention to reframe the reaction to a stimulus, so practicing tolerating this feeling is a big part of stopping a compulsive behavior in reaction to an anxiety trigger.

Response Prevention

The response prevention aspect of treatment is essentially asking a client to practice impulse control. Impulse control means learning to experience or tolerate a strong urge without acting on it. An ERP therapist would guide the client through this process, helping them become able to tolerate strong urges to engage in compulsive behaviors while encouraging them to not act on these urges.

Delaying Rituals or Doing Them Differently

The purpose of ERP is to delay the compulsive reaction, or find a way to do it differently. Given that OCD often feels like a dictator, it can be hard to resist the urge and compulsion. However, ERP helps people remember that they do not need to react, and that they are in control and can choose to respond. When this happens, it can change the timing and the way the ritual is completed. Even changing someone’s ritualistic patterns can help them realize, with time, that they don’t need to react compulsively at all to their triggers.

Self-Monitoring

ERP therapists ask clients to self-monitor their symptoms between sessions. Clients may be asked to keep track of emotions, thoughts, or behaviors using worksheets or logs, as well as keeping track of triggers. For instance, a person with OCD might be asked to track obsessive thoughts they have and then the compulsive routines or behaviors they engage in.

How Long Does ERP Therapy Take?

Depending on the specific symptoms treated and individual differences of the client, ERP can begin showing positive effects almost immediately. After the first session, the person could experience a reduction of symptoms. Studies show that people using ERP can show dramatic reduction of the severity of their symptoms in four weeks of treatment.² Much of this progress will continue over time, but some may require additional sessions in the future to maintain progress.

How to Find an ERP Therapist

Most people begin their search for an ERP therapist online. Using an online therapist directory, you can narrow down your search using built-in filters. These filters can be applied to help find a therapist who is close to a certain location, who specializes in ERP and who is in-network with a certain insurance carrier. In many instances, ERP therapy is covered under mental health insurance plans, which can make it more affordable.

You may need to talk with several providers to ask if they are trained in this type of treatment and, if not, ask for any recommendations of other providers who are. Most therapists are happy to provide assistance with these kinds of specialized referrals.

If you have (or suspect you have) OCD, you could consider using a resource like IOCDF, which offers assistance in connecting you to their network of providers who have been trained in ERP. For those with scheduling restrictions or who prefer online therapy, there may be options for online therapy sessions. You could also use another online OCD resource, like NOCD, to receive treatment from home.

What to Look For in an ERP Therapist

The ideal ERP therapist will share many traits with any other effective mental health clinician. A good ERP therapist will:

• Be an expert in the practice of ERP with plenty of education and experience with the treatment
• Accurately assess and evaluation the symptoms, where they stem from, and the purpose they serve
• View the client as a whole person without only focusing on the symptoms
• Treat each person as an individual and offer tailored treatments
• Discussed the pros and cons of using medication combined with ERP
• Ensure that other mental health professionals are consulted to address co-occuring issues

Therapists may claim they are proficient in ERP, so it’s a good idea to ask more specifically about their track record with the practice before starting therapy with a new therapist.

What to Expect at Your First Appointment

Your first therapy session will more than likely not include any exposure or response prevention activities. Typically, the first appointment is reserved for the completion of intake paperwork and of a clinical assessment. A clinical assessment is typically conducted in an individual session with a licensed therapist. You will be asked questions about your background, your current symptoms, and your current life and routine.

At the end of the assessment, you may receive a diagnosis, which will be discussed with you. You will also be given information about options for treatment, which could include ERP therapy. While the clinician will likely recommend treatment based on their assessment, you should also speak up about your preferences and also to ask any questions you have. If you return for additional sessions, these will likely be more focused on ERP therapy targeted at reducing your symptoms.

What to Expect During the ERP Process

After your intake session, you can expect to create a fear hierarchy with your therapist and then start to undergo exposures. While this process can be uncomfortable, your therapist should be highly trained and able to keep you from experiencing too much distress.

Here are some things you can expect during the ERP process:

• You’ll feel an initial increase in anxiety when exposed to stressors: This can be challenging, but don’t give up. Your therapist will support you in facing your triggers.
• Your therapist will help make sure your anxiety levels are safe and manageable: Through exposure you’ll soon realize that, though distressing, these feelings are not a threat. You’ll gain confidence that you are safe and your feelings of anxiety are manageable.
• Over time, you’ll feel your anxiety lessen when exposed (habituation): As you stop resisting the obsessions and resulting anxiety, the less anxious you will feel when exposed to your triggers.
• Hopefully, you’ll see that your triggers hold less power over you: As you gain mastery over your response to anxiety-inducing triggers, you find yourself more in control of your life.
• You’ll be better able to manage anxiety triggers in your everyday life: After receiving ERP treatment, when triggers occur in your daily life, you’ll find yourself able to use the techniques learned in therapy to cope with anxiety in a healthy way, and choose your response when faced with challenging thoughts or situations.

How Often Are ERP Appointments?

ERP can be completed in 10-20 therapy appointments that are 60-90 minutes or more in length. That being said, treatment can be a longer-term commitment, with appointments two to three times per week, depending upon provider availability, OCD severity, and other factors.⁷ Talk with your therapist about the frequency and duration of appointments that are recommended for your unique situation.

Can Virtual ERP Be Effective?

Virtual ERP can be effective for people who cannot find an in-person therapist in their area or who takes their insurance. It can work well for people who have a private space for sessions and who are motivated to find relief. Virtual therapy isn’t for everyone, so if in-person ERP is working for you, it doesn’t mean that it will continue to work the same way with virtual therapy. It is important to know if virtual therapy in general works for you before considering ERP virtually.

Can I Do ERP On My Own?

It is possible to try ERP on your own, however it can be challenging as people often need someone to help facilitate next steps. It is important to work with a therapist, at least in the beginning, and come up with homework to continue to do work on your own with supervision.

Is ERP Effective?

ERP is recognized as an evidence-based treatment for OCD by the American Psychiatric Association and the American Psychological Association.⁸ A 2004 meta-analysis of the available research on the efficacy of ERP found that about two thirds of people with OCD who received the treatment experienced an improvement in their symptoms. That study and another published in the Journal of Clinical Psychiatry also indicate that, of those who receive treatment, one-third to one-half will experience a complete remission of their OCD symptoms.

While studies have found that general CBT treatment for OCD is effective for reducing symptoms, ERP has outperformed standard CBT treatment.¹ In addition to reducing OCD symptoms, people receiving ERP have also reported improved sleep patterns and an overall improvement in their quality of life.

Exposure and response prevention is effective in treating people with OCD, regardless of their age. Studies have also found that ERP is effective in different settings and treatment intensities. People who received treatment at home versus in office settings showed similar improvements in OCD symptoms, as did those who were treated once a week versus several times per week. While some people with OCD will be prescribed medication in addition to receiving therapy, the research suggests that outcomes are similar among both medicated and non-medicated individuals receiving ERP treatment.²

When Is ERP Less Effective?

Among those who do not experience relief or remission of OCD symptoms from ERP treatment, there are some factors that appear to contribute. Factors that may contribute to poorer responses to treatment include comorbid depression with OCD, poor insight, and more severe OCD symptoms.² In addition, ERP has high rates of patient drop-out compared to other treatments, meaning many people will not complete treatment. The rate of drop-out in ERP treatment is estimated to be 18.7%.⁹

Common ERP Therapy Misconceptions

While ERP is an effective, evidence-based therapeutic approach for treating OCD, there are a few common misconceptions about the intervention that are important to dispel. 

• Myth: ERP is designed to hurt the client. Fact: While ERP is uncomfortable and even distressing at times, clients are supported while facing their fears, starting with less triggering fears in order to build confidence and create safety in the therapeutic relationship.
• Myth: ERP is just facing your fears and you can do it on your own. Fact: ERP is guided by a trained, licensed therapist who can help you create a hierarchy of fears to tackle from least to most intense, while offering valuable coping strategies and response skills along the way that you can then apply to your real-life situations outside of the therapy office.
• Myth: Flooding and ERP are the same. Fact: ERP works with clients on facing their fears gradually over time, with plenty of scaffolding of skills and coping strategies along the way. Flooding involves an intense, immersive exposure to a client’s greatest fear with less support.

Exposure and Response Prevention Examples

Let’s imagine that a client with OCD is seeking ERP treatment because of their fear of germs or contamination. The client has likely developed intense rituals and routines that center around washing their hands, sanitizing and disinfecting their environment, and possibly avoiding certain places, things or interactions that may be germ-infested. It is likely that they are experiencing a lot of anxiety about contamination, and also that they are finding that their compulsions have started to disrupt their normal life or routine.

An ERP therapist would work to first understand the client’s specific fears and obsessions and the compulsions they use to manage these and would assess the severity of their symptoms. They would then provide the client with information about OCD, explaining that the symptoms and behaviors they describe are experienced by many other people with the disorder. They would help the client understand that while the compulsive washing, disinfecting, and avoidant behaviors have provided temporary relief from their anxiety, they have likely made their OCD symptoms worse in the long run.

The therapist would explain that the most effective treatment for OCD is ERP and provide some information about the treatment. They would explain that while it seems scary, people that go through ERP usually experience a significant reduction in their symptoms, and sometimes even a resolution of their symptoms. The therapist can only move forward with ERP treatment if the client understands and agrees to the treatment.

If the client agrees to begin ERP, they would work with the therapist to develop a fear hierarchy which outlines triggers that cause low, moderate, or high levels of anxiety. Sometimes, a client would be asked to use a scale to rate the level of anxiety each trigger would cause. These numbers then help to rank the fears from low to high.

For a client with contamination fears, their hierarchy might look like this:

Exposures would begin shortly after the hierarchy is developed, beginning with lower-ranked fears. Sometimes these exposure tasks would be completed in session with the therapist coaching and guiding the client, and other times exposures could be assigned as homework between sessions. Typically, each exposure is done more than one time, and sometimes made more difficult. For instance, a person might first go 2 hours without washing their hands and then may be asked to go 3 or 4 hours the next time.

Each time, the client is being asked to expose themselves to the feared object or situation and to not engage in any compulsive behaviors. For instance, notice in the list above that many of the tasks specify not only that a person touch a surface but also to do so without washing their hands or using hand sanitizer afterwards. This response prevention component is an essential part of the treatment.

ERP therapists who are treating clients with OCD are careful to not provide too much reassurance to clients during exposure tasks. While this can seem harsh, there is a specific reason why reassurance is not provided. Getting reassurance (online, from an authority figure, or even a friend) is a common compulsion that people with OCD use to temporarily relieve their anxiety and can become a part of their symptoms. Reassurance, like other compulsions, tends to reinforce the fears driving them and also become less effective over time, leading to the need for more reassurance.

The therapist will monitor the effectiveness of treatment by checking in about the client’s success with exposure tasks, their ability to refrain from compulsive behaviors, and by any changes in the levels of anxiety they report. Exposures are often repeated until the client reports a decrease in their levels of anxiety when confronted with the trigger. Typically, this will happen in the course of a few minutes of beginning the exposure task.

Treatment is considered complete when the client has successfully faced the higher level fears on their fear hierarchy, when they are able to refrain from compulsive behaviors, and when their anxiety is decreased. ERP treatment is usually completed in about 12 sessions. Early sessions are often 60 or even 90 minutes in length, and tend to become shorter as progress is made.⁸

History of ERP

Exposure and response prevention is sometimes credited to the work of Stanley Rachman in the 1970’s, but he cites its origins earlier in 1966, and credits the work of Victor Meyer.¹⁰ Victor Meyer was a psychologist working in the UK who documented trials of certain exposure and ritual prevention techniques with two OCD clients who were hospitalized. These techniques were essentially what is now called exposure and response prevention therapy.¹¹

Over the next two decades, these techniques were continuously tested and refined. The work of Stanley Rachman helped to formalize the treatment into what is now known as ERP. ERP is founded on core tenets of cognitive behavior therapy and continues to be considered a subtype of this treatment.