Exposure and response prevention (ERP) is a type of psychotherapy most often used to treat Obsessive Compulsive Disorder (OCD). ERP is a specific form of Cognitive Behavioral Therapy that helps reduce OCD symptoms by repeatedly exposing people to anxiety triggers while teaching them to resist urges to engage in compulsive behaviors.
ERP treatment is typically completed in about twelve sessions, and is considered complete once the client has successfully faced their higher-level fears. Sessions often start at 60 to 90 minutes in length, and become shorter as time progresses.
Central Concepts of Exposure and Response Prevention
As its name suggests, ERP (also sometimes abbreviated as EX/RP) has two major components: exposure and response prevention. 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. Triggers for anxiety might include specific thoughts, images, memories (all called imaginal exposures) or could include actual feared objects or situations (called in-vivo exposures). 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.
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 Exposure therapy (without the response prevention component) is used to treat a range of anxiety disorders and also disorders where anxiety is a key symptom (like PTSD or OCD). It is believed that the success clients experience in exposure therapy has to do with a process called habituation.
In behavioral psychology, habituation describes the process of adapting to a stimulus after being repeatedly exposed to it. For example, background noise in your office might be a distraction when it first begins but if it were constant, you would likely become used to it and eventually would tune it out altogether. In exposure therapy, 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.
In the short term, exposures can result in increased levels of anxiety. Understandably, clients are often reluctant to begin exposure therapy because it involves facing feared situations that they have previously avoided. 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 exposures.
The second component of ERP is response prevention, and unlike exposure therapy, is more specific to the treatment of specific disorders. 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 Obsessive Compulsive Disorder (OCD).
People with OCD cope with their anxiety and obsessive thoughts by engaging in compulsive and repetitive actions. The compulsions could be behavioral in nature like checking locks or washing hands or could be cognitive, like counting or repeating words silently. 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.
While preventing someone from using a coping skill again might sound counterintuitive, the reality is that these compulsive behaviors are usually disruptive, and a primary reason that OCD is such a debilitating condition. Over time, compulsions tend to become more time-consuming and disruptive because existing behaviors become less effective at reducing anxiety. Response prevention can interrupt and even reverse this progression of symptoms.
What Can ERP Help With?
Exposure and response prevention is usually used to treat OCD. It is a frontline treatment for OCD because it is proven to be effective. 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. Some of the other disorders that have been effectively treated with ERP include:
Exposure therapy, without response prevention, is also used to treat other types of mental illness that feature symptoms of anxiety and avoidant behaviors. The disorders that Exposure therapy is effective in treating include:
- Specific Phobias
- Panic Disorder
- Generalized Anxiety Disorder
- Posttraumatic Stress Disorder
- Social Anxiety Disorder
Common ERP Techniques
Therapists who use exposure and response prevention use a variety of techniques and activities to help clients at different stages of treatment. Some of the techniques and activities used in ERP include:
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.
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.
ERP therapists ask clients to self-monitor, or track, 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.
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.
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.
Let’s imagine that a client with OCD is seeking ERP treatment because of fears they have about 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:
|Fear Rating (1-10)||Exposure Task|
|2||Shaking a person’s hand without using hand sanitizer|
|3||Going 2 hours without washing hands|
|3||Skipping daily vitamin|
|5||Touching a doorknob without using sleeve or a tissue|
|6||Allowing a person to wear shoes inside the house|
|8||Going to bed without disinfecting door knobs and surfaces in the home|
|10||Going to a doctor’s office and sitting in the waiting room without a face mask|
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 symptomology. 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.6
How to Find an ERP Therapist
Most people begin their search for an ERP therapist online. Using an online 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 or OCD and who is in-network with a certain insurance carrier. In many instances, ERP therapy is covered under insurance plans, which can make it more affordable.
Another way to find in-network therapists is to go directly through your insurance provider. Calling the number on the back of your insurance card or going online to use the insurance carrier’s online search tools will usually provide you with a list of providers who accept your insurance. Finding someone who is trained in ERP could be a little more challenging, though.
You may need to call 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.
What to Expect at Your First Appointment
Your first appointment 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 counselor, therapist, social worker, or psychologist. 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.
Is ERP Effective?
ERP is recognized as an Evidence-Based Treatment for OCD by the American Psychiatric Association and the American Psychological Association.6 A 2004 meta-analysis of the available research on the efficacy of ERP found that about two thirds of patients with OCD who receive the treatment experience 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 is effective in reducing OCD symptoms, ERP has outperformed standard CBT treatment in studies.1 In addition to reducing OCD symptoms, patients 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.8
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 co-morbid depression, poor insight, and more severe OCD symptoms.8 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
ERP has also been used to treat other mental disorders and some research exists to suggest it could be effective in treating other issues. The data supporting ERP’s use with other disorders is much more limited in scope compared to the data that exists on the treatment of OCD. Of the available data, initial research suggests that ERP could be effective in treating Tourette’s syndrome, body dysmorphia, hypochondriasis, and eating disorders like anorexia and bulimia. More research is needed to validate the effectiveness of ERP in treating these disorders.
How Is ERP Different from Standard CBT?
ERP is considered to be a form of CBT but is also viewed as a separate treatment. 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 symptoms of a variety of mental disorders like depression, trauma, anxiety or addiction.
ERP is focused on reducing specific fears and fear-based behaviors like those associated with OCD (e.g. checking, washing, counting, or avoiding). The techniques and methods used in ERP treatment are also more specific than in standard CBT treatment. 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.
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.