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  • DefinitionDefinition
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Exposure Therapy for OCD: How It Works, Examples & Effectiveness

Headshot of Melissa Boudin, PsyD

Written by: Melissa Boudin, PsyD

Rajy Abulhosn, MD

Reviewed by: Rajy Abulhosn, MD

Published: February 22, 2023
Headshot of Melissa Boudin, PsyD
Written by:

Melissa Boudin

PsyD
Headshot of Rajy Abulhosn, MD
Reviewed by:

Rajy Abulhosn

MD

Exposure therapy, more specifically exposure with response prevention (ERP), is a subset of cognitive behavioral therapy (CBT) and the gold standard treatment for obsessive compulsive disorder (OCD). Treatment involves facing feared items (obsessional stimuli) 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

Choosing Therapy partners with leading mental health companies and is compensated for marketing by NOCD.

Learn More

What Is Exposure Therapy?

Exposure therapy involves purposefully exposing oneself to a feared object or situation. Exposure therapy for OCD is half of a larger treatment modality called exposure and response prevention. The goal of exposure with response prevention (ERP) is to face your fears (the exposure) while resisting compulsive behavior (response prevention). 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.

Why Exposure Works for OCD

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 with response prevention allows people to lead a value driven life on their terms, not by the rules their OCD creates.

Eda Gorbis, PhD, LMFT“It’s shown empirical improvement for thousands of patients,” says Eda Gorbis, PhD, LMFT, “ameliorating 75% of symptoms in 75% of the cases.”

The International OCD Foundation (IOCDF), an organization dedicated to helping those affected by OCD, states that ERP and/or 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 Can Exposure Therapy Help With OCD?

Exposure treats OCD by interrupting the OCD cycle. Obsessions (thoughts that elicits anxiety and distress) are reinforced by compulsions (acts that provide temporary relief from the distress). By engaging in ERP, we stop reinforcement by learning to tolerate discomfort with high willingness. In short, exposure techniques create learning experiences where obsessional stimuli can be confronted without using rituals (response prevention).5

When completing ERP therapy for OCD, the person will create a hierarchy. These triggers (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 is a natural decrease in anxiety without engaging in anxiety-reducing behavior (compulsions). When an individual 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.

The habituation model explains that “exposure is effective because it provides structured contact with a feared stimulus while minimizing opportunity for avoidance, escape, or ritualizing.”6 By taking away ritualization, an individual begins to trust their ability to cope with distress, anxiety, and uncertainty.

Inhibitory Learning Model

A more recent, experimental model of ERP, the inhibitory learning model, acknowledges that habituation may not be so straightforward. It states that “ERP needs to help people learn safety in such a way that it is strong enough to block out (or inhibit) the original fear.”7 By engaging in ERP, one learns that it is “safe” to experience uncomfortable emotions, even when OCD is triggering fear.

How Avoidance Reinforces Fear

People may mistakenly believe if something creates fear or anxiety, staying away from it will help. In reality, using avoidance 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.

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.

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

Choosing Therapy partners with leading mental health companies and is compensated for marketing by NOCD.

Learn More

How to Find a Therapist for Exposure Therapy

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.

Gorbis says, the “International OCD Foundation, ADAA and word of mouth helps with finding credible therapists. Compile a list of 2-4 therapists that might be a good match for you. When calling them, screen each one before deciding which therapist is the best fit. Ask them whether or not they specialize in OCD and related anxiety disorders, what their method of treatment is and whether or not it’s individually tailored to specific case needs. Are they doing ExRP or talk therapy alone?”

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?

Additional questions, Gorbis adds, include, “How many patients a year do they treat? How well do they know ExRP? What percentage of success do they have? Where were they trained? Whether or not they use assessment tools in the treatment? Whether or not they use pure ExRP or a mixed bag of tools?”

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 Exposure Therapy for OCD

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 and their corresponding exposure outcomes:

1. Margot: 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 4 or more hours of rituals that her OCD demands.

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 from 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. Indigo: 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.

Here is part of Indigo’s exposure hierarchy:

  • Sleep with steak knife on nightstand (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. Tallulah: 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 their 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 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.

Alternatives to Exposure Therapy for OCD

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.

Final Thoughts on Exposure Therapy for OCD

OCD can be debilitating and overwhelming. If you or someone you love is struggling with OCD, know you are not alone. Reaching out to a trusted friend or OCD specialist can be a scary, but powerful, first step.

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

Choosing Therapy partners with leading mental health companies and is compensated for marketing by NOCD.

Learn More

For Further Reading

  • Best Online OCD Resources
  • Books about OCD
  • Mental Health America
  • National Alliance on Mental Health
  • MentalHealth.gov

Stories You Might Like 


Why OCD Thoughts Feel Real

Every day, from the time I wake up to the time I go to bed, I’m overwhelmed by disturbing thoughts that I don’t want to have. They’re usually about things that matter a lot to me, and I’ve started doing specific things (sometimes over and over) just to make sure the thoughts won’t come true. I’ve also been avoiding situations that might bring the thoughts back. Why do I feel like this all the time? If you’re asking yourself this, you’re not alone. Read More

What is Exposure & Response Prevention Therapy?

ERP therapy alters OCD’s pattern by addressing both obsessions and compulsions. In ERP, an individual is encouraged to confront the stimuli that trigger distress related to their obsessions while also resisting the urge to perform compulsions in an attempt to reduce their distress. Read More

Here is What A Typical Journey Through ERP Therapy Looks Like

If you’ve looked into help for obsessive-compulsive disorder (OCD), you’ve probably seen references to exposure and response prevention. ERP is the gold standard for OCD treatment. ERP therapy teaches you how to manage your OCD thoughts, images, and urges so they eventually stop bothering you as much. This lets you overcome your fear responses and regain the control that OCD tries to take away. Read More

This content is sponsored By NOCD.

Exposure Therapy for OCD Infographics

What IS Exposure Therapy How Can Exposure Therapy Help with OCD? How Long Does OCD Exposure Therapy Take to Work?

Sources Update History

Choosing Therapy strives to provide our readers with mental health content that is accurate and actionable. We have high standards for what can be cited within our articles. Acceptable sources include government agencies, universities and colleges, scholarly journals, industry and professional associations, and other high-integrity sources of mental health journalism. Learn more by reviewing our full editorial policy.

  • Law, C., & Boisseau, C. L. (2019). Exposure and Response Prevention in the Treatment of Obsessive-Compulsive Disorder: Current Perspectives. Psychology research and behavior management, 12, 1167–1174. https://doi.org/10.2147/PRBM.S211117

  • Melchior, K., Franken, I., Deen, M. et al. Metacognitive therapy versus exposure and response prevention for obsessive-compulsive disorder: study protocol for a randomized controlled trial. Trials 20, 277 (2019). https://doi.org/10.1186/s13063-019-3381-9

  • How is OCD Treated? (2019, August 05). Retrieved December 1, 2021, from https://iocdf.org/about-ocd/ocd-treatment/

  • The National Institute of Mental Health. (2019, October). Obsessive-compulsive disorder. National Institute of Mental Health. Retrieved December 6, 2021, from https://www.nimh.nih.gov/health/topics/obsessive-compulsive-disorder-ocd

  • Abramowitz, J. S., & Jacoby, R. J. (2015). Obsessive-compulsive disorder in adults. Hogrefe Publishing.

  • Benito, K. G., & Walther, M. (2015). Therapeutic Process During Exposure: Habituation Model. Journal of obsessive-compulsive and related disorders, 6, 147–157. https://doi.org/10.1016/j.jocrd.2015.01.006

  • Abramowitz, J. (n.d.). The inhibitory learning approach to exposure and response prevention. International OCD Foundation. Retrieved December 6, 2021, from https://iocdf.org/expert-opinions/the-inhibitory-learning-approach-to-exposure-and-response-prevention/

  •  How to find the right therapist. International OCD Foundation. (n.d.). Retrieved December 2, 2021, from https://iocdf.org/ocd-finding-help/how-to-find-the-right-therapist/

  • Society of Clinical Psychology. (2016). Exposure Therapies for Specific Phobias. Retrieved from https://div12.org/treatment/exposure-therapies-for-specific-phobias/

  • Anxiety and Depression Association of America. (2022, October 28). Treatments for OCD. Retrieved from https://adaa.org/understanding-anxiety/obsessive-compulsive-disorder-ocd/treatments-for-ocd

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We regularly update the articles on ChoosingTherapy.com to ensure we continue to reflect scientific consensus on the topics we cover, to incorporate new research into our articles, and to better answer our audience’s questions. When our content undergoes a significant revision, we summarize the changes that were made and the date on which they occurred. We also record the authors and medical reviewers who contributed to previous versions of the article. Read more about our editorial policies here.

February 22, 2023
Author: Melissa Boudin, PsyD
Reviewer: No Change
Primary Changes: Updated for readability and clarity. Reviewed and added relevant resources. Added “How Avoidance Reinforces Fear”, “How Long Does OCD Exposure Therapy Take to Work?”, and “Alternatives to Exposure Therapy for OCD”. New material written by Eric Patterson, LPC and reviewed by Dena Westphalen, PharmD.
December 28, 2021
Author: Madeline Moersch, LCSW
Reviewer: Rajy Abulhosn, MD
Show more

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