Exposure therapy, otherwise known as 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 Exposure Therapy?
The goal of Exposure with Response Prevention (ERP) is to face your fears (the exposure) while resisting compulsive behavior (response prevention). Over time, one learns that they can choose to respond differently in the face of fear and anxiety. The patient can choose to live by their values rather than living to avoid discomfort.
When a patient 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.
Is Exposure Therapy Effective 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 individuals to lead a value driven life on their terms, not by the rules their OCD creates.
“Its showed empirical improvement for thousands of patients,” says Eda Gorbis, PhD, LMFT, ” ameliorating 75% of symptoms in 75% of the cases.”
Organizations that support mental health also stand by ERP. For example, 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?
It is important for those engaging in ERP (or loved ones supporting someone in treatment) to understand the mechanisms of the therapy. A lack of understanding can lead to barriers in learning and symptom reduction.
The OCD cycle is at the crux of ERP. 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, an individual 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
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.
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: 58 y/o With 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. Stan: 30 y/o With Harm OCD
Stan 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 Stan with OCD and they begin working toward recovery.
Here is part of Stan’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, Stan realizes that much of their treatment is resisting engaging in self-punishment. Stan’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 Stan’s treatment success.
3. Tallulah: 26 y/o With 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, 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.
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 its individually tailored to specific case needs. Are they doing ExRP or talk therapy alone?”
Here are questions guided by the International OCD Foundation: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.
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.
