Is Exposure and Response Prevention (ERP) a Good Treatment Option for OCD or Anxiety?
Key takeaways:
Exposure and response prevention (ERP) is a type of psychotherapy. It is used to treat OCD (obsessive compulsive disorder) and other anxiety disorders.
ERP has two components: facing what you’re afraid of (exposure), paired with resisting the urge to perform an action that lowers your anxiety (response prevention).
ERP is usually done in a gradual manner with the support of a trained therapist or psychologist.
Table of contents
To tackle something scary, you may have heard of the concept of “facing your fears.” Turns out, that concept can be an effective way to treat certain anxiety symptoms or conditions.
Exposure and response prevention (ERP) is one type of therapy that helps you confront (and reduce) your anxieties. So if you have OCD (obsessive compulsive disorder) or another type of anxiety disorder, this might be an effective therapy for you.
What is exposure and response prevention therapy (ERP)?
ERP is a type of psychotherapy that helps you respond more effectively to your fears. It has two parts: exposure and response prevention. You practice exposure by doing exercises to face your fears step by step, working your way up to bigger and bigger fears.
Response prevention targets your compulsions or safety behaviors like checking or avoidance. Contrary to what it can feel like, compulsions and safety behaviors actually increase your anxiety. So during each exposure, you resist the urge to perform any action or ritual in response to your anxiety.
ERP helps you learn over time that:
Your anxiety will naturally go away on its own faster if you resist compulsions or safety behaviors.
You can handle your fears, even though it can still be uncomfortable.
You don’t need to spend time and energy doing compulsions or safety behaviors to cope.
What types of conditions can ERP be used for?
ERP is an effective therapy for treating OCD. It’s considered the first-choice treatment for the condition. OCD is a mental health condition that involves obsessions and compulsions. ERP can help you reduce these OCD symptoms so they no longer cause as much distress or disruption in your life.
ERP can also be used to treat:
Phobias
PTSD (post-traumatic stress disorder)
Panic disorder
Social anxiety disorder
Generalized anxiety disorder
Why does exposure therapy work?
It may seem strange that doing something you fear on purpose could help with anxiety symptoms. But it does.
There are two main theories about why ERP works: habituation and inhibitory learning.
1. Habituation: Habituation means your anxiety about a fear becomes less over time, with less need to perform compulsions or other behaviors to lower your fear. By doing ERP exercises again and again, you may habituate and have lower anxiety about specific fears as well as lower anxiety overall.
2. Inhibitory learning: More recently, experts believe inhibitory learning is the key to why ERP works. This theory suggests ERP challenges your fears in the first place, allowing you to gather new evidence that shows you might not need to be as afraid as you originally thought.
What happens during ERP treatment?
In ERP, you first work with your therapist to create an exposure hierarchy. This is a list of situations that trigger your anxiety. You rank the situations from the least distressing to the most distressing.
For example, if you have contamination OCD fears, your hierarchy might look something like this:
| Exposure exercise | Distress level |
|---|---|
| Using someone else’s phone | 2 |
| Trying a bit of someone else’s food | 3 |
| Eating without washing your hands first | 4 |
| Shaking someone’s hand | 5 |
| Letting your dog come in from outside without washing off their paws | 6 |
| Going without a shower for 24 hours | 8 |
| Going 2 hours without washing your hands | 10 |
Next, you and your therapist identify exercises (exposures) to practice facing each fear on your hierarchy. You start with exposure exercises that you rank as moderately challenging, perhaps in the 3-to-5 range.
Each exposure exercise will have a set start and stop time, which is determined by your anxiety level. You want your anxiety level to decrease by half from where you started. During each exposure, you will also focus on response prevention. You will resist using compulsions such as checking, reassurance seeking, or avoidance.
Here’s what to expect during an exposure exercise:
At the start of a new exposure, you’ll rate your anxiety level, often on a scale from 1 to 10.
Once you begin the exposure, you may notice your anxiety start to rise. You may also have urges to use a compulsion to stop the anxiety. Resist these urges.
As you sit with your anxiety during the exposure, track your anxiety rating. Your therapist may periodically ask you to tell them your anxiety rating throughout the exposure.
Make note of when your anxiety peaks, when it’s at its highest, and what number you would rate your anxiety peak.
Once your anxiety starts to go back down — and it will! — continue the exposure until your anxiety has reduced by half from your peak. For example: If your highest anxiety rating was a 6, you would stop the exposure when your anxiety gets to a 3.
Keep track of your progress. Your therapist will likely have a log or notebook where you’ll record what exposures you have done along with your anxiety ratings for each.
You will repeat most exposures multiple times. When an exposure no longer causes higher anxiety, you move on to the next trigger in your hierarchy. Gradually, you work your way up the hierarchy to your most distressing triggers. You will do this as you feel ready and with lots of support from your ERP therapist.
How long does ERP therapy take to work?
How long ERP therapy takes can vary person to person. Some people notice their OCD symptoms get better after 12 to 16 sessions of ERP therapy. However, you may need more or less depending on your treatment goals.
The length of ERP treatment can depend on the type and severity of your symptoms. It also depends on how many fears you are working on. Someone working on just one fear or compulsion may not need as much treatment as someone working on a few.
Homework is also a part of ERP. After working in session on a particular exposure, your therapist may have you practice that same exposure at home. And completing homework can lead to better results.
You and your therapist will decide when treatment is complete. This is usually when you are able to face more distressing situations with less anxiety and fewer urges to engage in compulsions.
How to find an ERP therapist near you
If you think ERP might be helpful for you, you can search for therapists in your area who are trained in ERP. Check out directories like:
International OCD Foundation’s Find Help directory
Gaylesta (LGBTQIA+ therapists)
InnoPsych (therapists of color)
Open Path Psychotherapy Collective (low-cost therapy)
You can also do an internet search for local therapists’ websites. There, you can usually find information on the types of therapy they provide. If you have health insurance, you may be able to look for ERP therapists through your health plan’s provider directory. Lastly, don’t be afraid to ask friends, family, and other trusted healthcare providers for a recommendation.
The bottom line
ERP is an evidence-based treatment for OCD, anxiety disorders, and other mental health conditions. You face a feared situation (exposure) while resisting the urge to do compulsions (response prevention). It works because it helps change your relationship to your fears so they don’t cause as much distress. You also learn that you can tolerate anxiety, even if it’s uncomfortable. If you think ERP therapy could help you, use an online directory to locate an ERP therapist near you.
References
Abramowitz, J. (2018). The inhibitory learning approach to exposure and response prevention. International OCD Foundation.
American Psychological Association. (2022). Exposure and response prevention. APA Dictionary of Psychology.
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Benito, K. G., et al. (2015). Therapeutic process during exposure: Habituation model. Journal of Obsessive-Compulsive and Related Disorders.
Chellingsworth, M. (2014). Exposure and response prevention. University of Exeter.
Eating Disorder Hope. (2022). Exposure and response prevention (ERP) for eating disorders.
Ferrer-Garcia, M., et al. (2019). A randomized trial of virtual reality-based cue exposure second-level therapy and cognitive behavior second-level therapy for bulimia nervosa and binge-eating disorder: Outcome at six-month followup. Cyberpsychology, Behavior, and Social Networking.
Fründt, O., et al. (2017). Behavioral therapy for Tourette syndrome and chronic tic disorders. Neurology Clinical Practice.
Hezel, D. M., et al. (2019). Exposure and response prevention for obsessive-compulsive disorder: A review and new directions. Indian Journal of Psychiatry.
International OCD Foundation. (n.d.). How to use the resource directory.
Kaczkurkin, A. N. (2022). Cognitive-behavioral therapy for anxiety disorders: An update on the empirical evidence. Dialogues in Clinical Neuroscience.
Penzel, F. (2000). OCD and contamination. International OCD Foundation.
Pierce, S. (2018). OCD expert Elizabeth McIngvale, Ph.D., shares personal OCD journey, treatment options for patients. Texas Medical Center.
Therapist Aid. (2015). Exposure hierarchy.
Wheaton, M. G., et al. (2021). Homework completion in treating obsessive-compulsive disorder with exposure and ritual prevention: A review of the empirical literature. Cognitive Therapy and Research.
For additional resources or to connect with mental health services in your area, call SAMHSA’s National Helpline at 1-800-662-4357. For immediate assistance, call the National Suicide Prevention Lifeline at 988, or text HOME to 741-741 to reach the Crisis Text Line.
