Obsessive-compulsive disorder (OCD) is a highly treatable mental health condition characterized by a cycle of obsessions and compulsions. Obsessions are intrusive thoughts, urges, feelings, sensations, or images that cause distress, while compulsions are physical or mental actions performed to relieve the distress from obsessions and/or prevent a feared thing from happening.
If you’ve looked into help for OCD, you may have seen references to exposure and response prevention (ERP) therapy. ERP is an evidence-based treatment that’s been scientifically proven to be the most effective therapy for managing OCD symptoms. According to research, 80% of people with OCD who do ERP can see a significant reduction in their symptoms.
ERP is a specialized therapy that teaches you how to manage triggers so they don’t bother you as much, and to stop relying on compulsions for relief. This lets you overcome your fear and regain the control that OCD tries to take away.
The International OCD Foundation compares the ERP process to rewiring a home alarm system. Alarms exist to alert you to danger, but what if a home’s alarm was so sensitive that it went off every time something touched the house—a raindrop, a tree branch, or even a stiff wind? There would be no way of telling whether a real danger was present, and you wouldn’t be able to get a moment’s peace. OCD hijacks the body’s alert system in a similar way. It registers intense danger even when the threat is very small. Your mind fixates on the perceived threat, and your anxiety levels rise. To get rid of anxiety, you feel like you have to perform a particular action to feel better. Sometimes, the distress and resulting compulsions get so bad that you start avoiding situations that set off your body’s alarms.
ERP therapy exercises help you break the cycle of OCD and rewire your body’s alarm system. You learn to challenge your OCD when it tells you something is a catastrophe. You move through the fear, learn to rely on healthier responses, and become more capable of managing your anxiety.
Keep reading to learn more about ERP therapy and what you can expect throughout your treatment journey.
What can I expect from ERP therapy?
Let’s be honest—ERP therapy can be challenging and scary. Just getting started requires a lot of motivation and courage—after all, for ERP therapy to work, you have to willingly enter situations that scare you and deliberately avoid responding in the usual compulsive ways.
It sounds difficult, but you don’t have to go through it alone (and it’s advised that you don’t do ERP on your own). It’s best to do ERP with a therapist who specializes in OCD and ERP. They can help you understand your experiences and teach you the tools to manage your OCD symptoms.
Therapists who specialize in OCD can accurately identify the disorder and provide a formal diagnosis—this is a crucial point, as OCD is often misunderstood or misdiagnosed. They also have the capability to help you manage intrusive thoughts that may revolve around taboo subjects.
Your therapist will design ERP therapy exercises such as exposures and response prevention techniques, which are customized to your needs and goals. Each exercise targets a particular OCD-related fear. Your goal is to experience that fear without running away from it or performing rituals that you normally do to reduce your distress.
Throughout your ERP therapy, you’ll probably face several fears— starting with the smallest and gradually working your way up to the most distressing triggers. As you get used to the experience, you’ll feel less anxious and more capable of making healthier choices.
What happens in the first couple of sessions?
Here’s what you can expect during your first couple of ERP sessions.
1. Understanding your fears and compulsive behaviors
The first step is talking about your fears and compulsive behaviors with a therapist. You’ll cover four topics:
- Your intrusive thoughts, images, feelings, sensations, and urges.
- Your mental and physical compulsions, including what you do to reduce your anxiety or keep an unwanted consequence from happening.
- What you fear will happen if you don’t perform a compulsion.
- What you avoid so you won’t feel nervous or have intrusive thoughts or compulsions.
2. Setting expectations
Next, you and your ERP therapist will talk about OCD in general and the experience of ERP, including why it works and what your therapist expects you to do.
3. Starting treatment
You’ll start your treatment plan once you’ve covered the basics of ERP. That usually means making what therapists call an exposure hierarchy or, less formally, a “fear ladder.” To create your fear ladder, you’ll start with a list of places, situations, and things you typically avoid out of fear.
Your therapist may ask you to rank each in terms of distress on a scale of 0 to 10. ERP therapists call this the Subjective Units of Distress Scale (SUDS). You create your ladder by ranking your avoided situations from lowest to highest. While you may rank them from lowest to highest, it’s more than likely you and your therapist will start with something that falls toward the bottom of the scale.
You’ll then set a goal related to each avoided situation. Your goal should be as realistic and specific as possible. For example, if you have intrusive thoughts of throwing yourself off a train platform, your eventual goal might be to take the subway to work every day for a week. But don’t worry—you won’t have to do this right off the bat. You’ll set a few smaller goals to achieve first, like having a friend accompany you to the train station and watching people board.
Once your exposure hierarchy and goals are set, your therapist will lead you through your first exposure and response-prevention session. Most of the time, therapists start with a situation that’s low on your SUDS scale. You’ll learn to get through the situation without resorting to rituals or compulsive behaviors.
In early ERP therapy, you’ll typically face the same situation multiple times. The scenario may be the same each time, or you may work yourself up to a goal. For example, if you avoid cleaning the cat’s litter box because of a fear of contamination, you may start by sitting nearby while a friend cleans the box, then work your way up to putting the scoop back, and finally begin scooping the box yourself.
ERP therapy examples for different OCD subtypes
With OCD, your obsessions and compulsions may center around a certain theme or subtype. Here are some more exposure and response prevention examples that may be used for different common OCD subtypes:
- If you have relationship OCD, your therapist may ask you to resist asking your partner if they’re upset after they’ve already given you an answer.
- For people dealing with harm OCD, an ERP exercise may involve leaving a kitchen knife on the counter after preparing vegetables.
- For religious obsessions and fears (tied to scrupulosity OCD), a therapist may guide you in adhering to the recommendations of your faith leader rather than repeating prayers dozens of times per day.
- Someone with sensorimotor OCD might purposely increase their heart rate, then sit with their anxiety as it returns to normal without checking or counting to make sure it’s decreasing.
Your therapist will witness you doing the ERP exercise in session, and you will do it yourself and report back as a form of therapy homework. Either way, therapy sessions end with a recap where you talk about what happened, how you felt, and how you made it through the exercise.
ERP intentionally increases your anxiety
When you first start exposing yourself to situations you usually avoid, you’ll probably feel a bit anxious and afraid. Naturally, you’ll want to escape the feeling and the situation that causes it, so you might feel the need to do your compulsive behaviors. Understand these feelings are completely normal to experience—in fact, that’s what therapy is all about.
OCD rituals or compulsions exist because they make you feel less afraid. Your body knows that when you do them, you feel much better—at least temporarily. To break that OCD cycle, you need to fully experience the anxiety associated with a particular situation. You need to feel your way through it and choose a different behavior because your body won’t believe you can otherwise.
This is ERP’s make-or-break moment—when you choose to feel the anxiety and stay in the situation without performing a compulsion. If you can hang in there and tolerate the distressing feelings you experience, your mind and body will learn that you don’t have to perform your rituals and the distress will typically fade away on its own.
What happens as treatment progresses?
Once you’ve gone through the exposure and response-prevention process with moderate fear, you’ll start working your way up the fear ladder. You and your therapist will decide when to move from one avoided trigger to the next.
You can move up your fear ladder when you’re able to face a fearful situation and manage it with little to no discomfort or anxiety.
When you get there, you can start working on something more fearful.
In therapy, you’ll practice ERP in specific contexts, but as you become more comfortable and skilled at response prevention, you’ll start applying it to manage sudden triggers.
OCD triggers can arise unexpectedly—at work, at school, and elsewhere. As treatment progresses, it’ll become easier to apply response-prevention skills when OCD takes you off guard. When you can use ERP in these kinds of situations, that’s when life really starts to change.
How will I feel throughout ERP?
As you get more experience with ERP therapy, you’ll get more familiar with the anxiety and discomfort that come from facing your fears. However, that doesn’t mean you’ll feel less anxious right away or that you won’t initially want to perform rituals to reduce distress.
In your ERP therapy, each new goal will still be somewhat anxiety-inducing—which is the point of this therapy. If a particular activity doesn’t cause you distress or it is easy to push through that distress, it’s a sign that you’re ready to move on to the next goal.
As you learn to manage your triggers, they will occur less frequently. People who use ERP therapy learn to accept uncertainty and, therefore, don’t find their thoughts to be as intrusive. You’ll spend less time in the OCD cycle and more time living your life. While you’ll still have periods of anxiety and moments when your OCD comes back, you’ll be better prepared to manage it. You’ll be free to live life on your own terms—not OCD’s.
How will ERP change me?
The more ERP therapy exercises you do, the more in control you’ll start to feel—making it easier to break the cycle of obsessions and compulsions. This is formally known as habituation.
Habituation is the natural process your brain goes through as it adjusts to the distress caused by your OCD symptoms. If you’re constantly facing your fears head-on without compulsing, your brain learns that a feared outcome doesn’t happen—or if it does, it’s really not as bad as you expected.
Your body and mind become familiar with feeling anxious and choosing not to engage in compulsive behavior. You convince yourself that you don’t need those behaviors to get through your fear. ERP therapy is all about this type of transformation.
It’s important to understand that ERP therapy for OCD doesn’t get rid of anxious thoughts. Instead, it teaches you to assess situations more rationally to determine whether there’s an actual threat. Once you realize you can do something besides engaging in compulsive rituals, a whole new world opens for you.
What can I expect as I near the maintenance phase of recovery?
You’ll know you’re getting close to the maintenance stage of your recovery journey when you can do exposures at the top of your hierarchy, manage the triggers that arise, and allow your anxiety to decrease naturally.
For most people, the change is distinct and transformative. You’ll find yourself participating in an activity that OCD would once have dominated. It will be a situation you wouldn’t have been able to handle at the beginning or even in the middle of your ERP journey, but by this point, you’ve worked your way up to it, and you’re ready. You’ll even end the activity feeling good—something that would have been out of your reach before doing ERP therapy exercises.
For example, let’s say you have a fear of using the public restroom because of possible contamination. Maybe you felt uncomfortable going into a public bathroom before, but after several ERP therapy sessions, you’ve gained the confidence to not only go into a public bathroom, but to use the toilet as well. While anxiety and discomfort may still linger in the back of your mind, you’ve gained the confidence to push through your fears and regain control of your life from OCD.
How can I expect to feel?
As you near the point of ERP therapy where you and your therapist consider decreasing or discontinuing sessions, you’ll probably still feel some anxiety when facing situations you used to avoid, and that’s completely normal. The difference is that the anxiety may fade much faster than it used to, and you’ll feel much less of an urge to make the anxiety and thoughts go away by performing compulsions. Your therapist will also go over relapse prevention planning with you to ensure you stay on the path of success.
Consider ERP therapy to manage OCD
Exposure and response prevention (ERP) therapy is the best and most effective treatment for breaking the OCD cycle of obsessions and compulsions. With the guidance of a licensed therapist, doing ERP therapy exercises can give you the knowledge and tools to address your fears head-on without responding with compulsions. If you have (or think you have) OCD and are seeking support, please reach out to a therapist specializing in ERP and OCD to start your treatment journey.
