Often when people—even professionals—are discussing treatment for OCD and the topic of exposure and response prevention (ERP) therapy comes up, someone may ask, “but isn’t that harmful?” There can be a lot of misinformation about any type of treatment, and that is why it’s so important for you to understand what ERP really is and what it isn’t.
ERP is a type of behavioral therapy specifically designed for treating OCD. In ERP, people with OCD are exposed to situations that provoke their obsessions and the resulting distress, giving them opportunities to resist engaging in compulsive responses. The ultimate goal of ERP is to free people from the cycle of obsessions and compulsions so they can live better.
So while it is true that ERP exposes people with OCD to their fears, it is often overlooked that this is not done in an overwhelming or unmanageable fashion. I tell all of my members that I am not throwing them into the deep end of the pool and suddenly expecting them to swim.
It’s quite the opposite: ERP is process-driven. It’s a well-thought-out treatment plan that will gradually introduce them to things that trigger their anxiety, step by step, while allowing them to learn to tolerate uncomfortable feelings. The goal of ERP is to free individuals from compulsions by accepting uncertainty.
Your therapist’s role in ERP
Specialty-trained, qualified, and licensed OCD specialists will never ask you to do things that go against your values or that will cause you or others harm, nor will they ever force you to do anything that you are unwilling to do.
Instead, a successful ERP therapist will guide, support, and motivate you. They will come up with reasonable and creative ways for you to gradually face the fears that are holding you back from living the life that you want to live. They will ask you to step outside of your comfort zone safely, so that you can see that you are capable of things you probably never thought you were. They will ask that you do things that are tough—not because they want to see you suffer (I promise, we don’t!)—but because they want to help you regain your life and free yourself from OCD’s grip. And they will do this with a manageable, step-by-step plan that’s highly personalized for you and unique to your challenges, desires, and goals.
As OCD specialists, we know that by doing this repeatedly and in a safe, deliberate process, you will learn that your brain is sending you false alarm signals when you are not really in danger. We also know that people with OCD may have high levels of distress intolerance, meaning they are not confident that they can tolerate feelings of anxiety or distress. A large part of ERP is learning that they can actually tolerate your feelings, as hard as this may seem at the moment. The more you expose yourself to the things that trigger your intrusive thoughts, feelings, and urges, the less anxious you will be, and the more you will recognize that you are able to tolerate discomfort. ERP will teach you that while discomfort is not pleasant, it’s also not dangerous, it won’t last forever, and you can tolerate it without resorting to compulsions. In this way ERP can also help you increase your overall self-efficacy, or your own perceived ability to do challenging things.
Throughout the process of treatment, your therapist will be checking in with you regularly, asking you what your anxiety or SUDS (subjective units of distress) levels are. They will ensure that you are at a manageable level of discomfort. Think of it as a ladder where every step allows you to reach a new level and increases your ability to sit with anxiety and get through it.
If an exposure is genuinely too difficult and you cannot do it yet, it’s your therapist’s job to fix that and to make it more manageable. Exposures should be challenging, but manageable. They should be things that you can do on your own outside of therapy sessions, instead of continuing to avoid them. Of course, all exposures are going to provoke some anxiety, but if you’re feeling the need to avoid them altogether or you’re not able to do them at all, that’s a problem that your therapist can work with you on.
Your role in ERP
What we will do, as highly-trained specialists, is ask that you trust the process of ERP. ERP is the gold standard treatment for OCD for a good reason: it works. It’s highly successful and is backed by science.
The end result of ERP is not for you to be in therapy for the rest of your life, but for you to eventually “become your own therapist” and manage OCD on your own. So we also expect that you will recognize the important role you have in treatment, including practicing the skills you learn outside of therapy sessions. You may only be in sessions 1-2 hours per week, leaving you alone for 99% of the week. That’s why homework is a pivotal part of treatment: ERP cannot be successful without practice. Even the best, most dynamic therapists cannot do the work for you—your success will depend on your determination and your willingness to believe that even though treatment can be hard, living with OCD is harder.
We will ask that you trust your therapist as someone who is highly trained in OCD and ERP. A good therapist will be there to motivate you along the way, encourage you, and help empower you to do the hard work of ERP. They will remind you that you are doing the things you thought you’d never be able to do. That is what a good ERP therapist does.
They will also be there to hold you accountable. Accountability is an important part of any successful therapy. People need what I call truth-tellers in their lives: These are people who will tell you difficult things that will help you in the long run. These are people who care about your well-being and who want to see you succeed. Having a therapist who is willing to guide you throughout this process and point out when you are doing compulsions in a roundabout way or when you are seeking reassurance can be imperative in helping you to be successful on your recovery journey.
The safest way to practice ERP
Some people may try to do ERP on their own in order to recover from OCD, but it can be very challenging to start ERP. Without first receiving guidance from an ERP-trained professional, they run the risk of not recognizing key compulsive behaviors, derailing their progress with exposures they’re not ready for, or finding themselves unprepared for setbacks along the way.
As with any therapy, ERP can be harmful if it’s delivered by someone without proper training and a deep understanding of the treatment. The best way to learn to manage OCD is to start ERP therapy with a licensed therapist who has specialty training in using ERP to treat OCD.
A specialty-trained therapist will have the experience necessary to uncover all of your compulsions, teach you the techniques you need to master response prevention and sit with uncertainty, and keep you safe, motivated, and on track as you continue to manage OCD in the long term. Specialty-trained therapists will also know what to anticipate when you describe your thoughts and behaviors, and how to build your personalized treatment program. Their expertise is in teaching you how to manage your OCD so you don’t feel stuck trying to “get rid of” the unpleasant feelings caused by disturbing thoughts.
People can search for providers through the International OCD Foundation (IOCDF) or Psychology Today. Both networks allow you to search for therapists in your area who treat people with OCD (we recommend that you ask this list of five questions ahead of your first session with any therapist to ensure they are trained in ERP).
You can also find therapists who specialize in ERP and provide virtual treatment. NOCD’s network of ERP-trained therapists is available to people inside and outside of the U.S. and is one of the most cost-effective solutions available today—we even accept many insurance plans to help make treatment even more affordable. When you schedule a free 15-minute call with us, our team will help you find a licensed, ERP-trained therapist in your area and to help you begin working with them as soon as possible.