Exposure and response prevention (ERP) therapy is a specialized type of cognitive behavioral therapy (CBT) designed to treat OCD by breaking the cycle of obsessions and compulsions. While general CBT can help with conditions like depression or anxiety, it may be ineffective—or even harmful—for OCD, making it essential to seek a therapist trained in ERP.
Exposure and response prevention (ERP) therapy is a specialized form of cognitive behavioral therapy (CBT) that was created specifically to target the symptoms of obsessive-compulsive disorder (OCD). Though the two treatments share many of the same characteristics and fall under the same umbrella of behavioral health interventions, there are a few crucial differentiators between ERP and CBT.
Exposure and response prevention therapy is a form of cognitive behavioral therapy—it’s an action-oriented, time-bound mental health treatment. However, not all forms of CBT are beneficial for people with OCD. CBT can be extremely helpful for people with depression or anxiety, but it’s often ineffective for OCD, and in some cases, it actually makes symptoms worse.
If you’re feeling a little confused, don’t worry. In this article, we’ll aim to help you clearly understand the differences between ERP and CBT so you can find the most effective treatment for OCD.
What’s the difference between CBT and ERP?
Cognitive behavioral therapy (CBT) was initially developed in the 1950s to treat people with depression. CBT is based on the relationships among cognition—perceiving and understanding our own thoughts—our emotions, and our behaviors. CBT has been widely studied and proven to be effective for treating many mental health issues, including anxiety, eating disorders, and substance use.
By focusing on present thoughts and behaviors (rather than analyzing the past) CBT aims to teach practical skills to change behavioral patterns that do not benefit you. CBT involves recognizing cognitive distortions—the unhealthy thinking patterns that affect your decisions and actions.
“The cognitive behavioral therapy model was really kind of revolutionary,” says Dr. Patrick McGrath, Chief Clinical Officer at NOCD. “Instead of trying to figure out why everything was happening and looking at old Freudian ideas of toilet training and relationships with your mother, it was just taking a look at what’s going on now. What can we do in the moment to work on changing those things?”
There are multiple subtypes of CBT, including dialectical behavioral therapy (DBT), acceptance and commitment therapy (ACT), mindfulness-based cognitive therapy (MBCT), and of course, exposure and response prevention (ERP) therapy.
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Using the CBT framework, exposure and response prevention therapy was developed to help people with OCD manage their symptoms. Instead of focusing on cognitive distortions, ERP is aimed at disrupting the cycle of obsessions and compulsions that happen in OCD.
Through decades of research, ERP has been shown to be effective for up to 80% of people with OCD who use it. Most found that their ability to manage their OCD symptoms improved within 12-20 sessions.
“The biggest difference between ERP and other forms of CBT is that ERP therapists are not in the business of convincing somebody that their thoughts are right or wrong, whether they’re valid or not,” says McGrath.
The goal of ERP is not to “argue” with OCD, or force the anxiety to go away—the goal is to sit with your anxiety without being ruled by it. When the urge to seek certainty arises, ERP encourages you to recognize that trying to achieve a 100% level of certainty about your thoughts is pretty much impossible, regardless of whether you have OCD or not.
“You might think, ‘Well I want to explore this and I want to know why I’m having this,’” says Dr. McGrath. “It turns out that’s really not as important as learning that you can handle whatever it is that pops into your head.”
How does ERP work for OCD?
OCD involves recurring intrusive thoughts, images, urges, feelings, or sensations known as obsessions. To alleviate the resulting distress, or prevent something scary from happening, you perform compulsions, which are repetitive behaviors or mental acts. Compulsions only temporarily reduce anxiety and they end up reinforcing the OCD cycle.
ERP is based on the principle of confronting obsessions (known as exposures) and preventing compulsions (response prevention). By repeatedly facing your fears without resorting to safety behaviors, you learn that your anxiety diminishes over time, and that you don’t need to rely on the false(and temporary) sense of security that your compulsions provide.
How exposures work
Exposures are anything you can do or experience that triggers your anxiety, fear, or disgust. The purpose of exposures in ERP is to practice intentionally having obsessions, feeling physical sensations, noticing your emotions rising, and experiencing the urges that come with them.
Exposures can be imaginal, where you think of obsessions or feared situations, in-vivo, where you confront triggers as they come up in real life, or interoceptive, where you actively trigger physical sensations that cause panic.
During ERP, you’ll work with a trained therapist to create a hierarchy of anxiety-provoking situations, starting with less distressing fears and gradually progressing to more challenging ones.
How response prevention works
According to Dr. McGrath, response prevention is “the elimination of avoidance, reassurance, distraction, substance use, or any other immediately gratifying thing that you might do in the moment to feel good and to make that anxiety go away.”
Deliberately refraining from performing compulsions is how you break the vicious cycle of OCD. Response prevention could look like a non-engagement response, like having an intrusive thought and then saying to yourself, “I am going handle being uncomfortable.” Or, it could mean not taking an action, for example not asking for reassurance or stopping yourself from going online to do research.
Does general CBT work for OCD?
While common techniques like cognitive restructuring and relaxation exercises may provide some relief in people with OCD, they fail to target the condition’s core symptoms. In fact, the application of other types of CBT may sometimes accommodate compulsive responses like rumination or reassurance-seeking, making OCD symptoms worse.
“Let’s say someone with OCD shares their obsessions around harming their child in a session with a CBT therapist who specializes in something other than ERP,” explains Dr. McGrath. “The therapist might encourage that patient to think or say something contrary to their ego dystonic thought. Something like: ‘I’m a good person, I love my children, and I would never harm them.’ While this sort of self-assurance can help treat other disorders, for people with OCD, it will become a compulsion.”
Dr McGrath adds that a CBT therapist might also tell this patient to do some diaphragmatic breathing or muscle relaxation when their anxiety becomes uncomfortable. “Again, this just becomes another safety-seeking behavior, and every time they use it, the patient unwittingly strengthens the cycle they’re trying to escape,” he says.
So how can you ensure that you’re getting the best treatment for your OCD? It’s best to find a therapist who specializes in treating OCD—and has training in ERP specifically—rather than somebody who does general CBT. If you have a co-occurring condition such as depression or social anxiety, your ERP therapist can also help you address these issues alongside your OCD.
Bottom line
Exposure and response prevention (ERP) therapy falls under the umbrella of cognitive behavioral therapy (CBT), but it’s specially designed to target the symptoms of OCD. While CBT can be helpful for mental health conditions like depression, it’s often ineffective for OCD, and in some cases it can exacerbate its symptoms.
If you think you have OCD, or you are seeking treatment for OCD, reach out to a therapist who specializes in ERP so you can learn more about how the treatment works.
Key takeaways
- Exposure and response prevention (ERP) therapy is a targeted form of cognitive behavioral therapy (CBT) that focuses on confronting obsessions and preventing responding with compulsions.
- Unlike general CBT, which can unintentionally reinforce OCD behaviors, ERP directly addresses the cycle of obsessions and compulsions through gradual exposure and response prevention techniques.
- For effective OCD treatment, it’s crucial to work with a therapist who specializes in ERP rather than relying on general CBT methods.