Exposure and response prevention therapy, also known as exposure and ritual prevention, or ERP, is a form of therapy that was developed specifically to treat obsessive-compulsive disorder (OCD). ERP works by disrupting the cycle of obsessions and compulsions, gradually reducing your distress and anxiety through a process known as habituation.
To really understand how ERP works, first we need to understand how OCD works. OCD starts with obsessions: unwanted, intrusive thoughts, images, ideas, or urges. They can include doubts about your identity, mental images about harm coming to loved ones, fears about your health, and a wide range of other things. What they all have in common is that they create distress—anxiety, fear, doubt, or worry.
This leads to compulsions, which are the physical or mental behaviors you perform to reduce this distress or keep something unwanted from happening. Compulsions may provide short-term relief from the anxiety caused by obsessions, but they actually make obsessions worse by reinforcing the belief that the obsessions were a threat in the first place.
How does ERP therapy work?
During ERP, you’re encouraged to gradually and carefully confront your obsessions, sit with the discomfort you feel, and resist the urge to perform compulsions. This might sound scary, but you’ll start small—and your therapist will guide you every step of the way.
“OCD wants you to believe that compulsions will make you feel better or keep obsessions from happening,” shares Dr. Patrick McGrath, Chief Clinical officer at NOCD . “But it doesn’t work. Obsessions always come back. In reality, compulsions teach you to run from obsessions, which only gives them more power,” he explains.
When you’re guided by a trained therapist, you learn to accept uncertainty and doubt, and you teach your brain that discomfort from obsessions will go away on its own. It’s essential to see a therapist that specializes in ERP, as they have the right tools to help. Other therapists may use methods that unintentionally worsen OCD symptoms. With ERP, you will soon be able to simply acknowledge that you’re having an unwanted thought, idea, image, or urge, and it won’t feel nearly as distressing.
Throughout the ERP therapy journey, you’ll confront your obsessions both in and outside of therapy sessions through therapy exercises called exposures. Sometimes you and your therapist will plan these exercises, and other times they’ll simply occur in everyday life. But don’t worry, with proper practice and guidance, as well as mental tools you’ve learned from your therapist, resisting compulsions when uncomfortable thoughts arise will become a habit, and you—not OCD—will be in control of your life.
What does the exposure part of ERP look like?
Starting exposure therapy can seem daunting, and it’s completely understandable to feel hesitant about facing the thoughts and situations that cause you distress. But it’s important to know that you’re not expected to jump right into the deep end.
Dr. McGrath explains that the process is gradual, and you’ll start with the things that feel most manageable. With the support of your therapist, you’ll build the skills and confidence you need to tackle the harder stuff over time.
The first stage of the ERP process involves keeping track of your obsessions, triggers and compulsions.
- Obsessions are every intrusive thought, image, idea, and urge that causes you distress.
- Triggers are the situations that cause obsessions to occur.
- Compulsions are all the physical or mental behaviors you do in an attempt to feel better or keep something “bad” from happening.
After this, you will be guided to organize your obsessions and triggers into a hierarchy based on how much distress they cause. They’re ranked on a simple scale ranging from 1 (minimal distress) to 10 (extreme distress).
This step may seem simple, but it’s necessary for creating your treatment plan. “By starting with the triggers that cause the least distress, you and your therapist can gradually work your way up the hierarchy, gaining confidence and facing difficult feelings without becoming too overwhelmed at any point,” explains Dr. McGrath.
As you go through the process, you’ll work with your therapist to build skills that help you resist compulsions and make steady progress over time. The hierarchy you create at the beginning of your journey helps you build a foundation of skill through easier exposures, helping you eventually overcome your most difficult challenges.
The beauty of the hierarchy is that it can also keep you motivated along the way. “When you learn that you can tolerate your discomfort at a 3/10 distress level, you can aspire to the freedom and achievement you’ll feel from conquering triggers that cause a 9/10 distress level later on,” Dr. McGrath explains.
What is response prevention?
People often refer to ERP as simply “exposure therapy,” but exposing yourself to obsessions and discomfort actually doesn’t do anything on its own—the key to making progress in ERP is the second component: response prevention. “By resisting compulsions, you break the vicious cycle of OCD and learn that you are able to tolerate distress and accept uncertainty,” shares Dr. McGrath.
The idea behind response prevention might seem straightforward, but there’s a lot more to it than you’d expect. That’s why it’s so important to do ERP with a therapist who has undergone exposure and response training, rather than trying it on your own. Your therapist will guide you through specific techniques and help you avoid common mistakes that could hold back your progress.
Dr. McGrath says that a common response prevention technique is known as non-engagement response. This involves using brief, easy phrases to help you acknowledge the uncertainty of intrusive thoughts without giving them too much importance. Saying things like “Maybe, maybe not,” “So what?” or “Okay, fine,” can help you sit with the discomfort and not feel the need to respond to the thoughts.
Response prevention also helps your therapist identify sneaky compulsions that might typically go unnoticed, such as avoidance. “When the fear of triggers prevents you from doing things you would normally do, avoiding them is actually compulsive and can be tough to notice, especially if it’s an ingrained habit,” explains Dr. McGrath. Mental compulsions like rumination and mental checking can also be difficult to identify yourself, and the guidance of a therapist who specializes in OCD can be especially helpful in identifying them.
ERP therapists can also help you avoid replacing one compulsion with another, which is common for people who try ERP on their own. For instance, many people intentionally distract themselves from their discomfort when they attempt ERP on their own, and they end up doing things they wouldn’t normally do. “While it may feel as if they’re coping with distress without relying on compulsions, they’re actually engaging in new compulsions—and keeping OCD in control of their lives,” says Dr. McGrath.
Exposure and response prevention examples
Once your exposure hierarchy and goals are set, your therapist will lead you through your first session of ERP treatment. Most therapists start with a situation that causes lower amounts of distress so it is easier for you to handle. They will help guide you to get through the situation without resorting to rituals or compulsive behaviors.
Here are a few examples of how ERP therapy might work.
- Contamination OCD: If you’re worried about germs, your therapist might have you touch something you think is dirty, like a doorknob, without washing your hands right away. Over time, you’ll gradually expose yourself to more triggers and resist the urge to immediately clean yourself off.
- Relationship OCD: If you constantly seek reassurance from your partner, you may be asked to avoid asking them for reassurance after a doubt pops up. Instead, you’ll sit with the discomfort and let it pass on its own.
- Harm OCD: If you fear you might accidentally hurt someone, you might practice holding an object that triggers you, like a butter knife, and remind yourself that the fear doesn’t reflect reality.
Depending on your situation and comfort levels, your therapist may witness you doing the ERP exercise, or they might ask you to do it yourself and report back. 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.
Why is ERP treatment so successful?
Over decades of studying the therapy, researchers have identified two main processes that contribute to ERP for intrusive thoughts and OCD being so successful. These processes are known as habituation and inhibitory learning.
Habituation
Habituation refers to the natural process of your brain adjusting to the distress caused by obsessions and compulsions. When you repeatedly confront your triggers without giving in to compulsions, your brain starts to realize that the feared outcome doesn’t happen, or if it does, it isn’t as bad as you anticipated.
Over time, as you sit with the anxiety and discomfort instead of trying to avoid it, that intense feeling gradually fades. This is a key part of ERP because it shows that by facing your fears head-on, you can reduce the power they have over you, making it easier to manage OCD in the long run.
Inhibitory learning
Inhibitory learning can also help you conquer OCD. Essentially, inhibitory learning occurs when you repeatedly prove your OCD fears and worries wrong.
Let’s say you’re afraid that you’ll get horribly sick unless you wash your hands for three minutes every time someone touches you. You and your therapist will gradually work on washing your hands less and less over time, without resorting to any other compulsions, like using excess hand sanitizer. As you learn a new way to respond to OCD, your brain inhibits the recall of the old way of responding (compulsions). Eventually, you’ll learn that excessively washing your hands wasn’t actually preventing you from getting a deadly illness, and OCD can no longer use that fear to control your life.
Dr. McGrath shares that there are also other things that can indicate that ERP is working. “Sometimes, something you worried about can actually happen, and you’ll learn that you’re capable of handling unexpected, uncomfortable experiences,” he explains. “You and your therapist might also work to focus on your own values and choices as a way to resist OCD’s influence. In doing so, you can bring a new sense of confidence and courage to other areas of your life.”
Find the right OCD therapist for you
All our therapists are licensed and trained in exposure and response prevention therapy (ERP), the gold standard treatment for OCD.
ERP that works for you
Taking the first step in therapy can feel like the hardest part—whether it’s signing up for your first session or simply acknowledging that you need support. But fortunately, with the rise of virtual therapy, it’s easier than ever to find a form of therapy that works best for you.
Whether you’re searching for “ERP therapy near me” to find a therapist in person, or connecting from the comfort of your home online, what matters most is taking that initial step to seeking treatment.
Virtual ERP
Since OCD is a complex condition, you might be wondering if going into a therapist’s office is the best way to get treatment. Fortunately, virtual ERP has been shown to be just as effective as in-person therapy.
A recent study showed that ERP done in live, face-to-face teletherapy is just as effective as in-person ERP therapy. Research shows that virtual ERP leads to significant reduction in OCD symptoms and improvements in overall quality of life, depression, anxiety, and stress. Even more, virtual ERP brought these results over twice as quickly as in-person therapy.
The success of virtual ERP comes from how OCD affects us in our everyday environments. Since many obsessions are tied to specific places or situations, doing exposure exercises directly in those spaces—like your home—can be even more effective than doing them in a therapist’s office. Virtual ERP can even take place outside your home in order to target specific fears and obsessions.
Whether you’re doing ERP in person or virtually, what matters most is practicing response prevention consistently, even outside of therapy sessions. By starting with your therapist’s guidance in your everyday environment, you’ll build the confidence and skills you need to work through exposures on your own.
Bottom Line
ERP therapy is one of the most effective ways to manage OCD, and while the idea of facing your fears might sound intimidating, it’s important to remember that you’ll be supported throughout the process.
Whether you opt for in-person or virtual therapy, ERP helps you learn to sit with discomfort and resist compulsions, giving you the tools to take control of your life again. With patience, practice, and the right support, you’ll start to feel more confident in managing OCD and freeing yourself from the grip of intrusive thoughts.
Key takeaways:
- Exposure and response prevention (ERP) therapy is the most effective form of therapy for OCD.
- ERP is backed by decades of peer-reviewed research, and was created specifically for OCD.
- Exposures—the first component of ERP—are therapy exercises in which a therapist guides you to gradually, carefully confront the situations that trigger obsessions.
- Response prevention—the second component of ERP—involves learning to manage distress and anxiety, sit with uncertainty, and resist engaging in compulsions.
- ERP may be complemented with other forms of treatment such as psychiatric medication or acceptance and commitment (ACT) therapy.