- Exposure and response prevention, or ERP, is the most commonly recommended, evidence-based form of therapy for obsessive-compulsive disorder (OCD).
- The majority of ERP therapy patients experience significant improvements within 12 to 25 sessions.
- 80% of OCD patients experience positive results from ERP therapy.
- ERP works by specifically targeting your obsessions and compulsions.
- For more stories, visit the NOCD blog.
You might’ve noticed that exposure and response prevention, or ERP, is the most commonly recommended form of therapy for obsessive-compulsive disorder (OCD). And along with serotonin reuptake inhibitors (SRIs), it has consistently been shown to be the most effective treatment.
OCD is a common mental health condition characterized by intrusive, distressing thoughts and repetitive behaviors aimed at reducing that distress.
This means people with OCD do certain things over and over because they’re trying to get rid of really unpleasant feelings. It’s not because they want to behave compulsively, or because they necessarily think their behavior is rational.
What is ERP?
ERP is a type of behavioral therapy that exposes people to situations that provoke their obsessions and the resulting distress — while helping them prevent their compulsive responses. ERP was developed in the 1970s and is recommended by the American Psychological Association and many other organizations.
The ultimate goal of ERP is to free people from the cycle of obsessions and compulsions so they can live better.
Response prevention is key, because anything that gets rid of distress makes it impossible for us to get used to it. When people don’t turn to compulsions, they learn how to accept their obsessions instead of acting desperately to neutralize them. The thoughts are still difficult sometimes, but they no longer seem like a huge problem. And they learn that their anxiety dissipates with the passing of time — and not by using compusions.
This process of getting used to something is what psychologists call habituation. As patients habituate to the feelings their obsessions bring up, and as they reduce their reliance on compulsions, they spend less time and energy avoiding pain.
ERP is fundamentally about shifting one’s orientation to unpleasant thoughts and feelings — not about getting rid of them.
When we feel able to handle discomfort, obsessions (which used to create a sense of profound uncertainty) are no longer reinforced by avoidant behaviors that teach them the content of their every thought is both important and reflective of their true nature. And when we don’t feel an overwhelming need to be certain about ourselves, the future and our standing in the world, we can live with less unnecessary suffering.
Why is ERP effective for OCD?
Studies show that everyone experiences some of the intrusive thoughts involved in OCD. Maybe you’ve thought, “I could drive off the road right now,” or, “What if I don’t actually love my significant other?” People without OCD are usually able to write off distressing thoughts as strange and random occurrences, but those with this condition feel compelled to analyze and neutralize them. Obsessions and compulsions can reinforce each other, too. Often, it seems like a thought that had to be avoided with a compulsion must have been pretty important (and worthy of more fear). In most cases, OCD symptoms do not resolve on their own.
A cognitive approach — traditional CBT, for example — asks patients to challenge their obsessions. This can actually reinforce the belief that OCD thoughts are significant and that we’re morally responsible for the content of our thoughts. Although cognitive interventions can be useful in many ways, recent studies comparing ERP and CBT suggest that ERP is more effective specifically for OCD.
Any behavior that engages with the obsession — for example, reassurance seeking, avoidance or rumination — reinforces it. On the other hand, when you prevent yourself from engaging in your compulsions, you teach yourself a new way to respond, provide yourself with the opportunity to learn that the feared outcome probably won’t occur (or that you can handle it if it does), and will very likely experience a noticeable reduction in your anxiety.
By preventing these behaviors, ERP teaches people that they can tolerate their distress without turning to compulsions. It thereby drains obsessions of their power. Especially when paired with medication, ERP is consistently demonstrated to be the most effective form of treatment for OCD.
How long does ERP last?
During treatment, it’s helpful to avoid an all-or-nothing approach to recovery. Patients shouldn’t expect to make a full recovery from OCD overnight. Progress takes time: While the duration of treatment varies from person to person, the majority of ERP therapy patients experience significant improvements within 12 to 25 sessions. This, of course, depends on how an individual responds to ERP and how severe the condition is to begin with. Some people see positive results within a few sessions. For others, the course of treatment will be much longer — and that’s okay. Each person is different, and OCD therapists can help each person to create a program that works for their specific challenges.
Generally, ERP therapy will be more intense when an individual first starts treatment. It’s not unusual for things to get a bit worse before they get better. For example, a person may meet with a therapist multiple times a week at first, then gradually reduce the rate of sessions when they start experiencing significant relief from their symptoms. It’s helpful to think of recovery in different phases: You’re actively recovering during the first part, and you’re maintaining your recovery during the second.
How effective is ERP therapy?
The good news is that ERP has been found to be remarkably effective for treating OCD. 80% of OCD patients experience positive results from ERP therapy.
As an active form of treatment, ERP is incredibly effective. “If you consider every single psychological treatment that’s ever been developed and tested, ERP is associated with the highest of what’s called effect size — a measure of how strong or effective a treatment is,” says Dr. Nicholas Farrell, a psychologist and Network Director of Clinical Training and Development for NOCD.
Is ERP helpful if it increases your anxiety?
You’re not alone if you question the effectiveness of therapy that asks people to do things that really bother them. This suspicion comes from a place of empathy: Why make people go through pain? Isn’t it okay to be anxious about things, and why wouldn’t you be bothered by disturbing OCD thoughts (like, say, harming your own baby)?
“[ERP therapy] is challenging. It’s not a simple treatment, like taking medication, or even a routine medical procedure that doesn’t induce any discomfort,” Dr. Farrell says. “It is a treatment that comes with some discomfort. And yet, the benefit associated with ERP is so substantial as compared to alternative treatments that we promote it as a first-line treatment because of the substantial success rates.”
Does it sound counterintuitive that you could treat a psychiatric condition by doing things like telling yourself over and over that you might lose control and harm someone? Yes, and it’s not the kind of thing most of us would like to spend our time doing. But let’s consider an example.
Say you’re so bothered by one fleeting thought — “What if I accidentally run someone over on my drive to work and don’t realize it?” — that it makes you physically sick. You think about it all day, write mental lists of reasons you’re a responsible driver, replay your past driving experiences over and over again and find yourself circling back on your drive just to make sure you didn’t cause an accident.
These thoughts are so distressing that you stop driving all together and start taking cabs to work even though you know your fear isn’t logical. The thoughts torture you, and it seems like your whole life revolves around avoiding any thought about how you could be in danger of accidentally hurting someone.
ERP therapy specifically targets these kinds of recurring and unwanted obsessive thoughts. It’s not really about someone who has one fleeting thought about potentially harming a loved one — we all have thoughts we’d rather not have. Rather, this is a form of treatment for people whose lives are stuck because of their thoughts.
That’s why patients are willing to push through the pain and strangeness, and why clinicians are willing to temporarily make the pain worse so things can get better If we don’t face our fears, our fears become the things that control us.
How ERP therapy works: An example
Let’s take the example of someone with hit and run OCD who is afraid of driving. During an ERP session, this patient might practice going for a drive with their therapist. At first, this might feel impossible. They might think, “I want to drive, but I just can’t. I’m too afraid.”
The patient will work with their therapist to come up with a hierarchy of anxieties and related exposures and gradually work their way through them. For example, they may start with simply sitting in the car during a therapy session and allowing the uncomfortable thoughts and fears to come up.
Instead of trying to reassure themselves, the patient may be asked to lean into uncertainty by repeating a statement like, “I may hurt someone and I may not. It’s impossible to know for sure.” Doing such an exposure contributes to learning and shows the patient that they can tolerate not knowing what will happen, as well as the discomfort associated with the thoughts.
After repeated exposure with response prevention, the patient may find they are able to drive their car for a short distance. Eventually, they learn that their feared outcome won’t occur, that they can manage the outcome if it does occur and that they can tolerate the anxiety or distress that arises when they have intrusive thoughts. In some cases, people find that their anxiety subsides to the point where they no longer experience intense fears of harming someone while on the road.
In ERP, a fair amount of distress is inescapable, and that’s an unfortunate fact. But clinicians and advocates of ERP, like the NOCD team, say the difficulty of treatment usually ends up insignificant compared to the drawn-out suffering of untreated people who go through their lives in anguish over thoughts that aren’t actually worth a ton of attention.
ERP is about shorter-term pain for long-term gain. But it has to be done carefully, with an experienced clinician you respect and trust. It’s good to weigh the pros and cons beforehand: What do you value, and how can ERP help you get there? What are your goals? And what are your limits for the amount of distress you’re prepared to go through? How long do you want to be in treatment? How’s your support system outside of therapy? These questions can help guide you as you decide whether or not ERP is the right fit for now.
ERP is most effective when the therapist conducting the treatment has experience with OCD and training in ERP. At NOCD, all therapists specialize in OCD and receive ERP-specific training. If you have questions or think that you may need ERP therapy for your OCD, call us and speak with our clinical team.
How is ERP done?
If you’re interested in learning more about how ERP works, you can check out the NOCD app on Android and iOS. We built it from the ground up to provide ERP tools, and worked with top experts to make sure it’s closely aligned with the version you’d get in a therapist’s office.
If you’d like to learn more about starting ERP therapy, you can schedule a free call with the NOCD clinical team to find out how this type of treatment can help you. All of our therapists specialize in OCD and receive ERP-specific training and ongoing guidance from our clinical leadership team. Many of them have dealt with OCD themselves and understand how crucial ERP therapy is.