Exposure and Response Prevention (ERP)

ERP is the empirically supported treatment for OCD, related disorders, and anxiety disorders. ERP is a behavioral modality within CBT. An exposure is when a client is deliberately exposed to their specific trigger(s), which could be a person, place, object, or situation. The same exposures are repeated at an assigned frequency so that the client can obtain habituation. Researchers within the OCD community use the term habituation, but it can be thought of like ‘desensitization.’ As clients engage in exposures, the perceived threat of their intrusive thoughts reduces, making them feel like they are less anxious, guilty, or disgusted. Exposures aren’t necessarily getting rid of these feelings. Instead, it is increasing the client’s tolerance of anxiety, guilt, and disgust.

Exposures are 50% of treatment. The other 50% is the reduction of compulsions. The words ‘compulsions’ and ‘rituals’ have the same meaning and are used interchangeably. The “response prevention” part of ERP is simply ritual reduction. Clients are taught exactly what compulsions they engage in. Clients are often surprised when they learn that some of their routine behaviors are compulsions. Loved ones are equally surprised when they learn about some of the more subtle, covert compulsions. After a client learns what a compulsion/ritual is, they start to track the more frequent compulsions. Awareness of when compulsions are being completed is essential to reducing them overtime.

During the treatment process, the provider begins by creating a list of exposures that are tailored to the client’s specific triggers. The client then rates each exposure based on the level of difficulty they believe it would be to complete the exposure. A hierarchy of exposures is created, and the provider will assign lower-level exposures to be completed first. This allows the client to develop confidence and momentum within the treatment process. It is not necessary for the clients to begin with easier exposure, but it is the most common and client-preferred way. This also helps minimize the chances of the client talking themselves out of treatment. OCD will look for any excuse to have the client doubt their need or ability to engage in treatment. Like we have said numerous times throughout the literature on this website, OCD is very manipulative.

The exposure the client does with their provider during sessions will also be done daily for homework. A provider who does not engage in exposures with their client, is a lazy provider. Your therapist should always do exposures with you during the session! Your provider will teach you how to make exposures slightly more difficult or easier if the level of difficulty slightly shifts when you do them at home.

The repetition of exposures allows the client to experience habituation more swiftly, ultimately making them feel better. When a client is non-compliant, ERP will not work. We will not waste your time and resources. This is why we will always be compassionate and transparent with you. If the client does not do the exposures as assigned, the chances of them working within a comfortable time frame reduces. If a client comes to their session and says that they did not have time to complete their exposure homework or that they “forgot,” we know that the client is engaging in the avoidance ritual. This might mean the exposures were too difficult and the provider can adjust the treatment accordingly or the client is struggling with motivation.

It is imperative that the client is completely honest with their provider. We need to know all the details of the intrusive thought. This might seem awkward, silly, embarrassing, or scary depending on the intrusive thought, but we can assure you, we have heard it all! Similarly, we need to know all details related to compulsions. We are aware of what compulsions clients do after engaging in sexual acts, defecating, and you name it. We hear everything!

If you are nervous about engaging in ERP treatment, we understand. If you read about ERP online, it will seem scarier than it needs to be. The most difficult part of ERP is getting started. As the weeks go on, it gets much easier, and clients become increasingly more confident that exposures work. We are happy to chat with you on the phone prior to making an appointment to answer any questions. We are here to support you and look forward to getting you better!

For additional information, you can visit the IOCDF website here.