2024 Exposure and Response Prevention [ERP] Therapy for OCD: How it Works & Techniques

May 1, 20249 min
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“I love organizing my socks by colors, this is definitely OCD!”

“Stop being so obsessed with that actor, you may develop OCD!”

“I am such a cleanliness freak. My family says I have OCD!”

Have you ever heard someone say any of these? There are high chances that you have. Well, let me tell you that OCD is much more than this. OCD or Obsessive Compulsive Disorder, is a mental health condition that goes beyond keeping things clean and tidy.

OCD causes a person to get stuck in a cycle of obsessions and compulsions. Obsessions are repetitive, intrusive thoughts, images, and urges that get stuck and are difficult to dismiss.

Compulsions are behaviors that help us feel temporarily relieved from anxiety. Some of these can be seen externally, such as tapping, touching, and checking. However, these behaviors can also be hidden: rituals, thinking about a person over and over again. Anyone can experience intrusive thoughts and sometimes engage in repeated actions, but for someone with OCD, these thoughts and actions can just go on and on. 

If you have ever googled the treatment options for OCD, you are likely to have come across Exposure and Response Prevention Therapy for OCD. Let’s dive deeper into why it is considered the gold standard for OCD treatment.

Exposure and Response Prevention Therapy

What is Exposure and Response Prevention [ERP] Therapy? 

Research shows that Cognitive Behavioral Therapy is one of the most effective treatments for anxiety and related conditions. It helps you to understand how your thoughts, emotions, and behaviors are connected and influence your mental health.

Exposure and Response Prevention [ERP] is a type of CBT therapy that helps you manage your obsessions to the point that they don’t bother you. The aim is to help you face your fears so that you feel in control. 

The International OCD Foundation compares ERP to rewiring an alarm system. Alarm systems keep us safe and alert us to danger. However, what happens when the system is too sensitive and alerts us to every single thing that touches the house, for example, a bird sitting on the house, or a raindrop? Would you be able to identify what is a real danger and what is not?

OCD also works as an extremely sensitive alarm system. Our mind becomes alert at every signal and the result is anxiety. Imagine that you do something to stop the alarm from blaring, What does this tell you? It is a confirmation to your brain that you may be in danger.

Through ERP, you learn to rewire your alarm. Here is an example of how it can be used: 

Tom has contamination OCD, which means he is extremely scared of germs. He believes that everything around him is dirty and he constantly cleans and sanitizes everything. He refuses to touch anything at school and doesn’t play with other students since he can get dirty. 

Tom reaches out to a CBT therapist, who introduces him to ERP. His therapist tells him about the OCD cycle and introduces him to the idea of exposure (facing his fears ). In the later section, we will see how Tom uses ERP techniques to heal.

Typical Exposure Therapy Vs. Exposure & Response Prevention

As the name suggests, typical exposure therapy exposes you to triggers. A trigger can be a situation, action, or anything that makes you feel worried or anxious.

The goal of exposure is to reduce anxiety and fear. The idea is that with repeated exposures, your anxiety will decrease in response to the feared stimuli. Imagine that someone has a fear of dogs. In typical exposure therapy, you will gradually expose yourself to a photo of a dog, then a video, seeing a dog from a distance, and eventually going closer to a dog.

Trigger and Response

ERP also uses exposure but it is often used specifically to manage OCD. It targets those problems that may have cycles or rituals associated with them. The goal is not only exposure but also to stop us from engaging in compulsions. In the case of Tom, he may not only be exposed to a dirty doorknob but also slowly asked to refrain from cleaning and sanitizing.

How does ERP Work?

ERP works to interrupt the OCD cycle. Tom, for now, doesn’t recognize that his compulsions are feeding into his OCD cycle i.e., the more he experiences relief, the more he fears contamination. 

By engaging in ERP, you learn to tolerate discomfort. No one really likes facing their fears, right? However, in OCD, these fears can limit your experiences and hold a tight grip on you. Over time, Tom can learn to face his fear of germs, without depending on cleaning and sanitizing.

Who Will Find Exposure and Response Prevention Therapy Most Helpful?

ERP is most often used for the management of OCD and anxiety. Anyone who experiences distress and disturbances in their daily lives due to obsessions and compulsions may find it helpful. Here are some examples:

  • Someone with an extreme fear of contamination
  • Someone with intrusive  thoughts of harming themselves or others without a real intention or plan
  • Extreme fears related to one’s religion and mortality, for example, fear of committing sins

Why does ERP work in treating OCD or other anxiety conditions?

The big question is: Does ERP [Exposure Therapy] work for OCD symptoms? The short answer is, yes, it does. 

We often believe that the best way to deal with our fears is to avoid them. Unfortunately, staying away from our fears can increase our fear and reduce our confidence in dealing with them. Avoidance in the long term can worsen anxiety.

ERP uses this understanding and gradually reduces anxiety through habituation. Our everyday lives are full of examples of habituation. We may move into a crowded locality, but eventually, we get used to it. Exposure-based treatments use this simple process to reduce attention to the triggers.

Let’s think about Tom again. Every time he sees a dirty doorknob, he avoids it and doesn’t feel anxious. This teaches him that he can’t tolerate dirty doorknobs. On the other hand, if he learns to touch the doorknob without avoiding it, eventually he becomes used to touching the doorknob.

ERP techniques or methods to treat OCD Mental Health Issues 

Tom worked with his mental health professional to identify his triggers, obsessions, and compulsions. He was now ready to start using ERP techniques.

1. Psychoeducation

Tom got to learn more about OCD. An essential component of psycho-education is identifying your OCD cycle. 

Tom identified how his avoidance and behaviors of cleaning were maintaining his fears of germs.

2. Practicing exposures

You make an anxiety or worry ladder to place your triggers. You start slowly exposing yourself to the least triggering stimuli.

Tom made a ladder and slowly practiced exposures.

Fear

Intensity

Using the doorknob

100

Using a hanky to open the doorknob

70

Seeing someone use the doorknob

50

Looking at a dirty doorknob

30

Thinking about a dirty doorknob

20

3. Tolerating uncertainty

ERP introduces a gap between your thoughts and the need to take action. The fear of uncertainty often makes us jump to engage in a compulsion. 

Tom feared that by touching the doorknob, he might contract a disease or get dirty. The moment he would have this thought, he would jump to clean. His therapist asked him to delay his actions slowly.

4. Exposure scripts 

Not everyone is comfortable facing their fears head-on. Your therapist may begin by recording a script. You will then imagine yourself facing your feared object.

5. Response prevention 

This is perhaps the toughest, yet most important, aspect of ERP. You make a conscious and deliberate effort not to engage in compulsions.

6. Delaying the ritual 

Your therapist introduces a time gap between your thoughts and behavior.

Tom would be asked to initially wait 10 minutes before he picked up his cleaning tools.

7. Doing the ritual differently 

Instead of your typical compulsions, you do something else instead. In a way, you tweak your rituals.

Tom was asked to use a handkerchief to clean the doorknob instead of using sanitizers and cleaners.

What Does a Typical OCD ERP Session Look Like?

A typical ERP session can look like:

  1. Discussion of what is to be worked on
  2. Track progress on what you did outside the session (If it’s the first few sessions, there may be a discussion on what techniques can be used)
  3. Thinking of barriers in exposure ( What worked for the client and what did not?)
  4. Reflecting on learning
  5. Acknowledging progress through the sessions

What is the success rate of exposure therapy for OCD?

The success rate of a treatment can depend on various factors. When you start exposing yourself to your triggers, it can feel scary and overwhelming. It may also feel like you are doing a ‘bad job’. However, it is essential to remember that exposure and building your confidence can take time.

Over time and across research, the success rate of ERP for OCD has been 50-60% (Herzog et al, 2022). This means that at least half the people will see a noticeable difference in the reduction of their symptoms. By working with a therapist, you can best identify if ERP will work for you.

How long does exposure therapy take to work for OCD?

How many sessions of exposure therapy are there for OCD? With mild OCD, you may need about 8 to 20 sessions, with exercises outside the session (Farrell et al, 2023). The number of sessions can change depending on the intensity of your symptoms.

How to Find a Therapist Skilled in ERP?

Finding a skilled therapist can be challenging, but at Mave Health, you can see mini websites of therapists who have previously worked with ERP and have been successful in the management of OCD.

Here are some questions that you can ask your professional:

  1. What techniques will be used to manage my symptoms?
  2. What is your background and experience in treating OCD?
  3. What factors can make the treatment successful?
  4. I am not ready for ERP, is there something else I can try instead?

Can I do exposure therapy on my own?

While you can identify your OCD cycle and make your worry ladder, it is not advisable to try exposure therapy on your own, at least initially. Therapy is a controlled and safe environment. 

If you work with a professional, it not only holds you accountable to continue working on your goals but also ensures that you feel safe while facing your triggers.

4 Myths & Common Misconceptions About ERP Therapy 

Myth 1: The goal of ERP is to get rid of obsessions

Fact: The aim is not to magically remove your obsessions but to increase your skills in the face of unwanted thoughts.

Myth 2: The goal of therapy is to convince your brain that OCD threat is not dangerous

Fact: The goal of therapy is to rewire your brain and not feel unsafe when every thought arises.

Myth 3: ERP is a quick fix

Fact: ERP can take time, especially if your symptoms are intense and have bothered you for a long time. 

Myth 4: ERP is easy

Fact: Facing your fears can be difficult. With practice, you can slowly learn to face your fears.

Is ERP the Only OCD Treatment Option?

It is important to note that while ERP is a popular treatment, it may or may not work for you. If you are someone who is not ready for exposure therapy, you can opt for cognitive therapy, which helps you identify the thoughts and behaviors that continue to keep you stuck in the OCD cycle.

You can also try Acceptance and Commitment Therapy (ACT). The goal of this therapy would be to accept your unwanted thoughts, rather than avoid or attempt to eliminate them. 

Support groups for OCD can be a great starting point for someone who is not ready for individual therapy. Some support groups that you can look out for are organized by SoulUp and IPH Pune.

Conclusion

Exposure and Response Prevention Therapy can present an opportunity to rewire your brain’s alarm system. It is not a walk in the park, but with a trained professional you can feel supported and more confident in facing your fears. While you may experience initial discomfort, it can pave the way for a better life. Connect to a Mave Health therapist to learn more about how therapy can help you!

References

Common Myths About OCD Treatment. (n.d.). 

Butler, R. M., & Heimberg, R. G. (2020). Exposure therapy for eating disorders: A systematic review. Clinical Psychology Review, 78(1), 101851. 

A Guide to Exposure and Response Prevention Therapy | McLean Hospital. (n.d.)

Here’s What a Typical Journey Through OCD ERP Therapy Looks Like. (2021, February 2). NOCD. 

Herzog, P., Osen, B., Stierle, C., Middendorf, T., Voderholzer, U., Koch, S., Feldmann, M., Rief, W., & Brakemeier, E.-L. (2021). Determining prognostic variables of treatment outcome in obsessive–compulsive disorder: effectiveness and its predictors in routine clinical care. European Archives of Psychiatry and Clinical Neuroscience, 272(2), 313–326

International OCD Foundation. (n.d.). International OCD Foundation | Exposure and Response Prevention (ERP). International OCD Foundation. 

Is Exposure to Your Triggers an Effective Treatment for OCD? (2016, May 17). Psych Central. 

Exposure Therapy for OCD: Understanding the Rationale is Key to Success. (n.d.). Verywell Mind. Retrieved April 24, 2024,

Farrell, L. J., Waters, A. M., Storch, E. A., Simcock, G., Perkes, I., Grisham, J. R., Dyason, K. M., & Ollendick, T. H. (2023). Closing the Gap for Children with OCD: A Staged-Care Model of Cognitive Behavioural Therapy with Exposure and Response Prevention. Clinical Child and Family Psychology Review

Law, C., & Boisseau, C. L. (2019). Exposure and response prevention in the treatment of obsessive-compulsive disorder: Current perspectives. Psychology Research and Behavior Management, Volume 12(1167-1174), 1167–1174.

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Mave
Clinical Psychologist