A Guide to Exposure and Response Prevention (ERP)

Conditions like anxiety and obsessive-compulsive disorder (OCD) can negatively impact a person’s life. They may struggle with unwanted fears, worries, and doubts about their identity. These create feelings of distress that may contribute to maladaptive behaviors. Fortunately, exposure and response prevention (ERP) is one treatment available for such conditions. Here, we’ll guide you through what ERP is, how it works, what conditions it treats, and the different techniques.

What is Exposure and Response Prevention (ERP)?

Exposure and response prevention is a type of cognitive behavioral therapy that gradually exposes an individual to anxiety-inducing situations in a controlled and safe environment. The objective of this therapy is to trigger obsessions present in individuals with OCD in order to reduce them. Obsessions are unwanted and intrusive thoughts, images, and urges that trigger distressing feelings.

To fully understand ERP, it is important to know the difference between OCPD vs. OCD. While obsessive-compulsive personality disorder is characterized by the need for control, perfectionism, and inflexibility, OCD is marked by obsessions and compulsions.

The point of ERP is to provide patients with coping skills when a triggering situation or obsession presents itself. These skills will prevent compulsions from taking over, which are behaviors that are done repetitively to get rid of the obsession or decrease the accompanying feelings of distress.

Given its effectiveness in treating obsessions and compulsions, ERP is considered a first-line type of CBT for OCD.

One important characteristic of ERP is that it doesn’t completely eliminate distressing thoughts and situations. While it may sound like a limitation of the therapy, we must keep in mind that some level of distress is required to cope with everyday situations.

When starting with ERP, obsessions will continue to be a challenge in the short term, but they will become less overwhelming. Developing more coping skills will allow you to be free from the cycle of obsession and compulsion.

Related Handout: OCD Coping Skills (PDF)

How Does ERP Work?

ERP works in two steps.

First, individuals are directly exposed to stimuli that evoke distress, fears, or obsessive thoughts. This is the exposure component.

Second, patients learn therapeutic techniques to prevent their usual compulsions or maladaptive responses. As a result, they become more accustomed to experiencing a trigger while not giving in to the compulsion. This is the response-prevention component.

What Conditions Does ERP Treat?

Exposure and response prevention is used to treat various conditions, such as:

• Anxiety
• Phobias
• Eating disorders
• Obsessive-compulsive disorder

It is most often considered the gold-standard treatment for OCD in children and adults.

How Effective is ERP Therapy?

Since its development in the 1970s, several studies have supported its effectiveness.

A study conducted in 1993 separated patients with obsessive-compulsive disorder into groups: one receiving group behavioral therapy, another receiving individual behavioral therapy, and the last receiving progressive muscle relaxation. Both groups that received behavioral therapy improved, with those in the individual group demonstrating quicker reductions in OCD severity [*].

Another study in 1997 showed that patients who received treatment, including ERP, responded well and improved significantly on measures of obsession severity and anxiety [*].

A more recent review meta-analysis conducted in 2021 showed that groups of patients who receive ERP are superior to other groups that involve both neutral and active treatments and should be considered the optimal therapy for patients with OCD [*].

What are the Different Types of ERP Techniques?

There are different techniques involved in ERP, which are also considered exposure and response prevention steps.

• Psychoeducation. Psychoeducation involves learning about obsessive-compulsive disorder, its symptoms, treatments, and other information. Doing so will help the patient understand their condition more thoroughly and may provide clarity on how to go about the prescribed treatment.
• Exposure. This part of ERP is where the patient is gradually exposed to their specific triggers in a safe, controlled environment.
• Tolerating uncertainty. When people with OCD have distressing thoughts, they respond by engaging in compulsive behavior. With ERP, however, individuals face their distressing thoughts and the uncertainty that comes with them, learning how to tolerate the uncertainty.
• Response prevention. Response prevention is one of the main elements of ERP. This includes the intentional resistance of engaging in avoidance behaviors or compulsions.
• Delaying rituals. As patients are gradually exposed to their triggers, it can be helpful to delay rituals. For example, a therapist may ask an individual to increase the time between their obsession and the corresponding compulsion. This can eventually lead to resisting the compulsion altogether.
• Modifying rituals. A therapist may also ask their patient to modify their rituals. Doing so may help a person realize that their obsessions do not become real if they don’t do their usual ritual or compulsion.

How Long Does ERP Therapy Take?

The duration of ERP as a treatment for conditions like OCD and eating disorders may vary depending on the severity of symptoms. On average, patients receiving ERP typically require around two months of treatment to see significant results. Some people may see results even more quickly, depending on their condition, individual differences, and other factors.

What to Expect During ERP Therapy

Whether treating OCD in teens, children, or adults, there are some things you should prepare for beforehand.

During ERP therapy, you will most likely face several fears. At the start of an ERP session, you and your therapist will discuss triggers and make a list, starting with the least distressing fear to the most distressing one. Then, you will work with your therapist in gradually facing your fears and learning to resist the urge to engage in compulsions. As you grow accustomed to the experience, you’ll feel less anxious and more capable of making better choices in response to your fears.

You can expect to feel an initial increase in uncertainty, anxiety, and obsessive thoughts. You may find these thoughts and feelings distressing at first, but you will also learn that they cannot hurt you — they are safe and manageable.

Is ERP Suitable for Children and Teenagers?

ERP is suitable for children and teenagers. In fact, it is considered the first line of treatment for children and adolescents with OCD, either on its own or with medication.

Can ERP Be Combined with Other Therapies?

ERP is a type of therapy that can be combined with other modalities to address mental health conditions like OCD and other issues that occur alongside it. A study found that deep brain stimulation and ERP used in combination with one another reduced OCD symptoms significantly [*].

What to Look for in an ERP Therapist

Ideally, an ERP specialist should be a clinical psychologist who is a behavioral therapist and specializes in OCD. We encourage you to speak with prospective therapists about their experience with patients who have OCD and exposure and response prevention training before making a decision on who to consult.

The Bottom Line

Exposure and response prevention for OCD may seem daunting at first, especially since it involves facing your fears. However, it is also considered the most effective treatment for OCD and related conditions. Finding the right therapist will impact the quality of your treatment, so take your time interviewing prospective mental health professionals. ERP can make a big difference in your life, so if you suffer from conditions like OCD and related anxieties, it is a good option to consider.

For additional coping skills feel free to browse our collection of anxiety worksheets.

References:

1. Fals-Steward W, Marks AP, Schafer J. A comparison of behavioral group therapy and individual behavior therapy in treating obsessive-compulsive disorder. March 1993.
2. Freeston MH, Ladouceur R, Gagnon F, et al. Cognitive-behavioral treatment of obsessive thoughts: a controlled study. June 1997.
3. Ferrando C & Selai C. A systematic review and meta-analysis on the effectiveness of exposure and response prevention therapy in the treatment of Obsessive-Compulsive Disorder. September 2021.
4. Mantione M, Nieman DH, Figee M, et al. Cognitive-behavioural therapy augments the effects of deep brain stimulation in obsessive-compulsive disorder. December 2014.