Exposure & Response Prevention

What is Exposure Response Prevention or ERP?

Exposure and Response Prevention therapy (ERP) is a specific type of therapy often described as the gold standard of treatment when it comes to Obsessive-Compulsive Disorder or OCD. But what is ERP? It is a type of Cognitive-Behavioral Therapy.

CBT is a therapeutic modality that focuses on the relationships between our thoughts, feelings, and behaviors and how they influence each other. When it comes to OCD, ERP is recognized as the best evidence-based treatment approach to help sufferers with their symptoms. According to the International OCD Foundation, ERP targets the way you respond to obsessions (intrusive and unwanted thoughts, feelings, or urges) by helping eliminate compulsive behaviors. Most people think of ERP as specific to the treatment of OCD (Obsessive Compulsive Disorder), however ERP is also used to treat social anxiety, phobias or other anxiety disorders. Thankfully awareness of OCD and ERP is rising, but many people don’t understand the nuts and bolts of the treatment. So what really is ERP? Why should you care about ERP? Settle in and let’s dig in together. 

How can ERP be helpful?

ERP is designed to help people break free from the distressing cycle of obsessions and compulsions.  ERP does not involve trying to change or remove obsessive thoughts. Instead, the focus of ERP is on stopping engagement in ritualized compulsive behaviors (response prevention) by way of learning to tolerate the distress of the obsession (habituation).  ERP provides healthy coping skills for OCD triggers while gradually and systematically reducing and stopping compulsions. With the help of a trained professional, ERP is the practice of placing the power back in your hands.

In a 2019 article, researchers found in “50–60% of patients who complete ERP treatment clinically significant improvements.” This means that approximately half of the patients engaged in ERP experienced a notable decrease in OCD symptoms. ERP provides a liberating strategy for individuals struggling with OCD. 

What does ERP treatment look like?

The OCD Cycle

To really get a grip on how effective ERP is, let’s first talk about the OCD cycle. The OCD cycle is a negative reinforcement cycle. This means that while it may feel like things are getting “better” when a ritual is performed, the opposite is actually true. That is, things are getting worse for you and better for the OCD.

The cycle begins with a trigger(s). Triggers can be internal or external people, places, things or situations that “trigger” an obsession. Triggers cause a rise in distress or anxiety (in the image below all of the arrows represent distress). Obsessions are intrusive unwanted thoughts, images or urges. Distress continues to increase from the presence of the obsession.

Next, we stop in the faulty appraisal department, this is where we assess what we think about what we are thinking about. The sufferer evaluates what the presence of the obsession means about them. People who have OCD evaluate the presence of the obsession as negative, that the presence of the obsession means something bad about them as a person or that there is something wrong with them and they should not be having it. This is why it is important to remember that with OCD, obsessions are intrusive and unwanted. Not enjoyable. Not fun. Once the presence of the obsession has been evaluated as bad, distress continues to rise until the person engages in a compulsion.

Compulsions can either be internal (prayers, mantras, counting, replacing “bad” images with “good” ones etc.) or they can be external (hand washing, physically repeating, re-walking etc.). Compulsions can either be directly related to the obsession i.e. fearing that you have a germ on your hands = wash your hands until they are clean or feel clean OR fearing that something bad will happen to a loved one = running up and down the stairs 3 times will ensure that loved one’s safety. Initially once the compulsion is performed, the sufferer experiences relief. This relief is only temporary until the cycle starts again with a trigger.

Additionally, as OCD is left untreated performing one brief compulsion often no longer alleviates the distress brought on by the obsession, thus the sufferer can get stuck in a cycle of performing the same compulsion over and over until they experience some relief. The cycle repeats itself over and over, at times the sufferer may attempt to avoid anything that is a trigger or even associated with a trigger in an effort to keep the cycle from beginning because it is all too stressful to go through the whole process and they can no longer find relief from repeated rituals.

Exposure & Response Prevention as a Treatment for OCD

So where does ERP fit into the OCD cycle? As mentioned earlier, ERP is an effective tool in tackling OCD because it changes how you respond to the obsessions through changing your response. ERP was initially documented in the late 60’s by British psychologist Victor Meyer, who reported that his client’s “OCD symptoms improved when they were exposed to feared stimuli while, crucially, refraining from performing compulsions” (Hezel & Simpson, 2019). Since this initial research, many more studies have and continue to validate the effectiveness of ERP. 

ERP is used to target several aspects of the cycle (triggers, obsessions, when needed faulty appraisals and compulsions).  When done effectively, ERP, as it is plainly named, exposes you to the presence of the triggers and obsessions, then focuses on not engaging in the ritualized compulsive response aimed at reducing the distress brought on. With the help of trained therapists, this process is done in a stepwise progression, starting with easier less distressing triggers and obsessions and moving up as the sufferer becomes more successful.

Of primary importance when doing ERP is that you work with a trained professional. Here at the Houston Center for Valued Living, we have several professionals that have gone through the Behavior Therapy Training Institute (BTTI) an in-depth intensive training program focused on ERP, Supportive Parenting for Anxious Childhood Emotions (SPACE) and worked in residential setting focused on treating extreme OCD cases. Having a therapist that is trained in this type of therapeutic approach is important. Exposures should be repeated and prolonged, starting with in-vivo exposures in the therapists office and the therapists nuanced experience is invaluable when dealing with the tricky OCD monster. 

An Example… Jane’s ERP Plan

To paint a clearer picture of this, let’s go through an example of a typical therapy session with a client who suffers from contamination OCD. 

Jane has a fear of developing cancer. She reports having unwanted, intrusive thoughts about the various ways this can happen to her, specifically developing lung cancer from pollution in the air. She typically avoids situations that trigger her OCD and make her anxious. This includes avoiding going outside or leaving her apartment, not having friends or family over because she does not want to open her front door, having multiple air purifiers in every room, excessively using disinfectant spray to “clean” the air. Jane says she only opens her front door to bring in delivered food and necessities. Sometimes she wears a mask to sleep due to feeling afraid she will inhale pollutants while sleeping. 

So how can ERP help her? With the guide of an experienced and trained therapist, Jane can start to integrate ERP to target her compulsive behaviors. In our practice we begin with getting a full inventory of those unwanted, intrusive thoughts and the compulsive behaviors. Making a record of this is key to really create our ERP plan. With knowing all the intricate and detailed compulsive behaviors, we work together to put them in list form, scaling them on how severe each fear or behavior is.

We use the Subjective Units of Distress Scale, SUDS for short. In our practice, we use a SUDS scale ranging from 1 to 10, 10 being the level you feel the most anxiety and distress at. Within the ERP realm, making this list and using SUDS is called a hierarchy. A hierarchy is one of the best tools to have when starting ERP and doing what we call, exposures.

ERP is a lot like going to the gym… #mentalworkout. When you first start working out you slowly start to build your endurance and muscle with the lighter weights and workouts. Going for the heaviest weights and the toughest workouts when you are just starting off could be very difficult and could even cause strained muscles or hinder motivation. We apply that same principle to therapy, especially ERP therapy.  OCD sufferers can see how they are making progress as they gradually work their way up their hierarchy, building resiliency and their ERP muscle. 

So, in working with Jane, we created her hierarchy as follows:

10- leaving apartment/ staying outside front door without a mask on

9- having friends or family over without a mask on

8- having the front door open longer than 20 seconds without a mask on

7- not having the air purifiers on and running all day long

6- sleeping without a mask

5- running out of disinfectant spray/ not using disinfectant spray

4- rushing to bring in her delivered food and necessities while wearing a mask

3- avoiding taking steamy showers due to the humidity/ water particles getting in her lungs

2- avoids cooking & eating hot food due to steam/ eating cold foods do not produce steam

As Jane begins her ERP therapy, she will start with the behaviors and fears between the 2-4 range, gradually making her way up to the most severe.  Jane will learn to stay present with her distress and fears of steam rising in the air as she cooks and eats a hot meal. This is an exposure. This exposure is at distress level 2 for Jane, which is low but still causes distress. Jane and her therapist will work together to repeat this exposure until Jane’s distress level is cut in half of what it is when starting, i.e. hitting a distress level of 1….#habituation. Exposures are most effective with REPETITION, just like any workout….#mentalgains. 

As you can tell, Jane’s experience with the OCD cycle is vicious and all consuming. Jane’s effort to eliminate her distress from the obsessive thoughts has left her feeling more alone than ever. Jane would not like to have these distressing thoughts or continue reinforcing them, however she does not know where to begin. The OCD cycle has hijacked her lifestyle and well-being.

Is ERP the same as flooding?

With the example of Jane’s work in ERP, she worked with her therapist to gradually work her way to the more severe fears and compulsions on her hierarchy. However, we want to note that an ERP plan can sometimes get confused with Flooding. Flooding is a type of exposure therapy that most often starts with exposing the client to some of the most difficult fears or stimuli with the goal to reduce or eliminate their immediate distressed response.

As you can tell, this seems like the opposite approach to creating a hierarchy and working your way up to the more severe items. It’s important to remember that Flooding is a type of exposure therapy. Flooding was found to be ineffective in the long-run when treating various disorders.  While flooding does involve exposure to triggers and obsessions, flooding is not conducted in a repeated and prolonged manner. ERP however, follow systematic and repeated exposures which allows for cognitive changes to take place, increasing it’s long-term effectiveness.  

Common fears about ERP

So back to ERP… You might be wondering: why would I put myself in situations that I am trying to avoid? What if facing my fears only makes them worse and I can’t move forward? What if ERP doesn’t work and I have this anxiety forever? How does ERP really help me?

These are all common fears that come up with thinking about ERP. The magic of ERP is response change, repetition of exposures, and habituation to the stimuli that ignites fear and anxiety. Facing your obsessions and compulsions for what they are, puts the power and control back in your hands. OCD’s goal is to keep you trapped in its cycle and control what you value most through your behaviors and feelings. Yet, once you begin to practice regaining control over the intrusive thoughts and behaviors, you begin to lift the heaviness OCD weighs over your life. And that is how ERP really helps you. 

ERP therapy challenges you to overcome the stress and anxiety connected to your fears, obsessions, and compulsions. ERP is an evidence-based treatment for OCD, which means that it has effectively and repeatedly proven how it decreases a client’s anxiety, changes the response to fears, and implements healthier behaviors. 

Further Reading: OCD Book Recommendations

Are you curious if ERP is right for you? Below are some great book recommendations (amazon affiliate links below) about ERP and resources for family members with loved ones struggling with OCD. If you would like more information about treating OCD and ERP therapy, you can contact us at a 713-331-5538 or info@hcfvl.com.

The OCD Workbook: Your Guide to Breaking Free from Obsessive-Compulsive Disorder by Bruce Hyman

 Loving Someone with OCD: Help for You and Your Family by Karen J. Landsman

Read More About the Treatment of OCD on our Blog!

• What is OCD?
• Do I have Obsessive Compulsive Disorder?
• What is an Obsession (Obsessive Compulsive Disorder)?