Exposure and Response Prevention (ERP) treatment is the gold-standard treatment for OCD. This means it’s the treatment with the most research and most proven track record in helping those with OCD overcome the disorder. 

As a result of participating in ERP treatment, about 70% of individuals with OCD will experience significant and durable reductions in their OCD symptoms and around 60% of individuals with OCD will achieve remission. Of the approximately 30% who don’t benefit from ERP, a significant portion of these individuals were unable or unwilling to adhere to ERP treatment (such as unwillingness to complete at-home ERP practice in-between therapy sessions). 

Within my practice, it’s very rare for me to support a client who adheres to ERP treatment who doesn’t have a substantial reduction in their OCD symptoms and related improvement in their quality of life. 

So, what is ERP treatment?

Well, that’s a very large subject (and one that I explore in much more detail here). So, let’s review just the bare-bones essentials of what ERP is and how it works.

Almost everyone with OCD realizes that their life has become burdened by the presence of obsessions (usually called intrusive thoughts), related anxious feelings, and compulsive behaviors (sometimes called rituals). Although compulsive behaviors can help those of us with OCD neutralize intrusive thoughts – and reduce our anxiety – in the short-term, the intrusive thoughts always come back. And so the cycle of OCD continues.

ERP short-circuits this cycle and helps us get our life back. 

ERP begins with reviewing important facts about the human experience. These facts include:

• Everyone has unwanted, abhorrent / scary / taboo intrusive thoughts 

• Intrusive thoughts cannot be directly controlled

• It’s entirely understandable that our intrusive thoughts contribute to anxious feelings

ERP then builds on this foundation by identifying and reviewing the inevitability of uncertainty in our lives and the importance of willingness to take calculated risks as a part of our day-to-day experience. 

It’s very common for my clients to want to overcome their OCD while simultaneously having ambivalent feelings around participating in ERP (e.g., confronting their feared situations without completing their compulsions). I know what this is like since, in the case of my OCD, I “knew” I should be completing ERP treatment for three years before I finally summoned the willingness to actually complete my exposures. 

Although I hope my clients will be willing to begin exposures sooner rather than later, sometimes it takes months (or even longer) before a client is ready and willing to step into exposures.

In order for someone to be willing to participate in ERP treatment, it helps to understand how ERP works. As mentioned above, ERP short-circuits the OCD cycle and it does this by changing the way we respond to our intrusive thoughts. 

For most of us with OCD, once we have an intrusive thought, we instantaneously become anxious and then complete our compulsions to neutralize the thought and reduce our anxiety. In ERP treatment, we deliberately participate in activities that activate intrusive thoughts and anxious feelings and then, instead of trying to make the thoughts and feelings go away, we allow the thoughts and feelings to be present. 

In order to deliberately participate in activities that activate our intrusive thoughts and anxious feelings, we first identify our core fears and then construct a graded hierarchy which identifies and ranks anxiety producing activities on a 1-to-10 scale. 

Identifying our core fears helps us understand what we are really afraid of. Are we afraid of dying? Are we afraid of causing something terrible to happen? Are we afraid of being socially ostracized? Are we afraid of going to jail? Are we afraid of getting stuck with unwanted thoughts and related painful, anxious feelings forever, so that, although we’re still alive, our life has become like a walking torture-chamber? 

After we’ve identified our core fears, we construct a graded hierarchy. A graded hierarchy is a list of anxiety producing situations rated from least anxiety producing (“1) to most anxiety producing (“10). For instance, imagine I’m working with someone with contamination-related OCD and their core fear is that if their hands become contaminated they might die from a deadly germ (note that many of my clients with contamination-related OCD are less afraid of germs than they are afraid of their own thoughts and feelings related to the feeling of contamination). This individual may rate touching the door knob in my office as a “3” but touching the flusher of a toilet in a public restroom as an “8”. This touching of the object is the “exposure” and not washing their hands (or participating in other safety behaviors) is “response prevention”. 

Usually, we start the exposure and response prevention process by beginning with exposures that are outside of our comfort zone but not overwhelming. This usually means activities on the “2” or “3” of the graded hierarchy. It’s critical that we work together in exploring what exposures you’re willing to participate in that push you into an area that’s uncomfortable but not overpowering. As I always tell my clients: We will collaborate in identifying the right exposures for you and I will encourage you to take steps into uncomfortable exposures. But I will never force or pressure you to complete an exposure. 

We’ll practice these initial exposures over and over, first together in session and then on your own at home. I encourage my clients to practice at least one 45-minute exposure and response prevention exercise every day.

During the process of exposure and response prevention, we allow the unwanted thoughts and anxious feelings to be present while we practice OCD-related healing skills, including distress tolerance and psychological flexibility. Continued practice of these skills cultivates improved mastery and confidence that, while we don’t enjoy having intrusive thoughts and anxious feelings, we can tolerate those thoughts and feelings and continue living our lives even when they are present. 

As we practice these skills more and more, like any skill, we become better and better at them. Eventually, we become so good at these skills, they become second-nature or “muscle-memory” for us. And more and more often, we notice that it’s becoming easier and easier for us to handle the intrusive thoughts and related painful, anxious feelings. As the thoughts and feelings become easier to handle, we’re able to more freely live our lives with less intrusive thoughts, less anxious feelings.

In addition to our improved skills, we notice that our intrusive thoughts and anxious feelings are drifting away all on their own without us completing our compulsions. The process of our intrusive thoughts and anxious feelings going away all on their own without us completing our compulsions is called habituation. Habituation is similar to the process of jumping into a cold lake: Painful at first but the shock of the cold water goes away all on its own (and it’s not because your body heat heated up the entire lake). 

In general, it takes between 60 to 100 exposures (combined with response prevention) before someone with OCD notices a substantial, durable, and reliable reduction in their OCD symptoms. If they are completing their at-home practice five times a week, this means they can expect to have significantly reduced OCD symptoms within three to six months. 

While the above is the basic structure of the ERP process, everyone’s OCD journey is, of course, unique. Thus, the entire ERP process must be individually tailored for each person and that tailoring is something we’ll consistently collaborate on.