Exposure and response prevention (ERP) for OCD

Obsessive-compulsive disorder (OCD) is a mental health condition with often-distressing symptoms, thoughts, and compulsive urges. Although it may be subject to various mental health myths and stigmas, OCD is a real condition that is not a synonym for “clean.” It is not another way of saying “organized” or “quirky” and is not an acronym for “obsessive Christmas disorder.” Misinformation and social stigma around mental health conditions are two of the most significant mental health issues that the world is currently facing.

Although this disorder may be represented through media depictions of people compulsively washing their hands, handwashing is not the only compulsion affecting people with OCD. OCD can also involve only obsessive or intrusive thoughts without compulsions. Understanding OCD and how to treat obsessive-compulsive disorder can help reduce stigma and allow more individuals to find treatment.

One common way of treating obsessive-compulsive disorder is called exposure and response prevention therapy (ERP), which involves exposure to fears. It is highly associated with the effective management and remission of symptoms. In this article, we explain how exposure and response prevention works for treating OCD and what the potential benefits are.

What is OCD?

Obsessive-compulsive disorder is a serious mental illness that affects around two to three million US adults. It is characterized by the recurrence of upsetting and unwanted thoughts and urges, which may manifest as compulsive behaviors. Symptoms are not limited to a preoccupation with cleanliness or organization. OCD can present in various ways, including intrusive or obsessive thoughts.

The DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition) defines obsessive-compulsive disorder by the following criteria: 

1. Obsessions are unwanted reoccurring thoughts, urges, or mental images (usually that cause mental distress and anxiety). 
2. The individual attempts to ignore or repress the obsessions, often through compulsive or ritualistic behaviors. 
3. Compulsions are repetitive actions or mental acts that the individual feels they must perform in response to the obsession, usually with rigid rules applied. 
4. The repetitive behaviors are aimed at reducing or preventing distress or preventing a dreaded event from occurring. However, there is either no real physical connection between performing the compulsive behavior and preventing the feared outcome or the behavior is clearly excessive. 
5. Ritualistic behaviors take up more than one hour every day or cause impairment socially, at work, or in other important areas of daily functioning. 
6. The mental condition could not be described better by the diagnostic criteria of another mental disorder, such as generalized anxiety disorder or body dysmorphic disorder. 
7. The disturbance is not induced by substance abuse, pharmaceutical medication, or a general medical condition. 

If you are struggling with substance use, contact the SAMHSA National Helpline at (800) 662-4357 to receive support and resources. Support is available 24/7.

Intrusive thoughts commonly center around highly distressing themes such as the fear of harming another person, religious scrupulosity, or the fear that you have said, done, or want to do something profane, offensive, violent, or sexually inappropriate. Intrusive thoughts are not “quirky” urges or behaviors and are not funny. They are severe, intense, and often immensely distressing for the individual experiencing them. 

Intrusive thoughts and compulsive behaviors are not isolated to just people with OCD and related disorders. ERP therapy may be beneficial for anyone experiencing symptoms, even if they are not formally diagnosed with obsessive-compulsive disorder. The International OCD Foundation has formulated several resources for OCD education, including treatment options, helpful links, and official symptoms. They also discuss intrusive thoughts, childhood OCD, and common myths about treatment.

What causes an OCD cycle

The OCD cycle may begin with a trigger, such as an intrusive thought. This thought may feel so upsetting that an individual feels out of control or overpowered. For example, a person might suddenly think that they accidentally harmed someone they cared about earlier in the day, even if they know they did not. They might experience intense fear, doubt, and uncertainty throughout the day and feel unable to stop thinking about it.  

Once an intrusive thought or compulsion urge is triggered, it may feel like a real danger that the person with OCD or someone near them is exposed to. They may struggle to reason with themselves, even if they feel their thought or urge is illogical. In the example above, the individual with OCD may perform a compulsion, such as checking in with the person multiple times throughout the day, to calm their nerves. 

However, for many with OCD, thoughts become stuck in their mind, regardless of reassurance or momentary relief. Even if the person checks in with their loved one throughout the day, their relief may only last a few minutes. When they drive away, they may start to worry again that their experience was false or that something else has happened in the few minutes they have been gone or while at the person’s house. They may crave performing the compulsion again, and the cycle may continue. 

Obsessions and compulsions

According to the American Psychiatric Association, obsessive or intrusive thoughts may be complex for a person experiencing OCD. Often, the more someone tries to “turn off” or reject a thought, the more it may occur. They may feel that the only way to relieve the thought is to partake in a compulsion. Often, obsessions are based on a person’s fears or morals. For example, someone with a fear of abandonment may experience repetitive, obsessive thoughts about being abandoned and may partake in the compulsion of asking for reassurance to feel relief.

As the thoughts continue, people with OCD may partake in multiple compulsions, often in the form of rituals or repetitive behaviors.

An example of an obsessive and compulsive cycle might include the fear of your friend getting hurt while on a hike. You might start obsessing over the idea that your friend may fall and hurt themselves. 

In this situation, the compulsion may be asking your friend to stand on the other side of the path or asking if you can turn back and go home. If your friend cannot comply, you might physically put yourself between them and the side of the path or notify them whenever the path becomes narrow. In response, your friend might feel controlled or micromanaged, which may cause further fears and obsessions, restarting the cycle. 

What causes OCD?

OCD is a serious mental illness and it can be challenging to pinpoint the exact cause of OCD or other anxiety related disorders. However, it may be a combination of genetic, brain chemistry, and environmental factors.Studies have found that OCD is around 45% to 75% hereditary. Often, OCD may be passed down through the mother’s side. 

Some researchers believe that OCD can arise due to something called classical conditioning. Classical conditioning is when someone makes a cognitive connection between two unassociated stimuli. One of the most famous examples of classical conditioning is Ivan Pavlov’s experiment that got dogs to salivate at the sound of a bell by giving them treats every time the bell rang. 

A traumatic experience can become linked to unrelated stimuli, leading to anxiety and fear when exposed to the stimuli. Someone experiencing OCD may feel the need to engage in ritualistic behavior to make the distress stop. ERP works to undo this classical conditioning by exposing the individual to the stimuli that they fear and in doing so, rewire their brain to no longer make that association.

What is exposure and response prevention therapy? (ERP)

As an OCD treatment administered by therapists, ERP refers to exposure and response prevention. It is one of many systematic desensitization forms and is often considered the gold standard treatment for OCD because it has been proven more effective than any other treatment or placebo, including medication, cognitive-behavioral therapy (CBT), and other forms of treatment. It is widely used worldwide to treat OCD, phobias, and other anxiety disorders. 

Evidence-based treatments like traditional cognitive counseling or exposure response prevention techniques can be done remotely or from a therapist’s office. It targets the fears and obsessions of OCD to reduce their perceived power or control. For example, a person who fears making others angry with them might practice exposure by not partaking in reassurance-seeking compulsions. Although not partaking in a compulsion can cause stress, over time, it may show the patient that no harm has come from not partaking in it, reducing the fear response to the obsession itself and allowing the patient to tolerate distress by using healthy coping strategies.

ERP may help patients control their responses to intrusive thoughts, distress, or obsessions. They may see situations in a new light and feel in control of their mind and actions. This difference in fear response may allow them to use objects they were afraid to use before or learn new behavioral coping mechanisms to cope with anxiety if it occurs. Although OCD may not be fully treatable, it can be manageable with coping mechanisms. 

Although medications may benefit some people with OCD, ERP can be more effective. Anxiety medication is commonly used in conjunction with a course of ERP because it may lessen the severity of the thoughts and a person’s responses to them. However, because the medication does not address the underlying cause of OCD, it may not be a long-term solution. Using counseling in conjunction with medication may be effective. 

How does ERP work?

ERP sessions expose patients to their fears while preventing the compulsive responses and obsessions they may want to engage in. When they first enter a session, they may outline their obsessive thoughts and commonly engaged in compulsions. Then, they may mark each thought or obsession on a scale of one to 100 using subjective units of distress that indicate how much it scares them or how intense their urge to partake in compulsion is. Starting with one of the lower fear points, a therapist may help clients identify methods of exposing them to their fear.

For example, if a client’s lowest rated fear is a fear of being harmed by a shot or IV at the doctor, they may partake in the following exposure activities: 

• Holding an empty syringe in the session with the cap on 
• Talking about needles, shots, and IVs with the therapist
• Watching their therapist put the needle near their arm (without putting it in) 
• Holding the syringe with the cap off and looking at the needle 
• Having the therapist put the syringe on the client’s arm with the cap on, in the spot where a doctor might insert it 
• Having the therapist accompany the client to an appointment to donate blood, get a shot, or get an IV saline treatment 

The therapist may ask the client to track their anxiety throughout each repeated exposure. They might prompt them every few minutes to ask their anxiety level from one to 100. After the client’s anxiety reduces for each activity, they may move to a more frightening activity. These exercises are a type of inhibitory learning approach and could be repeated for each one of a person’s obsessions and compulsions. 

Note that exposure should not put a client in danger. If you feel that an exposure activity would harm you physically, do not partake in it. However, ERP can require a willingness to confront your ideas of what is harmful and what is not. A therapist may be able to help you understand if your fears avoidance behaviors that are driving your desires to not partake in specific exposures. 

Exposure for pure obsessive OCD

For clients who have pure obsession-type OCD (pure O), exposure may look different. In these cases, a client might struggle with obsessive thoughts without an urge to partake in a compulsion. These thoughts may be intrusive thoughts with distressing images or ideas or repeating ideas, pictures, or phrases within the mind. Exposure therapy for this type of OCD can be similar and may utilize operant conditioning.

For example, if someone has a recurrent obsession where they believe others can read their mind, the exposure activities might look like the following: 

• Repeating “yes, people can read my mind” in your head 
• Stating out loud, “you can read my mind,” to your therapist 
• Allowing thoughts to continue instead of stopping them or replacing them 
• Encouraging your thoughts to continue 

Although it can be terrifying for a person with OCD or other mental health disorders to partake in exposure therapy, they may find that anxiety levels go down after a few sessions. It may be best to practice this within a session with the supervision of your therapist before trying it at home. If your therapist feels confident with your progress on your treatment plan, they may offer you exposure worksheets to track your anxiety as you work on specific fears throughout the week. 

If you have violent, inappropriate, or unkind intrusive thoughts that scare you to talk about with your therapist, you may choose to leave these thoughts until you have taken care of other thoughts first. However, opening up about these intrusive thoughts can be beneficial. If your therapist is a trained ERP specialist, they might have experience with intrusive thoughts and know they can exist, meaning they may avoid judgment when treating them. 

How can ERP be effective? 

Research shows that exposure and response is only effective if a patient feels fear during the exposure, in other words, there must be a feared stimuli present. If they choose a fear that they feel in control of already, there may not be a change in symptoms. The practice may involve actively choosing to face fears that most scare you, knowing that your therapist is there to support you if needed. Willingness can be an essential aspect of this practice. 

Breaking the barrier of the OCD cycle may involve searching for and actively approaching ideas, thoughts, and actions that scare you the most. Although it can be challenging to face these, your therapist may help you get started. In your first few appointments, let your therapist know if you want to slow the process. Credible organizations and professionals offering ERP programs may help you develop your willingness to partake in treatment and explain the process in detail. 

How is ERP different than other forms of treatment?

Many types of treatment, including cognitive behavioral therapy, transcranial magnetic stimulation therapy, and exposure and response therapy, are effective at helping OCD. Cognitive behavior therapy (CBT), also known as individual behavior therapy, addresses the thinking patterns and thought distortions that lead to compulsive behaviors. On the other hand, ERP is considered a behavioral approach. During ERP therapy, the goal is to create systematic desensitization to feared outcomes. This practice can help people with obsessive-compulsive disorder realize that their feared outcomes are not reality. These two therapeutic approaches may have the most effective treatment outcomes when combined. 

Traditional talk therapy, including cognitive behavioral and acceptance commitment, can be an effective first line treatment for OCD when combined with practicing exposure and response prevention. For example, the patient may learn coping skills in CBT to help them face their fears during exposure therapy. Talking through the experience after practicing ERP exercises might be beneficial for developing effective response prevention strategies and recognizing thought distortions such as absolute thinking.

People with OCD may regard their obsessive-compulsive beliefs with varying levels of insight. This means that some people are more aware that their obsessive-compulsive beliefs are probably not true, whereas other people are completely convinced that their obsessive-compulsive beliefs are true to reality. CBT may be able to help patients in the latter category shift their thinking and realize that their obsessive-compulsive beliefs are not realistic and are in fact symptoms of a mental health disorder. 

Fears about exposure 

Some people may feel nervous about attending exposure therapy due to what it may mean for them. They might believe that opening up about their intrusive thoughts will make their therapist angry or disgusted with them. However, many people with OCD experience these thoughts. You are not alone. Many individuals may struggle before discussing these thoughts due to embarrassment or shame. However, exposure therapy can offer the chance to face these fears and take control of them. Having an intrusive thought does not necessarily mean you want to partake in it. 

Asking for help from OCD specialists can be a brave step. If you are unsure about ERP, consider making an appointment and letting your therapist know. You can have a first session to outline your goals and decide whether it is right for you. ERP can be challenging, uncomfortable, and scary, but it has high success rates and may benefit you.

Relapse prevention planning

One of the treatment steps that you might take with a therapist who specializes in treating compulsive behavior is to create a plan to prevent relapse. Relapse prevention planning for obsessive-compulsive disorder is similar to prevention planning for substance abuse disorders. A mental health relapse is defined as a return of the patient’s symptoms to the same level as before treatment. 

Relapse prevention planning is usually one of the last stages in the ERP treatment process, done when the patient is showing signs of significant improvement in their OCD symptoms. When it comes time for prevention planning, the exposure component is replaced with mostly CBT. 

Understanding how OCD works can be helpful in preventing relapse in people experiencing obsessive thoughts. Intrusive thoughts are not exclusive to people with obsessive-compulsive disorder, which can be an important thing for people with OCD to be aware of. They may fear that if an intrusive thought does occur, it means that they are headed into an OCD relapse. The fear that intrusive thoughts of any kind may lead to relapsing could rekindle the OCD cycle.

ERP therapy can significantly reduce the frequency of intrusive thoughts, but research has shown that intrusive thoughts are normal experiences that are not always symptoms of mental disorders. A mental health professional can work with the patient to create a plan for how to cope with intrusive thoughts and what to do if their OCD symptoms arise again in the future. Being mentally prepared and having an actionable plan for if symptoms return can help to prevent a relapse into compulsive behaviors. 

Counseling options

You may be able to find a specialized exposure treatment center or a therapist trained ERP in near you in your area. Some providers offer exposure group therapy or exposure camps for those experiencing OCD. In some areas, short-term residential treatment options are available for those with an OCD diagnosis. However, you can also partake in exposure treatment online if you cannot take advantage of other methods due to cost or distance. 

A recent study found that internet-based programs for OCD were more cost-effective than in-person programs. Other studies have found that specific internet-based treatments, like virtual reality exposure therapy, were highly effective in treating OCD. Online counseling can offer flexibility and control over treatment, as you can choose between phone, video, or live chat sessions. Your therapist may also offer worksheets and resources on exposure and OCD after your sessions. 

If you are interested in this form of counseling or want to try another effective treatment for OCD, consider signing up for a platform like BetterHelp, which offers over 30,000 licensed therapists specializing in various mental health conditions and symptoms. 

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