Exposure and Response Prevention Therapy

Scot Thomas, MD avatar
Reviewed by: Scot Thomas, MD
Updated: Sep 11, 2023

Obsessive-compulsive disorder, or OCD, is a mental health condition that affects slightly more than 1 percent of the U.S. adult population within a given year; adult lifetime prevalence has been estimated to be roughly 2.3%.1,2 Characterized by chronic, often-anxiety-producing obsessions (recurring, intrusive, uncontrollable thoughts) and compulsive behaviors in response to these obsessive thoughts, about half of the people in the U.S. who struggle with OCD experience severe impairment or disruptions to daily life.1,2,3 Some individuals may spend a few hours each day on rituals to try and dispel anxiety, while others are even more incapacitated by near-constant obsessions and related compulsive behaviors.1

One of the mainstays of OCD treatment is a form of cognitive-behavioral therapy (CBT) known as Exposure and Response Prevention, or ERP—sometimes also referred to as exposure and ritual prevention therapy.3,4 ERP involves first identifying both internal and external stimuli that trigger obsessions and obsession-related distress and, next, assigning them a hierarchical order in terms of the amount of distress that they elicit. With the help of a therapist, as treatment proceeds, the individual will be sequentially exposed to these situations while restraining from acting out the otherwise-alleviating compulsions.5

With time, individuals may be able to practice ERP techniques on their own at home as they work toward eliminating ritual behaviors throughout the day.5 The goal of exposure and response prevention therapy is to help individuals suffering from OCD habituate to these safe, controlled exposure situations to eventually stop compulsively performing disruptive ritualistic behaviors.

Basics of Exposure and Response Prevention Therapy

doctor prescribing exposure and response prevention therapy for addictThough individual protocols may vary somewhat, exposure and response prevention therapy might take place over a few hours per session, 2-5 times a week, for a few weeks total duration (or as necessary to achieve desired treatment effect). Homework, in the form of self-guided sessions, is often given in between therapist-led sessions.6,7

Individuals with OCD often suffer from more than one obsession and various associated repetitive behaviors. They may feel the need to constantly wash their hands for fear of germs, feel the need for symmetry and repeatedly organize things, or have thoughts of harm and constantly need to check that doors and windows are locked.

Exposure and response prevention therapy exposes individuals to their anxiety-producing thoughts while teaching them how to not respond with the ritualistic behaviors. The exposure component of ERP helps people to confront their fears by exposing them to situations that have historically triggered obsessions and anxiety. The response prevention aspect of ERP keeps a person from engaging in their ritualistic behaviors—such as hand washing after coming into contact with something considered dirty—as a coping mechanism.8 The ultimate goal is to lessen the anxiety felt after the perceived-averse exposure and minimize the compulsion to engage in ritualistic behaviors in response to it.

From start to finish, exposure and response prevention therapy may consist of several elements:5

  • Information gathering & treatment planning: At this point early in the therapeutic relationship, the clinician educates the patient about OCD and its treatment and collects information about individual symptoms. Early ERP sessions might be spent in the information gathering phase so that the clinician can better understand what the fears, obsessions, and compulsions are, and get a handle on the specific nuances of the OCD and associated behaviors. The avoidance patterns and triggers need to be specifically uncovered and identified. Pertinent external and internal stimuli that trigger distressing obsessive thoughts are identified, as well as the feared outcome if compulsive rituals aren’t performed. It is with this information that a fear hierarchy is established with regard to various situational triggers. Homework may be given that includes a personal assessment in order to better self-monitor triggers and responding behaviors.
  • In vivo exposure: Over the course of several therapy sessions, the therapist coaches the patient in confronting various trigger situations while providing instructions and support on how to resist engaging in compulsive behavioral reactions.
  • Imaginal exposure: Patients are instructed to envision the feared outcomes triggered by certain obsessions so that they better learn that such consequences do not occur, despite the lack of compulsive, ritualistic behaviors.
  • Self-guided exposures: As additional homework for the patient, they are tasked with eliminating rituals at home after practice exposures.
  • Relapse prevention planning to wrap up a course of ERP.

Exposure exercises may be “in vivo,” or direct exposure, or “imaginal” which is virtual exposure to fears that cannot be directly confronted, such as the fear of killing family members or fear of getting into an accident while driving. In following a hierarchical order, earlier exposure exercises generally address issues that produce a low to moderate amount of anxiety, building up to more anxiety-producing situations with subsequent sessions. In general, all anxiety-provoking thoughts and situations will be addressed in turn. Then, all remaining sessions can introduce new variations and help to build on what has been learned.

Individuals are encouraged to stay in the anxiety-ridden situations they are being exposed to for as long as possible without doing anything. With time, the anxiety will reduce on its own. The next time a person is exposed to the same trigger, the anxiety should be less than the time before. This is called habituation when, over time, a person who does not engage in compulsive/ritualistic behaviors will experience a drop in their anxiety levels associated with the triggering thought, object, or situation.6,9

It is important that the individual not engage in any avoidance or distraction techniques during exposure therapy. The point is to lessen the fear by exposure instead of engaging in ritualistic behaviors. The ritual prevention component of ERP can be difficult at first. If it were easy to stop engaging in obsessive-compulsive behaviors, people would be able to stop doing so on their own. This is why ERP builds up in a kind of hierarchy from low-level anxiety-producing triggers to higher ones over time, in each instance preventing the individual from carrying out their compulsion or ritual. Research suggests that complete response prevention during exposure therapy better outcomes than partial or no response prevention.10

Pros and Cons of ERP

Though ERP therapy may be the most effective psychotherapeutic intervention we have for OCD, not everyone treated in this manner—perhaps only half, according to some studies—will show recovery.11 One of the reasons for the relatively high rates of failure is that a significant number of people drop out prior to treatment completion or, if they do continue with the prescribed treatment duration, may not complete all of their ERP tasks or continue to engage in the homework or ritual prevention techniques outside of the sessions.

For some people, professionally administered ERP therapy can be difficult to find and costly to access. Additionally, ERP exposures can be frightening and difficult for patients.13 At times, a therapist may ask clients to engage in activities or put themselves into situations that may carry some element of risk. Some critics say it is cruel to expose individuals to what they fear most in the world. The benefits are thought to outweigh the risks, however, as exposure and response prevention therapy is among the first-line of treatment approaches for OCD.

ERP may be used as part of a treatment plan that includes other forms of therapy and medications, such as selective serotonin reuptake inhibitors (SSRIs).12 In some instances, ERP alone can be helpful for people who do not respond to medication therapy.3,4  Though ideally, ERP should be initially conducted with the help of a trained clinician, an added benefit of the treatment is that individuals can practice self-directed exposure and response prevention exercises anywhere and anytime that triggers may arise.12

ERP can be administered at different intensity levels and in a variety of treatment settings, including both outpatient and inpatient/residential.5 Through both clinician-led and self-guided exposure and response prevention therapy, people with OCD may be better able to gain insight into their obsessions and to gradually decrease the negative impact of ritualistic compulsions.

References

  1. Diagnostic and statistical manual of mental disorders: DSM-5(5th ed.). (2013). Washington, D.C.: American Psychiatric Association.
  2. National Institute of Mental Health (NIMH). (2017). Mental Health Information: Statistics—Obsessive-Compulsive Disorder (OCD).
  3. National Institute of Mental Health (NIMH). (2019). Obsessive-Compulsive Disorder.
  4. Substance Abuse and Mental Health Services Administration (SAMHSA). (2016). Advisory: Obsessive-Compulsive Disorder and Substance Use Disorders.
  5. Hezel, D. M., & Simpson, H. B. (2019). Exposure and response prevention for obsessive-compulsive disorder: A review and new directions. Indian journal of psychiatry, 61(Suppl 1), S85–S92.
  6. Hupper, J.D., & Roth, D.A. (2003). Treating Obsessive-Compulsive Disorder With Exposure and Response Prevention. The Behavioral Analyst Today, 4(1), 66-70.
  7. Jones, M. K., Wootton, B. M., & Vaccaro, L. D. (2012). The efficacy of exposure and response prevention for geriatric obsessive compulsive disorder: a clinical case illustration. Case reports in psychiatry, 2012, 394603.
  8. National Alliance on Mental Illness (NAMI). (2019). Obsessive-Compulsive Disorder.
  9. International OCD Foundation. (2019). Exposure and Response Prevention (ERP).
  10. Grant, J.E. (2014). Obsessive-Compulsive Disorder. N Eng J Med, 2014; 371:646-653.
  11. Strauss, C., Rosten, C., Hayward, M., Lea, L., Forrester, E., & Jones, A. M. (2015). Mindfulness-based exposure and response prevention for obsessive compulsive disorder: study protocol for a pilot randomised controlled trial. Trials, 16, 167.
  12. Fenske, J.N., & Petersen, K. (2015). Obsessive-Compulsive Disorder: Diagnosis and Management. Am Fam Physician. 2015 Nov 15; 92(10):896-903.
  13. National Alliance on Mental Illness (NAMI). (2019). Understanding Deep Transcranial Magnetic Stimulation for OCD.
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