What exactly is Exposure and Response Prevention (ERP) and what does treatment look like?
Exposure and Response Prevention (ERP) is a highly effective, evidence-based treatment for Obsessive-Compulsive Disorder (OCD) and related anxiety conditions. While the name can sound intimidating at first, ERP is not about forcing people into distress or taking away coping tools. Instead, it is a collaborative, structured approach that helps individuals gradually reclaim their lives from anxiety, fear, and ultimately learn to tolerate uncertainty. ERP is considered the gold-standard treatment for OCD, and research consistently shows it can lead to significant and lasting symptom reduction when done correctly.
Note: This blog post is purely for informational purposes only and is not a substitute for direct mental health advice from a qualified professional.
How OCD and Anxiety Stay Stuck
OCD and anxiety are maintained by a cycle. Before understanding the cycle, it’s important to define obsessions and compulsions. Obsessions are intrusive, unwanted thoughts, images, urges, or doubts that cause significant anxiety or distress. Compulsions are repetitive behaviors or mental acts performed to reduce anxiety or prevent a feared outcome related to the obsessions. These two experiences interplay in a very challenging way that can feel almost instantaneous.
During the OCD cycle a person suffering from OCD will be confronted by an obsession. Often this can take the form of a “What if?” question, such as “What if I offended that person and don’t even know it?”. This line of thinking will trigger feelings of anxiety or distress. Sometimes this can also feel like a significant urgency or importance. The person with OCD will then engage in compulsion (behavior or mental act) meant to reduce the anxiety or distress.
Following along with the previous example, this can look like mentally reviewing the conversation for inflammatory language or mentally analyzing the facial expression of the friend involved. This is called a mental compulsion. This can also take the form of a more explicit compulsion such as texting the person to apologize where no apology is needed, or asking if they overstepped during the previous interaction.
The person with OCD will often feel temporary relief if they feel they have been sufficiently reassured. Unfortunately, this compulsive reassurance only lasts until the next obsession or doubt comes along. Over time, the brain learns that anxiety is dangerous and must be neutralized immediately, making the cycle stronger.
ERP works by gently teaching the brain a new lesson:
Anxiety can be tolerated, and feared outcomes are either unlikely or manageable.
What Happens in ERP Treatment?
The first step in ERP treatment is education and assessment. You and your therapist work together to thoroughly identify obsessions, compulsions, avoidance, and safety behaviors. They then contextualize this information to help you understand how OCD shows up uniquely in your world. You will then learn how ERP works and why it helps. It is very important that clients have a thorough understanding of this step. ERP should never feel rushed or confusing because it’s important that clients understand how and why they need to remove the behaviors that often feel very protective for them.
During the education portion of treatment clients also co-create an exposure hierarchy with their therapist. Exposure involves intentionally approaching feared situations, thoughts, or sensations rather than avoiding them. Exposures are planned collaboratively and are introduced gradually. A good exposure is also tailored to the individual and the way their obsessions manifest to them personally. Exposures are also repeated over time so learning can occur, and the client’s brain can learn to relate differently to the fear.
There are two main types of exposure. In-vivo exposures, which mean real-life situations, and imaginal exposures, or using the mind. In-vivo exposure involves directly facing feared situations in the real world. Some examples of in-vivo exposures include:
Touching a doorknob without washing hands afterward
Leaving the house without checking the stove multiple times
Sitting near someone when afraid of harming them
Wearing clothes without repeatedly adjusting them for “just right” feelings
Sending an email without rereading it excessively
Some fears can’t be practiced safely or realistically in real life, so this is where imaginal exposure is used. Imaginal exposures involve intentionally imagining feared scenarios in detail. Often this takes the form of writing out imagined scenarios or listening back to stories involving the feared situation or event. These are referred to as exposure scripts. Some examples of imaginal exposures include:
Imagining causing harm and sitting with the uncertainty
Writing and listening to a script about making a catastrophic mistake
Imagining being responsible for a negative outcome
Visualizing illness or loss when the fear cannot be tested directly
Imaginal exposures are not positive thinking or reassurance; they are designed to help the brain stop treating thoughts as threats. This new learning happens when a client is exposed to the feared scenario while also abstaining from compulsions. This leads to the OCD cycle falling apart because the person learns that they do not need to perform compulsions to get rid of the anxiety and discomfort. This is where the “RP” in ERP comes in.
Response prevention means reducing or eliminating compulsions and avoidance behaviors after exposures and triggers. This can involve delaying and/or abstaining from compulsive washing, checking, confessing, or seeking reassurance. A well-trained ERP therapist can also help clients practice resisting mental compulsions. This can involve learning how to relate and respond to the intrusive thoughts without participating in the rumination cycle, which is commonly observed in those with mental rituals.
Response prevention involves letting anxiety rise and fall naturally and learning to tolerate uncertainty and discomfort without the need for compulsions. Importantly, response prevention is done at a pace that is challenging but achievable, not overwhelming. For instance, a therapist may start off by inviting the client to delay the compulsive behavior as a form of resistance. I lovingly refer to this as “kicking the can”. The idea is that if a client can delay a compulsion for 5 minutes, they eventually tolerate delaying for 10 minutes, and so on.
In summary, ERP involves understanding how OCD is unique to the client and gradually exposing them to their obsessions while helping them resist compulsions. Overtime with consistency and practice, their brain learns to tolerate uncertainty.
What to Expect During ERP
Anxiety is expected and temporary in ERP. This can feel different than traditional talk therapy where a person’s fears are reframed or reassured by the professional. ERP works because anxiety is allowed to rise and fall on its own. It’s also important to note that progress is not linear. Setbacks are part of learning, not failure. However, skills improve with practice and consistency. Over time, anxiety decreases faster and compulsions lose their grip. Ultimately, ERP is not about eliminating thoughts or feelings, but about changing client’s relationship to them.
Common Misconceptions About ERP
“ERP is cruel or extreme”
ERP is carefully planned and paced. Ethical ERP never involves surprise, humiliation, or overwhelming fear.
“ERP means never coping”
ERP does not remove healthy coping skills. It targets compulsions, not emotional regulation skills or self-care. However, sometimes traditional self-care behaviors can become compulsive and lose the intention behind the behavior. (I.e. praying “perfectly” for the sake of making an intrusive thought go away, as opposed to praying as a part of worship or normative religious ritual.)
“If I feel anxious, it’s not working”
Anxiety during exposure is a sign that learning is happening not that treatment is failing.
“I should wait until I feel ready”
Readiness often comes after starting ERP, not before.
Why Seeing an ERP Specialist Matters
ERP is a specialized treatment that requires advanced training and experience. Working with a therapist who is not properly trained can unintentionally reinforce compulsions, encourage reassurance or avoidance, mislabel OCD and sometimes lead to stalled or worsening symptoms.
An experienced ERP specialist understands subtle mental compulsions, knows how to design effective exposures, understands the role of a core fear, and helps you face fears without reinforcing the disorder. ERP is challenging, but it can also be very empowering. With the right support, individuals learn they can handle discomfort, uncertainty, and fear without letting OCD or anxiety dictate their lives.
If you’re considering ERP, know that you don’t have to do it alone and you don’t have to do it perfectly. Progress comes from willingness, practice, and compassionate guidance from a trained professional.
“Courage is not the absence of fear—it’s feeling the fear and proceeding anyway.”
- Nelson Mandela
