The ERP Approach

Exposure and Response Prevention therapy, or “ERP,” is one of the most effective treatments for Obsessive-Compulsive Disorder (OCD) and other anxiety disorders. ERP involves facing the thoughts, situations, sensations, and uncertainties that cause anxiety while learning to resist the compulsions and avoidance behaviors that normally follow.

When OCD creates anxiety, it can feel like you need to do something to make that anxiety go away. You might check something repeatedly, ask someone for reassurance, search for answers online, avoid a situation, review something in your mind, or perform a ritual. These behaviors can make you feel better for a short time, but the relief does not usually last. You may soon find yourself questioning the same thing again.

ERP helps you change this pattern. Rather than continuing to respond to intrusive thoughts and anxiety with compulsions, you learn to face the uncertainty and discomfort without giving OCD the response it is demanding.

We will work together to determine what situations, thoughts, people, places, sensations, and uncertainties are triggering your OCD or anxiety. We will also look at what you do in response to those triggers.

Some compulsions are easy to recognize, such as washing, checking, or repeating a behavior. Others can be much harder to notice. Asking for reassurance, researching a question, reviewing a conversation in your mind, analyzing your intentions, or trying to figure out whether a thought is meaningful can all become compulsions.

Understanding these patterns gives us a better idea of where to begin with ERP.

We will then create a structured list of situations that you would like to approach differently. Some exposures may be relatively easy, while others may be more difficult.

You do not have to begin with your most difficult fear. We will determine together which exposures make sense to start with and gradually work toward situations that have had a greater impact on your life.

Once we choose an exposure, you will practice approaching the situation rather than avoiding it. At the same time, you will work on resisting the compulsion or safety behavior that you would normally use to reduce your anxiety.

For example, someone with contamination OCD might touch something they consider contaminated without immediately washing their hands. Someone with health anxiety might notice a physical sensation without repeatedly checking their body or searching for symptoms online. Someone with scrupulosity might allow uncertainty about whether they have sinned without repeatedly confessing, praying, or asking someone else for reassurance.

ERP is not about proving that your fears are irrational. It is also not about making sure that nothing bad will happen. Instead, you are learning that you can experience anxiety and uncertainty without having to perform a compulsion.

Some fears are difficult to address through exposure to a physical situation. For example, you may be afraid that something will happen in the future, or you may be troubled by an intrusive thought about something that cannot actually be recreated.

In these situations, we may use imaginal exposure. This can involve writing a narrative about the feared situation and reading it aloud or listening to a recording of yourself reading it.

The purpose is to allow the thought or possibility to be present without trying to resolve it through compulsions.

ERP does not only happen during our sessions. Practicing on your own is an important part of treatment.

As you become more comfortable with ERP, you will have opportunities to practice responding differently to OCD in your everyday life. This may involve resisting reassurance seeking, reducing avoidance, allowing an intrusive thought to remain unanswered, or doing something that anxiety has been telling you to avoid.

These practices help you take what you learn in therapy and apply it to your daily life.

OCD and anxiety can become more active during periods of stress or change. Having an increase in symptoms does not mean that you have failed or that the treatment did not work.

Once you have learned how to use ERP, you can continue using these skills when OCD becomes more noticeable again. Returning to exposures and recognizing compulsive behaviors can help keep OCD from gradually taking back parts of your life.

One of the most difficult parts of OCD is the desire for certainty. You may want to know for sure that you are healthy, that you did not make a mistake, that you have not sinned, that your relationship is right, or that something bad will not happen.

Unfortunately, many of these questions cannot be answered with complete certainty.

ERP helps you become more comfortable with that uncertainty. Instead of continually checking, researching, analyzing, or asking for reassurance, you can learn to allow the question to remain unanswered.

This is also where I find Acceptance & Commitment Therapy (ACT) helpful. ACT focuses on psychological flexibility and learning to respond differently to difficult thoughts and feelings. Rather than spending your time trying to eliminate anxiety, you can begin making choices based on what is important to you.

ERP and ACT can therefore work together to help you face your fears while also moving toward the life you want to live.

ERP is best known as a treatment for OCD, but exposure-based therapy can also be helpful for other anxiety and fear-based disorders.

At Northart Counseling, I use ERP to treat OCD and concerns such as:

• Scrupulosity and religious OCD
• Health anxiety
• Relationship OCD
• Contamination OCD
• Harm OCD
• Intrusive thoughts and mental compulsions
• Panic and fear of panic attacks
• Phobias and other fear-based disorders

The way ERP looks will depend on the concerns you are experiencing. For some people, treatment may focus heavily on reducing reassurance seeking or mental compulsions. For others, it may involve gradually returning to situations they have been avoiding or learning to tolerate uncomfortable physical sensations.

ERP can be difficult at times, but you do not have to figure it out on your own. We will work together to understand your OCD or anxiety, identify the patterns that are keeping it going, and gradually work toward changing those patterns.

The purpose of ERP is ultimately to help you regain the freedom to live your life without having to organize it around fear, anxiety, and uncertainty.