Exposure and Response Prevention (ERP) is the ‘gold-standard’ treatment for reducing symptoms of Obsessive and Compulsive Disorder (OCD). ERP has also been found to be effective in symptom reduction for phobias and anxiety disorders.
This cognitive-behavioural therapy (CBT) helps people gradually face their fears and obsessions, which, over time, is intended to reduce the need for engagement with thoughts, images, and urges which trigger unwanted behaviours (compulsions) and/or rituals to cope. This is called “habituation”, essentially becoming more comfortable with discomfort to allow for greater time and energy to be directed towards more meaningful aspects of life.
ERP has two major focuses being:
- Exposure: identifying and gradually facing feared thoughts, images, situations, and/or urges.
- Response prevention: reducing the impacts of rituals, compulsions, and safety behaviours associated to the feared thoughts, images, situations, or sensations.
So, what are the steps of ERP?
This step-by-step guide we will focus on OCD treatment developed collaboratively between a client and psychologist; however, this is also relevant to the intervention and treatment of phobias and anxiety disorders.
1: Assessment and learning
ERP starts with a thorough assessment of symptoms. This will explore:
- The obsessions experienced (thoughts, images, or urges).
- The compulsions and/or rituals used to cope.
- How symptoms impact functioning at home, school, work, and relationships.
Learning about OCD as a diagnosis and how it impacts the individual is a key early step in treatment, giving them the foundation and insight to be able engage in treatment.
This will also involve the introduction of tools such as mindfulness, designed to scaffold and support the individual through the distressing and challenging aspects of exposures.
2: Identifying triggers and developing a hierarchy of fears
Identification of specific triggers is used to build a “hierarchy of fears”. OCD triggers from least to most anxiety inducing will rate the associated distress on a scale from 0–100 scale.
3: Planning and doing exposures
This may look like starting with lower-level triggers, challenging but not overwhelming, which has been effective in providing validation, maintaining engagement, been linked to beneficial treatment outcomes.
Once the “hierarchy of fears” has been identified, individualised exposures will be determined collaboratively. These may include:
- Real-life (In-Vivo): directly confronting fears, such as touching something “contaminated,” leaving things “imperfect,” and/or reduction of checking or counting behaviours.
- Imaginal: imagining feared situations, such listening to or reading short scripts about feared scenarios.
- Body-focused (Interoceptive): inducing physical aspects of anxiety in session
The goal of exposure is not to suffer, but to stay with the trigger long enough for anxiety to rise and then naturally start to fall, without engaging in the compulsion and/or ritual. Over repeated exposures, this weakens the link between the trigger and the need to continue with the unwanted behaviours.
4: Response prevention
Response prevention is what is done when a trigger is active and may involve:
- Reducing checking or counting.
- Reducing reassurance seeking.
- Acknowledging the trigger without responding with the support of mindfulness exercises
By stepping back from compulsions and/or rituals, you teach your brain (Habituation) that the discomfort is not an emergency, which allows anxiety to fall naturally over time.
5: Repetition, progress, and setbacks
ERP and mindfulness work through repetition, not one-off exercises. Between sessions, agreed exposures and response prevention may be set as homework.
Progress is rarely linear, with some days feeling easier, and others like a step back. Research shows that fluctuations are normal and can be used to fine tune the plan rather than be seen as failure.
As confidence builds, individuals may move towards or challenging triggers on their “hierarchy of fears”, armed with tools and evidence that they can cope.
6: Maintaining gains and planning ahead
Towards the end of therapy, the focus shifts to maintain gains and relapse prevention. This may include
- Using “booster” exposures when new triggers pop up.
- Notice and step back from new or subtle compulsions utilising the tools learned in therapy.
- Make choices based on your values rather than what feels safest to OCD.
Follow-up research suggests that ERP studies suggest that most people who complete treatment retain meaningful benefits months to years later, especially when they continue to use these skills in daily life.
Getting help with ERP in Brisbane
ERP is a practical, evidence based way to reduce OCD symptoms and reclaim the parts of life OCD has taken over. Please consult with you’re a referral to the OCD Clinic Brisbane with your Doctor if you feel that OCD is interfering with the life your want to be living.
References
Foa, E. B., Yadin, E., & Lichner, T. K. (2012). Exposure and Response (Ritual) Prevention for Obsessive–Compulsive Disorder: Therapist Guide (2nd ed.). Oxford University Press.
https://global.oup.com/academic/product/exposure-and-response-ritual-prevention-for-obsessive-compulsive-disorder-9780195335291
NICE. (2005). Obsessive-compulsive disorder and body dysmorphic disorder: Treatment (Clinical Guideline CG31). National Institute for Health and Care Excellence.
https://www.nice.org.uk/guidance/cg31
Öst, L.-G., Havnen, A., Hansen, B., & Kvale, G. (2015). Cognitive behavioral treatments of obsessive–compulsive disorder: A systematic review and meta-analysis. Clinical Psychology Review, 40, 156–169.
https://doi.org/10.1016/j.cpr.2015.06.003
Rosa-Alcázar, A. I., Sánchez-Meca, J., Gómez-Conesa, A., & Marín-Martínez, F. (2008). Psychological treatment of obsessive–compulsive disorder: A meta-analysis. Clinical Psychology Review, 28(8), 1310–1325.
https://doi.org/10.1016/j.cpr.2008.07.001
