What to Expect in Exposure and Response Prevention Therapy (ERP)
So, you’ve completed the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS), been diagnosed with obsessive-compulsive disorder, and been recommended to participate in exposure and response prevention therapy, or ERP for short. You might be feeling a range of emotions, from sadness to concern to even fear, and wondering what exposure therapy actually involves. You might also be hesitant, or downright resistant, to the recommendation. My hope with this post is to dispel myths and enhance people’s understanding of this heavily research-backed treatment method so that misconceptions do not create any additional barriers to receiving appropriate care.
Most often, clients arrive at the first session bracing themselves for something akin to an episode of Fear Factor. While confronting your anxiety and fears is a part of the treatment, there are other components that are necessary for success. We’ll break down ERP into four phases: assessment and education, data collection and planning, exposure work, and relapse prevention.
1) Assessment & Education
The beginning stages of services will primarily be focused on assessment and psychoeducation. We will complete assessment measures to establish a baseline of your symptoms. Be prepared — the Y-BOCS will become our companion throughout our time together, as it is important for both of us to track how you’re responding to ERP and the progress you’re making. Psychoeducation on both OCD and ERP is fundamental, so you will be provided with a multitude of resources on both (articles, podcasts, webinars, workbooks, etc.) and guided through how OCD symptoms are maintained, the mechanics of ERP, and how our exercises will target those symptoms.
In an outpatient setting, sessions are typically an hour long, conducted on a weekly basis, and can take anywhere between 12 to 20 sessions. However, this may look different from person to person depending on their symptoms and needs.
2) Data Collection & Planning
ERP is homework-heavy, meaning that you will be assigned tasks to complete and will need to dedicate time on a daily basis to these tasks or skill practice. One of your first homework assignments will be tracking and identifying triggers, obsessions, and compulsions throughout the week. This task might feel especially burdensome, but it plays an integral role in the development of our exposure exercises. We’ll take this data and create a roadmap of how everything connects and identify the areas that will be most important to challenge and target.
From there, we will collaboratively begin to brainstorm various exercises and create a list or hierarchy to work through. The word “collaboratively” is intentional here — you will always play an active role in the decision-making process because this is your therapy and your consent is paramount. Exposure exercises are meant to provoke distress, yes, but they also need to be relevant and value-congruent. We are not completing a series of random tasks simply because they are disturbing; exercises are purposeful, strategic, and you will never be asked to do anything that conflicts with your beliefs or values. Deception and torment are not goals of exposure-based therapy.
There are several types of exposure exercises:
In vivo: confronting the feared situation or stimuli in real life.
Imaginal: vividly imagining the feared situation or stimuli, often through the development of a written “script” or narrative.
Interoceptive: Yo
We will aim for a spread of exercises that are reflective of the obsessions you are experiencing.
3) Exposure & Ritual Prevention
At this point, we will have an agreed-upon list of exercises to complete. The way the list is executed may vary; we might develop a structured hierarchy and scale exercises by level of distress, or we might approach it as an exposure lottery, randomly selecting which exposure to complete each session. Regardless of our approach, we will almost always complete the exercise together first, and then it will be assigned as homework for the following week. Each exercise will be framed as an experiment, with a clear intention established before we begin.
Exposure sessions will feel very different from a typical talk therapy session, and that is deliberate. It might feel awkward, it might be quiet, and you will likely feel uncomfortable or uneasy. Our goal is to help you learn about yourself, the validity of your fears, and how to manage distress without fighting your anxiety or ritualizing. This learning comes from a combination of the exposure task itself and your commitment to refraining from compulsions, which is what the “response prevention” portion of the treatment’s name refers to.
4) Relapse Prevention
This is where our time together begins to draw to a close. As noted earlier, the Y-BOCS will be incorporated at various points throughout our work together. Once we have completed our list of exposures, we will review any changes in your Y-BOCS severity score and reflect on everything you have accomplished. Empowerment and pride are positive byproducts of ERP, and this phase is a meaningful opportunity to recognize how far you have come! Additionally, this phase may include identification of areas that warrant revisiting, residual compulsions to monitor, and any further skills or strategies that will help you sustain the progress you have made.
And that’s ERP in a nutshell! If ERP has been recommended to you, I hope this overview has begun to address any questions or concerns you might have. For further reading, we recommend the following resource from the International OCD Foundation:
Katie Davin, LCMHC
Katie is motivated to assist individuals in tackling the obstacles that prevent them from connecting with others and experiencing life in the ways they want to. Katie helps clients achieve this by equipping them with knowledge and strategic, practical skills. Fueled by her love of all things science, Katie’s counseling is greatly informed by current research in the field as well as her own life experiences. She takes an eclectic approach and utilizes a variety of techniques best suited to each client. Ultimately, Katie aspires to make therapy an organic process by cultivating collaboration and acceptance within every session.
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