What Is Exposure and Response Prevention (ERP) Therapy?
A CBT Approach to Treating OCD and Anxiety
Many individuals have persistent, distressing thoughts like “Did I lock my car doors?” or “Did I leave the front door open?”. Even though these thoughts can be unpleasant, they usually pass with time. But for some individuals, the thoughts do not fade and lead to distress, requiring a response. Some of these kinds of thoughts that could require intervention include: the thought that you need to wash your hands an uncomfortable number of times or maybe turning back to check on the front door or car door to see if it was actually locked so much that you cannot leave the house.
When these thoughts become a pattern that leads to distress or a loss of your ability to move throughout your day, week, or life, it's often a sign of obsessive-compulsive disorder (OCD). OCD is a condition that involves a combination of distressing, obsessive thoughts and compulsive behaviors that a person uses in an attempt to reduce the anxiety or distress caused by those thoughts. This is exactly what Exposure and Response Prevention (ERP) is built to treat.¹ ERP is also beneficial for other related anxiety disorders and post-traumatic stress disorder (PTSD) as well.
Understanding the Cycle ERP Is Designed to Break
Before beginning treatment, it is helpful to have an idea of patterns that keep anxious thoughts and OCD returning. Usually, there is a trigger that sets off an unwanted and distressing thought or image. Some of the behaviors that may arise to get rid of the distress may be checking, washing, counting, asking someone for reassurance, or avoiding the situation altogether. The compulsion brings relief, but only for a little while. The main issue is that the brain learns from these behaviors; these compulsive behaviors seem to “fix” the distressing thoughts for a brief amount of time, so our brains can trick us into believing that the compulsion is the answer to the worry. The problem is that the worry just returns time after time, but our brains have a hard time making the connection that this strategy is not as effective as it may assume.
New York, a city built on density and speed, doesn't make any of this easier. There is no way of avoiding crowded streets and subways, touching door handles, etc. Hyperawareness of germs, safety, or social mistakes can quietly turn into a second job: checking the locks twice before leaving for work, leaving absurdly early for a subway ride in case there is a delay, or needing to wash your hands after opening a door. What may seem like a reasonable response to a cautionary situation may lead down a path of rigid routines that take over your life or your functioning.
What ERP Might Look Like in a Therapy Session
At East Side CBT, our therapists specialize in helping people with OCD, anxiety, PTSD, and other diagnoses manage their symptoms with ERP. You and your therapist will work together to map out what actually sets off the obsessive thoughts. Some triggers are external, like a specific place, object, or person. Others are internal, like a thought that pops into your head out of nowhere or a physical sensation such as a racing heart. It is common to build a hierarchy of fears and uncomfortable thoughts that you commonly notice. Then, the action phase starts, and your therapist will help you to gradually expose yourself to things that feel stressful in an effort to help you use healthier coping strategies to ride the wave of anxiety that comes up when triggered.
For example, if germs are a common fear, you and your therapist might start by developing a plan to hold your hand on a subway pole or a public restroom counter for thirty seconds at a time. After touching the pole or bathroom counter, your therapist will teach you how to resist the urge of using your hand sanitizer or washing your hands. That's what makes the exposure effective because the strategies your therapist will teach you will help you to manage the rush of anxiety that arises and allow it to reduce without engaging in the compulsive behavior.
After multiple attempts, starting in the therapy room and then out in the world, you will speak with your therapist about what you expected to experience versus what actually occurred. Over time, your brain begins to recognize the difference between what you feared would happen and what actually happened. You also reflect on what you learned about your ability to tolerate discomfort and uncertainty without relying on compulsions. As the situations lower on your hierarchy become easier to manage, you and your therapist gradually work toward the more challenging ones. As treatment comes to a close, the focus shifts to relapse prevention, helping you develop a plan to maintain your progress and continue using the skills you've learned on your own.
Gaining Your Control, Time, and Attention Back
Living in a busy, fast-paced city can create plenty of situations that trigger anxiety, from crowded public transportation and shared spaces to the constant pressure of work and daily responsibilities. ERP treatment with East Side CBT isn't about getting rid of every uncomfortable thought or anxious feeling. ERP helps you learn how to respond to them in a healthier, more effective way.
Once you stop pouring energy into checking things twice, asking someone else to confirm that you’re fine, or working around anything that makes you anxious, that energy has to go somewhere, and it usually goes back into your day-to-day life. You may notice the small moments, holding onto a subway pole without flinching, shaking someone's hand, walking out the door without turning around to check the stove one more time. The goal is for you to learn to trust yourself to handle whatever happens next instead of needing it all mapped out ahead of time.
If you feel like you could benefit from learning the strategies in ERP, East Side CBT can help! Reach out to us to schedule a consultation with one of our experienced therapists to learn more about how ERP can help. We provide evidence-based Exposure and Response Prevention (ERP) therapy for children, adolescents, and adults at our Upper East Side and Bergen County offices.
Contact us today to schedule a consultation and learn how ERP can help you regain confidence, reduce anxiety, and break free from the cycle of OCD.
Frequently Asked Questions
What is Exposure and Response Prevention (ERP)?
Exposure and Response Prevention (ERP) is a specialized form of Cognitive Behavioral Therapy (CBT) that helps individuals gradually face feared situations while resisting compulsive behaviors. Over time, this weakens the OCD cycle and reduces anxiety.
Is ERP considered the best treatment for OCD?
ERP is widely recognized as one of the most effective evidence-based treatments for OCD and is recommended by major clinical organizations for many individuals with obsessive-compulsive disorder.
Can ERP help treat anxiety?
Yes. ERP can also be effective for certain anxiety disorders, particularly when avoidance behaviors or reassurance-seeking maintain anxiety over time.
How long does ERP therapy take?
Treatment length varies depending on your goals, symptoms, and progress. Your therapist will work with you to develop an individualized treatment plan.
Works Cited
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.