Exposure and Response Prevention (ERP)

Definition of Exposure and Response Prevention

Exposure and Response Prevention, or ERP, is a type of Cognitive Behavioral Therapy (CBT) and the most effective, evidence-supported treatment for the treatment of OCD with or without medication. In ERP treatment, clients are gradually and repeatedly exposed to the thoughts, images, or situations that bring on obsessions, while resisting their compulsions or physical rituals. Through increased frequency and intensity of the exposure, clients reach a point at which they feel so accustomed to the trigger that they no longer partake in these behaviors.

How Exposure and Response Prevention works

ERP works by exposing the individual with OCD, little by little, to the thoughts, images, or situations that trigger obsessions.

Dr. Jerry Bubrick, director of the Obsessive-Compulsive Disorder Service at the Child Mind Institute, states, “Though it’s uncomfortable, people learn they can can tolerate the anxiety that comes with it and they get better.” By directly confronting the obsessive thought in a systematic process, the individual gradually becomes accustomed to it, learning that the feared outcome does not occur and feeling less tempted to engage in physical compulsions.

At first, facing the situation that triggers obsessions or compulsions can induce high levels of anxiety for the client. With time and under the guidance of a trained therapist, however, these levels of anxiety naturally drop as the individual learns to respond differently to the situation. Ultimately, this leads to a reduction in the frequency and intensity of the obsessions and compulsions.

Dr. Bubrick explains, “When we systematically and slowly introduce [individuals] to things they’re afraid of, they feel the anxiety, but they learn how to get used to it and how to adapt, and it doesn’t bother them anymore.”

How long does ERP take to reduce OCD symptoms?

Some degree of relief can generally be found from ERP in about 10 to 20 sessions, though the time it takes to see results and reduce obsessions varies for each individual. Response times depend highly on the severity of obsessions and rituals, the therapist's ability to gently push the client, and the client's ability to consistently attend therapy and engage with the treatment.

"The practice of working through one’s fears and anxieties is different for every individual," explains Kevin Ashworth, Clinical Director of the NW Anxiety Institute. He continues, "Learning to accept one's fears and develop a new perspective to overcome them can take as little as one session, while fears that have been maintained for years typically require three months to see significant change."

How effective is ERP?

ERP has been shown to be helpful in about 75 – 85% of individuals. Extensive research supports that ERP is the first-line treatment for individuals with OCD, and that most individuals are able to tolerate the treatment.

After just a few sessions, many individuals realize just how much control they have over their own brain patterns, and that engaging in physical compulsions is not necessary to effectively control anxiety. Finding a therapist with expertise in OCD is critical to the success of treatment, as there are nuances in treatment that a qualified expert will understand how to navigate.

What types of ERP treatment are there?

The type of ERP treatment that an individual receives depends heavily on the individual’s unique obsessions, compulsions, and life circumstances.

Dr. Fugen Neziroglu, co-founder and director of the Bio Behavioral Institute, explains, “Sometimes, this takes a lot of creativity, especially when you have a pure obsession and you need to create the situation in real life.”

For example, someone with contamination or germ OCD may feel compelled to excessively hand wash or shower due to fear of “infecting” others. For those with severe OCD, this cleaning compulsion can heavily impact their personal activities, relationships, school, and career. ERP asks the individual to face going to the supermarket, school, or work while resisting the urge to constantly hand wash or shower after every encounter.

Whatever the obsession may be, Dr. Fugen emphasizes, “A good therapist will work with you outside of the office, go where the problem is, or come to your home.”


Sources

  • Lifetime and past year prevalence of OCD among adults and children.
    • Harvard Medical School, 2007. National Comorbidity Survey (NCSSC). (2017, August 21).
    • National Institute of Mental Health.
  • Role impairment among individuals with OCD.
    • Ruscio, A.M., Stein, D.J., Chiu, W.T., Kessler, R.C. (2010). The epidemiology of obsessive-compulsive disorder in the National Comorbidity Survey Replication. Molecular Psychiatry 15(1), 53-63.
  • Prevalence of OCD among children.
    • International OCD Foundation. (2018). Who Gets OCD?
  • Age of OCD onset.
    • International OCD Foundation. (2018). Who Gets OCD?
  • Prevalence of symptoms.
    • Beyond OCD. (2018). Who is Affected by OCD?
  • Prevalence of OCD worldwide.
    • Murray CJ, Lopez AD. The Global Burden of Disease: A Comprehensive Assessment of Mortality and Morbidity from Diseases, Injuries, and Risk Factors in 1990 and Projected to 2020. Cambridge, MA: Harvard University Press; 1996.
  • Prevalence compared to other diagnoses.
    • Christopher Pittenger, MD, PhD, Ben Kelmendi, BS, Michael Bloch, MD, John H. Krystal, MD, and Vladimir Coric, MD. Clinical Treatment of Obsessive Compulsive Disorder. Psychiatry (Edgmont). 2005 Nov; 2(11): 34–43.
  • Seeking treatment for OCD.
    • Designed Thinking. (2012). OCD Facts and Statistical Data.

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