What Is ERP Therapy, and What Does It Actually Look Like?

ERP stands for exposure and response prevention. It is the treatment with the best track record for OCD. The way I do ERP is through Acceptance and Commitment Therapy, or ACT, from start to finish, so this article is really about ACT applied to exposure: what we do, what we're working toward, and how we know it's working.

OCD works in a cycle. Often it starts with an unwanted thought or doubt: "What if I left the stove on?" "What if my hands aren't really clean?" The thought brings anxiety, and the anxiety brings a strong urge to do something about it: check, wash, go over it again in your head, or ask someone to tell you it's fine.

It doesn't always start with a doubt, though. Sometimes it is a feeling that something isn't quite right. You arrange, repeat, or redo an action over and over, not because you're unsure of anything, but because you want that "just right" feeling, and until you get it, the anxiety stays.

Either way, doing the action brings the discomfort down for a little while. The problem is what it costs. Every time you do the ritual, you are following a rule: this thought or feeling has to go away before I can move on. The more you follow that rule, the more it runs your life, and the stronger the urge is the next time. The compulsion is what keeps the cycle going, not the thought or the feeling. That is why ERP is really about not engaging in those behaviors.

Exposure means getting close to the thing that provokes the anxiety, on purpose, instead of avoiding it. That might mean touching a doorknob and not washing right away, leaving the house after checking the stove once, letting a disturbing thought be there without arguing with it, or leaving something slightly out of place and not fixing it.

Response prevention means that when the urge shows up, you practice not doing the compulsion. You don't check again, you don't wash again, you don't repeat the action until it feels right, you don't ask for reassurance, and you don't go over it in your head. This is where most of the work happens.

We choose the exposures together, and we don't do them for their own sake. We pick something outside your comfort zone that you're willing to try, usually something connected to what matters to you, like a dinner you've been skipping or an hour of your day you'd like back. We make a plan around it, and you set the pace.

From an ACT lens, what we're doing in an exposure is increasing willingness. A lot of this work is really about becoming more willing to experience the discomfort that comes with certain activities.

If an activity provokes anxiety, my job as the therapist is to help you make room for those feelings, to have greater willingness to experience them, and to be more present-focused in the face of those difficult thoughts and feelings. Part of that is learning to notice a thought as a thought ("I'm having the thought that the stove is on") instead of a fact you have to act on. It is even about being able to enjoy and savor an experience while the difficult thoughts and feelings are present.

In other words, we allow the internal experience to be a part of the experience, while you stay fully engaged in the thing you're doing. You don't get to choose what your mind and body bring up. What you do have control over is your body: your arms, your legs, your mouth, and what you do with them. You are not avoiding the activities that are important to you and have real value.

From an ACT perspective, success in ERP is not about lowering anxiety.

Lower anxiety is often what comes as a result of this work. That is something you can reasonably expect. But it is a bonus, not the focus, and it is not what we measure. What we measure is this:

When you combine these three, you can see whether a person is being successful with ERP.

This is very hard for clients, and it is something they are often secretly hoping for. But think about what it means to need low anxiety in order to go through with something that is important to you. If I really need my anxiety to be low before I can do it, I don't have very much freedom. I am held captive by my own rules and rigidity.

What we are striving for is flexibility: the ability to move forward regardless of what thoughts and feelings are present. That is a big-picture, long-term benefit, as opposed to simply trying to reduce anxiety. In a certain way, it is freedom from yourself.

There is also a problem with focusing on reducing anxiety: avoidance creeps in. There are a lot of ways to reduce anxiety, and most of them involve avoidance. Checking, washing, and staying home all reduce anxiety, and that is the cycle we are trying to get out of.

And from an ACT perspective, anxiety just isn't a problem. I want to be sensitive about that, because it is distressing, and we respect that. But it is not a problem to fix. It is just a thing that is present. When we treat it like a problem, we end up almost obsessed with it.

Sessions are a mix of planning exposures, practicing them together, and talking through how the practice at home went. The practice between sessions is the most important part. Willingness is a skill, and it gets stronger with repetition.

Over weeks and months, most people find that the rituals take up less of their day, and that they are doing more of the things that matter to them, whether or not anxiety is present.

If OCD has been taking up more and more of your time, ERP is worth a real try, and I'd be glad to talk it through with you. You can read more about OCD therapy with me, or reach me through the contact page.