What is exposure and response prevention?

Exposure and response prevention (ERP) therapy is a type of exposure therapy that helps people confront their fears and anxieties in a safe environment. It incorporates elements of cognitive behavioral therapy (CBT), which focuses on recognizing and changing thought patterns and behaviors.¹

ERP has two main parts:

1. Exposure: Gradually facing the situations, thoughts, or objects that cause fear or anxiety.
2. Response prevention: Resisting the urge to perform any behaviors or rituals (compulsions) that usually follow these fears.

The goal of ERP is to help people learn that their feared outcomes are unlikely to occur, and that anxiety will naturally decrease over time without engaging in compulsive behaviors.

Through repeated exposure and practice, patients can build tolerance to their triggers and reduce the intensity of their responses. This process helps rewire the brain’s fear response and allows people to regain control over their lives.

What is ERP used for?

ERP is the gold standard therapeutic treatment for obsessive-compulsive disorder (OCD).² However, ERP is not only used for OCD treatment. It has also been used to treat other mental health concerns including social anxiety and certain eating disorders.^3,4

Exposure and response prevention techniques

Depending on the severity of the symptoms, ERP can be offered in different settings. For mild cases, someone might visit a therapist regularly as an outpatient client. More severe cases might involve attending daily sessions in a partial hospitalization program or at a treatment center. Here’s what you can expect from the ERP process:⁵

Initial assessment and planning

The first step of treatment involves an assessment in which the therapist learns about the patient’s specific symptoms. The therapist provides education about their diagnosis and how ERP works. The patient and therapist work together to identify what triggers the patient’s obsessive thoughts and distress. They identify not only external triggers (like objects or situations) but also internal ones (like thoughts or sensations).

Understanding obsessions and compulsions

The therapist and patient discuss the specific obsessions (repetitive thoughts) and compulsions (repetitive behaviors) the patient experiences. They explore why the patient performs these compulsions and what they fear will happen if they don’t engage in the compulsive behavior.

Creating a fear hierarchy

Next, they create a “fear hierarchy” by identifying situations that cause distress and ranking them from least to most scary. This helps organize the treatment plan, starting with less distressing situations and gradually moving to more difficult ones.

Exposure sessions

During exposure sessions, the patient faces triggering situations and is challenged to not perform their usual compulsions. Sometimes they are asked to imagine their feared outcomes so they can practice tolerating distress.

Learning and processing

After each exposure session, the therapist and patient review what happened and what the patient learned. Patients rate their pre-, peak-, and post-experience subjective units of distress (SUDS) to track progress. This helps the patient understand that the feared consequences don’t occur. The patient also gets “homework” to practice facing fears on their own and to try to stop all compulsive rituals in daily life.

Gradual progress

As the patient gets more comfortable in various scenarios, they gradually move up the fear hierarchy to confront more distressing situations. This step-by-step approach helps them build confidence and reduce anxiety over time.

Relapse prevention

ERP therapy usually concludes with a plan to prevent relapse. This involves strategies to maintain progress and handle any future challenges that might trigger symptoms again.

Exposure and response prevention examples

Here are some examples of how ERP can help people face their fears directly and learn that feared consequences often do not happen.

Exposure and response prevention for OCD

• Exposure: A person with OCD who fears germs might be asked to touch a doorknob or a public surface.
• Response prevention: They would then refrain from washing their hands immediately afterward, even though they feel the urge to do so.

Exposure and response prevention for anxiety

• Exposure: Someone who’s anxious about making mistakes might be asked to deliberately make a mistake when baking cookies or trying a new recipe.
• Response prevention: They would resist the urge to correct the mistake.

Exposure and response prevention for eating disorders

• Exposure: A person with an eating disorder who fears gaining weight might be asked to eat a “fear food” that they usually avoid.
• Response prevention: They would avoid engaging in compensatory behaviors such as excessive exercise or purging afterward.

ERP effectiveness

Exposure and response prevention therapy for OCD is highly effective, outperforming relaxation therapy and anxiety management.⁶ Around two-thirds of patients see improvements in their symptoms while one-third are considered “recovered.” It works well across different countries, settings, and intensities, and is more effective than other types of CBT. ERP improves not only OCD symptoms but also sleep and quality of life in people with OCD.

Combining ERP with medication doesn’t necessarily enhance its effectiveness. But using ERP in combination with medication yields better results than medication alone.

For anxiety-relaxed disorders, ERP has shown promising results. It’s helped college students overcome social anxiety and helped improve caloric intake in people with anorexia nervosa.^7,8 Results appear to be more mixed for using exposure therapy as a treatment method for people with posttraumatic stress disorder (PTSD).⁹

Can you do ERP by yourself?

While it’s possible to practice some ERP techniques on your own, it’s generally recommended you work with a trained therapist, especially when starting out. A professional can provide guidance, ensure you’re using the techniques correctly, provide motivation, and recommend the best pace for exposure.

They can also tailor the treatment to your specific needs and ensure you’re progressing safely and effectively. Visit our directory to find a therapist in your area who specializes in treating anxiety and OCD.