Exposure and Response Prevention Therapy

Posted by on Jun 12, 2014 in Blog, Exposure and Response Prevention, Exposure and Response Prevention, Obsessive-Compulsive Disorder, Treatment

Exposure and Response Prevention Therapy

What is Exposure and Response Prevention for OCD?

If you or a family member recently received an OCD diagnosis you may have a lot of questions. Having a name for your symptoms may provide some amount of relief, but you need more answers. “I know I have OCD now, so why is it still so hard to stop my compulsions” “How can I get some real relief?”

Let’s start with answering the first question—why is it so hard to stop compulsions? Well, to put it simply, your brain has learned that compulsions and avoidance work to reduce anxiety and discomfort!    It might be small and have taken some time to achieve relief, but at least it’s some relief. Logically, you might be fully aware that the compulsion is unnecessary and causing you more harm than good. However, it might be the ONLY thing that gives you any relief in the moment. There you have the battle that leaves so many with OCD feeling discouraged with themselves and trapped in compulsions they know full well they don’t need.

If you are feeling trapped by Obsessive-Compulsive Disorder in this way, it is NOT because you have weak willpower or self-control. It’s just the way our brain are wired. Our brains are wired to avoid discomfort. The way it learns to avoid discomfort effectively is through something called negative reinforcement. Negative reinforcement may occur when something unpleasant is taken away. An example would be when we turn the faucet to cold when the water gets too hot; excuse ourselves from an awkward conversation; take an alternate route to work when we see construction ahead; or go inside when the weather is rough. However, in OCD, when we feel anxious the compulsion can take the feeling away. Every time we use the compulsion we are strengthening the habit and fuel the cycle. Every time you use a compulsion you add more fuel. This is why it’s so difficult to stop compulsions–they work in the short term.  But it isn’t in your long term best interest. Just like scratching an itch gives relief but aggravates the rash, compulsions relieve anxiety, but aggravate OCD.

So are you doomed to be stuck in an endless loop of negative reinforcement? Absolutely not! However, beating your fears is a process of learning through addition, not subtraction. You can never fully erase fears from your brain, but each time you face a fear you have the opportunity to strengthen your brain, dampen those fears, and have them no longer control your behavior. This type of learning takes place when fearful expectations are not realized even in the face of what you fear. Let’s take the example of getting bit by a dog and developing a phobia of dogs. That association between dogs, danger, and an urge to escape may be very strong indeed. It’s likely to be an experience you’ll never forget. However, if you make a point to continue to interact with dogs and stay safe, that fear of being bitten “looses its teeth.”

The benefits of facing your fears are achievable in OCD as well. The answer is in a treatment called Exposure and Response Prevention Therapy (ERP) for OCD. ERP is designed to help patients break free from the OCD trap. It consists of two components. The first is exposure to things that trigger OCD fears. This is the facing your fears element. The second part is response prevention and refers to preventing one’s self from performing compulsions. This keeps artificial relief from interrupting the process before it has a chance to start working.

So how does ERP look in practice? The first step is for the therapist and patient to make an inventory of the triggers, fears, and compulsions the person experiences .

For example:
Trigger: Leaving home
Feared Consequence: “If I don’t check the stove the stove might be on and I’d be responsible for burning down the house”
Compulsion: Check stove 3 times before leaving home.

Trigger: Driving over a bump in the road
Feared Consequence: “I might have run someone over. If I don’t check I will be responsible for a hit and run”
Compulsion: Circle car around and check area

Next you and your therapist will work together to rank order the triggers from easiest to hardest to confront (without using compulsions).  Exposures typically begin with something that will be “challenging but manageable” for the patient. Generally these exposures elicit moderate anxiety or SUDS from 5 to 7 (SUDS: Subjective Units of Distress Scale from 0 to 10).

The therapist designs exposures to be done during sessions as well as exposure homework assignments for the patient to do outside of sessions.  An exposure session might consist of turning the stove off without looking at the dial then leaving the house for a few hours without double-checking the stove on the way out. This might be repeated over several days until the patient can do this exercise without experiencing much distress. Right there we are on our way to beating OCD! Similar exposures proceed to more difficult items on the fear hierarchy. Eventually, most patients experience significant improvements and relief from OCD.

Volumes of well-conducted research have shown that ERP is an extremely effective treatment for OCD in individuals of all ages (e.g., Franklin et al., 2011; Freeman et al., 2014; Foa et al., 2005). For more information on ERP and providers that offer this treatment see below:


International OCD Foundation

Provider List of OCD Specialists

Franklin, M.E., Sapyta, J., Freeman, J.B., Khanna, M., Compton, C., Almirall, D., et al.(2011)Cognitive behavior therapy augmentation of pharmacotherapy in pediatric obsessive-compulsive disorder: The pediatric OCD treatment study II (POTS II)randomized controlled trial. Journal of the American Medical Association, 11, 1224-1232.

 Freeman, J.B., Sapyta, J., Garcis, A., Compton, S., Khanna, M., Flessner, C., et al. (2014) Family-Based Treatment of Early Childhood Obsessive-Compulsive Disorder: The Pediatric Obsessive-Compulsive Disorder Treatment Study for Young Children (POTS Jr)-A Randomized Clinical Trial. Journal of the American Medical Association, 71, 689-698.

Foa, E.B., Liebowitz, M.R., Kozak, M.J., Davies, S., Campeas, R., Franklin, M.E., et al.(2005). Randomized, Placebo-Controlled Trial of Exposure and Ritual Prevention, Clomipramine, and Their Combination in the Treatment of Obsessive-Compulsive Disorder. The American Journal of Psychiatry, 162, 151-161.

Ben Tucker, M.S, BCBA is a Behavior Analyst who specializes in ERP for OCD.