ERP: Exposure and Response Prevention Therapy

ERP, or Exposure and Response Prevention therapy, is a type of cognitive-behavioral therapy (CBT) commonly used to treat anxiety disorders, particularly obsessive-compulsive disorder (OCD). In ERP therapy, you are gradually exposed to feared situations or thoughts (exposure) and then are encouraged to resist the accompanying compulsion or ritual (response prevention). This process helps you learn to manage your anxiety without relying on your usual compulsive behaviors. ERP techniques have lasting and deep effects. At the end of this post are exposure and response prevention examples that may help you see what the treatment would be like, but feel free to contact me to go over your specific concerns.

Exposure and Relapse Prevention Therapy Overview

The development of ERP therapy can be traced back to the 1960s and 1970s when psychologists and researchers were exploring effective ways to treat OCD. One of the pioneers in this field was Dr. Victor Meyer, who, in the 1960s, suggested that exposure to feared stimuli without engaging in the associated compulsive behaviors might help reduce anxiety.

In the 1980s, the work of psychologists Edna B. Foa and Reid Wilson played a crucial role in shaping ERP therapy as it is known today. Foa and Wilson combined the principles of exposure therapy with a focus on preventing the compulsive responses that typically follow anxiety-provoking thoughts or situations. They emphasized the importance of confronting feared situations directly and resisting the urge to perform rituals or compulsions.

Today, ERP therapy remains one of the most widely used and effective psychological treatments for OCD. It has also been adapted and utilized for other anxiety-related conditions, demonstrating its versatility and success in helping individuals manage and overcome their fears and compulsions.

Exposure and response prevention techniques involve facing feared situations, objects, thoughts, or images that trigger anxiety. The response prevention component involves refraining from engaging in the usual compulsive behaviors or rituals that alleviate anxiety temporarily. Over time, repeated exposure without engaging in compulsive behavior helps reduce the anxiety associated with the triggers.

ERP therapy is evidence-based and is highly effective in treating OCD and other anxiety disorders. It requires a structured and gradual approach. The goal of ERP for OCD is to help individuals gradually confront their fears, reduce anxiety, and learn healthier ways to cope without relying on obsessions or compulsive behaviors.

Exposure and Response Prevention Techniques

Below is more information about the process used with exposure and relapse prevention techniques, but here is a summary of what the therapy involves.

Basic Tenets of ERP Techniques

ERP techniques are primarily used to treat anxiety disorders, especially OCD (Obsessive-Compulsive Disorder). Exposure and relapse prevention techniques revolve around deliberately confronting situations, thoughts, images, or objects that trigger anxiety or distress. Exposure is gradual and systematic, starting with less distressing triggers and progressively moving towards more challenging ones. The goal of ERP techniques is “response prevention,” involving refraining from engaging in compulsive behaviors or rituals that typically reduce anxiety.

ERP techniques include imaginal exposure, where individuals vividly imagine the feared situations or thoughts, facing them without performing compulsions. Still, they also involve real-life exposure to feared situations or objects. For instance, someone with contamination fears might touch a doorknob without immediately washing their hands.

Adjunctive Processes

Exposure and relapse prevention therapy can also involve scripting, where we help you create narratives or scripts of feared situations or scenarios. Reading or listening to these scripts repeatedly helps desensitize individuals to their anxiety triggers. We also use “Interoceptive Exposure,” where we deliberately induce physical sensations or symptoms that are typically feared.

ERP is typically conducted under the guidance of a trained therapist and requires collaboration between the therapist and the individual receiving treatment. It’s important to know that we always proceed at a pace that you find challenging yet manageable, ensuring the process is effective and not overwhelming.

Using ERP Techniques in Practice

While the above provides an overview of ERP techniques, this section describes the process in more detail. In therapy, Exposure and Response Prevention Therapy techniques are designed to help you confront your fears and reduce anxiety associated with your obsessive-compulsive disorder (OCD) or other anxiety disorders. Here are some common ERP techniques that I use:

Hierarchical Exposure in ERP

In this case, I work with the individual to create a hierarchy of feared situations or triggers, ranking them from least distressing to most distressing. This helps in gradually exposing you to increasingly anxiety-inducing situations, always at a pace you are comfortable with. For example, in airplane flying, an initial step might involve going to the airport to watch airplanes take off and land. For fear of public speaking, you might be asked to practice a speech just in front of me.

Exposure and Response Prevention Techniques In Vivo

ERP techniques usually involve real-life exposure to feared situations or triggers. For instance, someone with contamination fears might touch a doorknob without washing their hands immediately afterward. We can use AR and VR techniques in the office to accomplish some of that. As we progress, we will work on prolonged exposure, where you stay in the feared situation or are exposed to the trigger for an extended period without engaging in the compulsive behavior. This helps in habituating to the anxiety and reducing its intensity over time.

Imaginal ERP Techniques

This ERP technique involves vividly imagining the feared situations or triggers in the mind. For example, someone with OCD related to harming others might imagine accidentally harming a loved one and resisting the urge to perform a ritual to neutralize the thought. We might work on this in the office, and you may be asked to do some of it at home as homework. Like imaginal exposure, the individual writes a detailed script describing their feared situation or obsessive thoughts. Then, they repeatedly read or listen to this script without engaging in compulsive behavior.

Response Prevention Techniques

These Exposure and Response Prevention techniques involve deliberately not engaging in the compulsive behaviors or rituals that usually follow the exposure to a trigger. It’s crucial in breaking the cycle of anxiety and compulsive actions. In this case, I might ask you to expose yourself to a feared situation, but one that is milder or controlled, and as you start to be compelled to take an irrational action, you will learn how to resist using my support.

Flooding in Exposure and Response Prevention Therapy

This involves exposure to the most feared situation or triggers immediately rather than gradually. It can be intense but effective for some individuals. I use this technique only when the client requests it because they have found that it helps in the past or when there is reason to believe it will work. I would never use this type of technique without the client’s permission.

Mindfulness and Acceptance

Integrating mindfulness techniques can help individuals observe their anxious thoughts or sensations without trying to control or suppress them. Acceptance-based strategies can also help reduce the struggle against unwanted thoughts.

ERP Therapy is tailored to each individual’s fears and triggers. I will gradually expose you to feared situations or thoughts while supporting you in resisting the urge to perform compulsions. Over time, this helps reduce anxiety and the need for compulsive behaviors, leading to improved coping mechanisms.

ERP Therapy Outcomes

Research shows that ERP therapy can be highly effective for many people with OCD. Formal studies have consistently demonstrated positive outcomes, with significant reductions in OCD symptoms and improvements in daily functioning. The success rates vary from person to person, but many people experience a notable decrease in symptoms and an improved quality of life. ERP therapy is more effective than other forms of therapy or medication alone for OCD. Exposure and Response Prevention for OCD have also been shown to have longer-lasting effects and a lower risk of relapse compared to medication alone.

Exposure and Response Prevention Examples

I have found ERP techniques to be helpful for people of all ages, and even with couples, when one person has OCD or a phobia and the other is going to work to help them overcome it. It can even be helpful in family therapy, where one (or more) people have OCD or a phobia, and the rest of the family wants to be part of the solution.

It’s important to note that therapy outcomes often depend on various factors, including the severity of the OCD or phobic symptoms, your commitment to the therapy, and your willingness to take some risks related to exposure. It also may depend on the level of other stresses in your life.

Overall, ERP therapy has a strong track record of success in helping people manage and alleviate symptoms of OCD and phobias, enabling them to lead more fulfilling lives. The effects of response and exposure prevention therapy can last a long time.

The following two more specific exposure and response prevention examples may help you see what treatment would be like.

Case Example 1: Exposure and Response Prevention for OCD

Here is a fictional case example of Exposure and Response Prevention for OCD—this one focuses on contamination OCD, which is one of the most common subtypes.

Client: Sarah, 27-year-old graphic designer
OCD Subtype: Contamination OCD
Main Fear: Germs from public surfaces causing illness
Compulsion: Excessive hand washing, avoiding touching doorknobs, using hand sanitizer repeatedly

Initial Assessment

Sarah reports spending up to 3 hours a day washing her hands and sanitizing. She avoids public bathrooms, refuses to shake hands, and experiences intense anxiety if she feels “dirty.”

Exposure and Response Prevention for OCD Plan

Goal: Reduce compulsive hand-washing and avoidance behaviors and tolerate uncertainty around contamination.

Exposure Hierarchy:

*SUDs = Subjective Units of Distress

Response Prevention

In each exposure, Sarah is not allowed to perform the compulsion (e.g., no hand-washing immediately after touching a doorknob). Instead, she is coached to sit with the discomfort and ride the wave of anxiety.

ERP for OCD Progress Over Time

Over 12 sessions of ERP for OCD, Sarah moves up the hierarchy:

• Her distress after touching public surfaces drops from 90 to 30.
• She begins using public bathrooms without rituals.
• She now only washes her hands when genuinely necessary (e.g., after using the restroom or before eating).

ERP for OCD Key Takeaways

• ERP for OCD is effective by breaking the cycle: Obsession → Anxiety → Compulsion.
• Over time, Sarah’s brain learned a new association: touching surfaces ≠ danger.
• The emphasis is on tolerating uncertainty, not achieving total comfort.

Case Example 2: Exposure and Response Prevention Therapy for Phobias

Here’s a case example of Exposure and Response Prevention Therapy for phobias—in this case, a dog phobia (cynophobia).

Client: Marcus, 35-year-old teacher
Phobia: Dogs
Main Fear: Being bitten or attacked by a dog
Avoidance Behaviors: Crosses the street to avoid dogs, avoids parks, won’t visit friends who own dogs, scans surroundings constantly for dogs

Initial Assessment

Marcus reports high anxiety (up to 100/100 on a SUDs scale) when near dogs—even small, calm ones. His fear developed after witnessing a dog bite a child when he was 10. He knows most dogs are safe but says, “I just can’t help the panic.”

Exposure and Response Prevention Therapy for Phobias Plan

Goal: Help Marcus confront and tolerate his fear without fleeing or seeking safety behaviors.

Exposure Hierarchy:

Response Prevention

Marcus is coached not to leave, cross the street, or use distractions during exposures. He practices slowing his breathing, staying in the moment, and letting the anxiety rise and fall on its own.

ERP for Phobias Progress Over Time

Over several sessions:

• Marcus’s SUD response to dogs drops significantly using exposure and response prevention techniques.
• He begins walking in parks again without fear.
• He can visit friends with calm dogs and interact with them briefly.

ERP for Phobias Key Takeaways

• Exposure and Response Prevention techniques work for phobias by desensitizing the fear response and helping the brain relearn safety.
• The “response prevention” is often not fleeing, avoiding, or mentally reassuring oneself.
• Repeated, gradual exposure reduces fear over time—even if it doesn’t eliminate the simple phobia, it makes it manageable.

Conclusion and My Work

I provide ERP Therapy as both a standalone therapy and in combination with other techniques. As mentioned above, exposure and response prevention techniques will always go at a pace you are comfortable with. ERP for OCD and phobias often requires some homework to be most successful. The treatment course can often be time-limited, and gains are often clear and measurable.

I also use ERP techniques for specialty services such as Fear of Flying, Public Speech Anxiety, and Sports Psychology. It can be interwoven through couples and families with older children when people surrounding a person with OCD want to help. I would be happy to provide you with more exposure and response prevention examples closer to what you seek.

Please feel free to be in touch or schedule a consultation at any time to discuss Exposure and Response Prevention Therapy or how ERP Therapy might benefit you.

Dr. Alan Jacobson Founder and President

Dr. Jacobson is a licensed clinical psychologist providing individual, couples, and family therapy for over 20 years. He uses an integrative approach. choosing from a variety of proven and powerful therapeutic methods.

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