Exposure and Response Prevention Therapy (ERP)

There are a number of different therapies to treat the spectrum of conditions that fall under the umbrella of anxiety disorders. A common method of treatment is Cognitive Behavioral Therapy, where a trained therapist can help you identify and understand how to manage the factors that lead to an anxiety attack. One such way of doing this is somewhat controversial, but not without its positive effects – exposure and response prevention therapy, or ERP.

What Is Exposure and Response Prevention Therapy?

The mindset of exposure and response prevention therapy (ERP) is that controlled and prolonged exposure to the objects or situations that trigger an anxiety attack will lead to them causing diminishing levels of anxiety. Culmination of ERP will result in very little and, ultimately, manageable anxiety. The Centre for Addiction and Mental Health profiles ERP as “the most widely practiced therapy” for obsessive-compulsive disorder (OCD) and phobias, both of which are presentations of anxiety disorders. The Psychotherapy Brown Bag blog describes ERP as the “frontline psychotherapy for OCD.”

The main goal of the therapeutic exercises is for the patient to stay in contact with the trigger without engaging in ritual (escape) behaviors.

Therapy continues to the point where the patient is able to refrain from ritual (escape) activities on their own, for extended periods of time.

Another facet of ERP therapy is “imaginal therapy,” where a patient is required to imagine scenarios that cannot easily be recreated (like a fear of flying or a traumatic memory that triggers an anxiety reaction). Once the imagination (or memory) has been established, a therapist will walk the patient through their reactions in the same way as non-imaginal (in vivo) therapy.

In a 2003 study published in The Behavior Analyst Today entitled “018-008.pdf” target=”_blank” rel=”noopener”>Treating Obsessive-Compulsive Disorder with Exposure and Response Prevention,” the researchers argued that the therapeutic effects of ERP are derived from subjects confronting their fears, and researchers blocking their avoidance or escape reactions. ERP aims to help patients see that their anxieties are unrealistic by showing them that nothing bad happens when those anxieties and other related disorders are in effect.

Using ERP to Treat Phobias

If a patient is afraid of spiders (one of the top 10 phobias in the world), their ERP therapy to get over their arachnophobia would involve gradual exposure to spiders – seeing a live spider, being in the same room as a live spider, or touching a spider/letting a spider touch them. This process of getting used to something that would have cued an anxiety reaction is called “habituation.”

With ERP, the patient is not only exposed to their cues, but their habitual response is also prevented. So, if the patient’s normal reaction to a spider is avoidance (leaving the room), they will not be allowed to indulge in that reaction (they will not be allowed to leave the room). The point of the exercise is to develop, and then increase, the patient’s tolerance for their anxiety/phobic/OCD triggers.

Using ERP to Treat OCD

With obsessive-compulsive disorder – which is so widespread that the National Institute of Mental Health says it affects about one percent of the US population, or 3.14 million people – ERP is used to present a scenario that forces the patient to break from their compulsion. A common example is checking (one of the four most common forms of OCD – the others being contamination, intrusive thoughts, and hoarding). Checking is the practice of obsessively ensuring that items, such as lights, stoves, alarms, and appliances, are turned off or on. The “checking” form of OCD is borne from:

  • Fear that someone will break in if an alarm is not confirmed to be on
  • Fear that the house will burn down if a stove is not confirmed to be off
  • Fear that the house will burn down if a light switch is not confirmed to be off

The fear manifests in the obsessive compulsion to check these things, repeatedly, dozens, or maybe even hundreds, of times. The patient is never satisfied, even after ascertaining that an alarm is on, a window is closed, a stove is off, etc.

Exposure and response prevention therapy would work by exposing the patient to situations that cause mild OCD-related anxiety symptoms. As they habituate – get familiar with those cues – the therapist will increase the severity of the OCD cues of the situation. This will trigger a stronger OCD reaction, but since the patient overcame the mild sensation of OCD, and since ERP therapy does not allow them to respond as they naturally would, they will be pushed to adapt to the increased triggers, to the point where they have no choice but to confront the baseless nature of the unrealistic fears that prompt an OCD reaction.

Other Uses of ERP

A 1995 article published in the journal of Behavior Research and Therapy (“Exposure with Response Prevention Treatment of Anorexia Nervosa-Bulimic Subtype and Bulimia Nervosa”) and reviewed by Vanderbilt University shows how ERP can be used to treat eating disorders. In cases like this, response prevention comes in two forms: vomiting, where after the patient is presented with all the food they can eat, and they are prevented from purging; and binging, where the patient is exposed to foods that they would dearly love to binge on, but prevented from actually doing so.

In both cases, the patient is monitored until their respective desires (to binge or purge) pass. The goal is to learn to not partake in the self-destructive behavior of the anxiety disorder at hand, whether it is an eating disorder (bulimia nervosa, in this instance) or the larger scope of OCD, phobias, and other anxiety disorders.

Exposure and Response Prevention Therapy: Effective or Extreme?

The mental health community is divided on the use of exposure and prevention therapy to treat anxiety disorders. On the one hand, PsychCentral calls ERP “a good choice” and a “very effective treatment” for OCD, saying the anxiety “can sometimes even disappear” after careful administration of therapy.

In their review of ERP to treat eating disorders above, Vanderbilt reported two studies – “Exposure Plus Prevention of Bingeing vs. Exposure Plus Prevention of Vomiting in Bulimia Nervosa; A Crossover Study” in the Journal of Nervous and Mental Disease, and “Bulimia Nervosa: Treatment with Exposure and Response Prevention” in the Behavior Therapy journal – that supported “the usefulness of exposure techniques in the treatment of bulimic patients.”

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However, Psychology Today calls ERP “among the cruelest and most agonizing forms of psychotherapy.” In an excerpt of a book (Triggered: A Memoir of Obsessive-Compulsive Disorder) entitled “The Sickening Treatment for OCD,” Psychology Today cautions that exposure and response prevention therapy is not necessarily safe, since it still exposes the patient to risks (making a mysophobic patient touch contaminated objects will put them in danger of contracting disease, notwithstanding the success of making them overcome their escape response of obsessive washing of the hands).

That said, if the point of ERP therapy is to do away with the idea of 100 percent safety, or that safety isn’t always necessary (or even desirable), then patients can learn to survive, or even thrive, in the presence of what makes them anxious or phobic.

Indeed, even as the author mentions treating an OCD patient by physically placing their hands in a toilet, he writes that confronting his worst fears taught him how to manage his OCD, and to develop new ways of thinking and behaving while acknowledging a perceived danger, which is the overall nature of Cognitive Behavioral Therapy to begin with. ERP therapy, the writer says, provides a realistic assessment of risks by pushing patients face to face with those risks.

In answering the question of “How effective is ERP?” Canada’s Centre for Addiction and Mental Health reports that “upwards of 75 percent of patients experience improvement” in their anxiety/OCD symptoms during ERP treatment. The Psychotherapy Brown Bag blog writes that “multiple clinical trials” have shown ERP is “more effective than a variety of control treatments […] and antidepressants.” The Journal of Behavior Therapy and Experimental Psychiatry supports the idea that “ERP is an effective treatment for childhood OCD.” And Psychiatric Times writes that it is “well established that exposure-based behavioral therapies are effective treatments for [anxiety] disorders.”


Exposure and Response Prevention Therapy and You

So, is exposure and response prevention therapy the way to help you or your loved one? Only a trained therapist can answer that question, and that’s why we are here. Treating your anxiety, OCD, or phobias can be a long and challenging process, and sometimes there seem to be more questions than answers. Our admissions coordinators are standing by to answer any questions you may have about exposure and response prevention therapy, and we can connect you with the right treatment program to address your particular phobia or concern.

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