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Summary: Exposure and response prevention therapy helps people with obsessive-compulsive disorder by creating a safe environment where they can learn to separate their emotions from their obsessions, which can reduce compulsive behaviors and improve overall quality of life.

Key Points:

  • Obsessive-compulsive disorder (OCD) is never a choice: it’s a serious mental health disorder which, in most cases, requires professional support to resolve.
  • When obsessive-compulsive disorder becomes severe, it can become disruptive and completely prevent the ability to function and carry out most day-to-day tasks.
  • The symptoms of OCD can cause extreme emotional and psychological distress, and have a negative effect on family, friends, academics achievement, and the ability to find and keep a job.
  • Therapeutic approaches such as exposure response and prevention therapy (ERPT) can help people with obsessive-compulsive disorder manage symptoms and restore typical daily function.

What is Exposure and Response Prevention Therapy for OCD?

Here’s a comprehensive definition of exposure and response prevention therapy (ERP):

“Exposure and response prevention (ERP) is a form of cognitive behavioral therapy (CBT) that is widely used in the treatment of OCD. It is considered the first-line psychological treatment due to its very strong evidence base and effectiveness in reducing symptoms and improving functioning in people with OCD.”

In recent years, ERP has gained prominence as the first choice treatment for OCD for one reason: it’s more effective in reducing symptoms than any other treatment we know about. ERP reduce symptoms on four of the most widely used assessments for OCD:

  1. Yale-Brown Obsessive Compulsive Scale (Y-BOCS), primarily assesses severity
  2. Obsessive Compulsive Inventory – Revised (OCI-R), assesses specific OCD symptoms
  3. Florida Obsessive-Compulsive Inventory: (FOCI), a short assessment of presence/severity
  4. Dimensional Obsessive-Compulsive Scale (DOCS), assesses four components of OCD

Evidence for the effectiveness of OCD in peer-reviewed clinical trials and meta-analyses show:

  • Clinically relevant improvement on severity assessments
  • Positive treatment effect with early, significant clinical gains
  • Persistent positive treatment effect with clinical gains remaining stable months after treatment
  • Significant improvement compared to sham treatment and treatment-as-usual

To learn about how exposure and response prevention therapy can help people with obsessive-compulsive disorder during residential treatment, please read the following article on our mental health blog:

Is Residential Treatment Effective for OCD?

That’s a quicky summary of ERP and a short example of the evidentiary basis for using it as a first-line treatment for obsessive-compulsive disorder (OCD). Next, we’ll take a closer look at the component of exposure therapy, and how exposure how exposure and response prevention therapy can help people with OCD.

How Exposure Response and Prevention Therapy (ERP) Helps People With Obsessive-Compulsive Disorder

The main purpose of ERP is symptom reduction: that’s the core goal of the treatment and the reason patients commit it. The procedure revolves around intentional, organized, step-by-step exposure to the obsessive thoughts a patient identifies as driving their disorder. This gradual exposure – and the accompanying support of a skilled professional therapist – can decrease distress and intense anxiety and/or fear their obsessions trigger. This can reduce the powerful emotions that drive compulsions and compulsive behavior.

The first objective of ERP is to interrogate, evaluate, and restructure the patterns of thought that cause functional disruption in daily life.

When a patient and provider restructure the dysfunctional patterns of thought associated with OCD symptoms, it’s possible to significantly reduce the emotional distress cause by OCD. The publication “Management of Obsessive-Compulsive Disorder in Adults provides a list of the types of thought and behavior ERP can address and help patients resolve.

Obsession, Compulsion, and OCD: The Process ERP Targets

  1. Intrusive, unwanted thoughts occur, including thoughts that cause:
    • Doubt
    • Fear
    • Anxiety
  1. Patient experiences dysregulated response to intrusive thoughts, associated with:
    • False, inaccurate, exaggerated beliefs
    • Memories that don’t reflect what really happened
    • Inaccurate assumptions based on faulty/impaired memories
    • Illogical, unhelpful conclusions based on compromised memories and assumptions
  2. Patient experience negative emotional outcomes of inaccurate interpretation of personal thoughts and beliefs:
    • Anxiety
    • Guilt
    • Fear
  3. In response to items 1-3, patient engages in compulsive behaviors, including behaviors meant to:
    1. Reduce current emotional distress
    2. Prevent future emotional distress
    3. Eliminate anxious thoughts about future events
    4. Reduce fear of negative outcomes of future events
  4. Patient achieves short-term transitory relief, i.e. relief that doesn’t last. Thia causes patient to:
    1. Return to [4], repetition of cycle of compulsions
    2. Return to [2], repetition of dysregulated patterns of thought
  5. Entire sequence of events repeats.

How does ERP correct this process?

During ERP therapy, skilled clinicians collaborate with patients with an OCD diagnosis to identify the unwanted emotions responsible for the presence of obsessive thoughts and compulsive behaviors. In the initial treatment sessions, they grade, rank, or categorize them in order of disruption and severity, from most to least disruptive/intense. Here’s the scale they use: the SUDS.

Subjective Units of Distress Scale (SUDS)

  1. 100: Severe/highest anxiety/distress
  2. 90: Extreme anxiety/distress
  3. 80: Very anxious, impaired concentration/thinking
  4. 60-70: Anxious, anxiety/distress affects typical daily activity
  5. 5 or 50: Moderate anxiety/distress, may marginally impact daily activity
  6. 30-40: Mild anxiety/distress, little to no impact on daily activity
  7. 20: No notable anxiety or distress, only typical, manageable daily stressors
  8. 10: Awake, alert, fully functional
  9. 0: Completely at ease

After the patient and provider generate their list, they rank each item that causes distress – i.e. negative emotion that triggers compulsive behavior – in an intentional, step-by-step process. The majority of patients and therapists begin with something moderate – a SUDS score of 50 – that is challenging, tests the process, typically allows success, but not likely to feel overwhelming.

Then what?

Take the Time, Commit to the Process, Restructure Your Thoughts, Manage Your Emotions

A typical number of ERP sessions includes a dozen (12), at minimum, with most courses of treatment including a maximum of twenty (20) individual ERP sessions, with some patients requiring more, and some requiring less. Treatment involves using the prioritized list of anxieties/fears generated at the beginning of the process. Within an overall atmosphere of safety, trust, empathy, and compassion – all supported by a positive therapeutic alliance, the clinician and the person with OCD follow these general steps:

  • Choose item from ranked/prioritized list, and begin controlled, facilitated exposure
  • Develop the skills to restructure habituated, dysregulated emotion response to the chosen item
  • Learn skills/techniques to regulate habituated response – i.e. compulsions – to emotions triggered by misinterpretations of unwanted thoughts
  • In an environment of characterized by feelings of safety, empathy, and trust, the clinician and the person with OCD work through the ranked list until the patient learns to restructure the misinterpreted thoughts, manage the resulting dysregulated emotions, which – for the majority of patient who engage in ERP – significantly reduces or completely eliminated to need to act on behavioral compulsions.

We can think of this process as similar to the process that causes OCD, but in reverse. In OCD, patients create dysfunctional connections between thoughts and behaviors – inserting negative emotion into the situation – but in ERP, patients with the help of their provider, detach their extreme emotions from their unwanted thoughts. When their unwanted thoughts, identified in their list of ranked fears, no longer result in misinterpretation that generates the negative emotion that drives their compulsions, they can experience significant symptom relief, and begin to resolve the negative consequences of OCD in their daily lives.

While we understand that it may appear counterintuitive to expose patients to the very things that trigger their OCD on purpose, there’s one reason ERP has become a first-line treatment for OCD: it works.

Decades of carefully controlled research on exposure therapy confirm its safety, acceptability to patients, and overall effectiveness. The specific physiological process behind ERP is not yet known. However, when we learn the process is safe, we can grasp the core logic supporting it, if not the precise physical mechanisms. If a patient and a clinician drill down and uncover the thought dysregulation that results in the extreme emotions that drive compulsions, then the recovery process can begin.

Why it Matters: How Exposure and Response Therapy Can Help People With Obsessive-Compulsive Disorder

What we want anyone with a clinical diagnosis of OCD of any severity is this:

Evidence-based treatment for OCD works. Exposure and response therapy can help people with obsessive compulsive disorder manage symptoms and life a full life.

We understand that exposure therapy may seem intimidating, but the process is time-tested, effective, and can help patients with the most severe forms of OCD.

In other words, it’s worth the effort.

It’s also vital for anyone with OCD to know the consequences can be extreme. Without treatment,  and moderate OCD can gradually convert to severe and debilitating OCD.

Untreated OCD: Potential Negative Outcomes

  • Withdrawal from friends, family, and social connections
  • Difficulty maintaining productive, mutually supportive relationships
  • Declining school and vocational achievement
  • Problems finding and keeping a job
  • Impaired/reduced likelihood to achieve independence
  • Increase likelihood of self-medication/misuse of drugs/alcohol
  • Increased frequency of alcohol/substance use disorder (AUD/SUD)
  • Development of co-occurring mental health and/or behavioral disorders
  • Suicidality: thinking about suicide
  • Non-suicidal self-injury (NSSI): harming oneself without suicidal intent

When OCD occurs alongside other mental health conditions, both diagnosis and treatment can become complex. The symptoms often of OCD may resemble those of other disorders which can be a problem, because what helps one set of symptoms may not help another. In addition some cases, medication for one condition may make another worse.

That’s why we emphasize the need for qualified intervention, as early as possible. An experienced provider can arrive at the right diagnosis and a provide a referral for appropriate care. They can also diagnose the presence of any co-occurring disorders, despite complications presented by OCD.

Evidence shows that nine of ten people with OCD also have an additional mental health condition. The Disorders that co-occur most often with OCD include:

  • Bipolar disorder
  • Attention-deficit hyperactivity disorder/other disorders with impulsivity symptoms
  • Anxiety disorders
  • Substance use disorder (SUD)

Experts from the International OCD Foundation report that OCD may co-occur with, and share underlying causes with the mental health issues such as eating disorders, hoarding, and body dysmorphic disorder, and additional, repetitive, body-focused disorders.

In closing, we need to address anyone who doesn’t want to try exposure therapy. First of all, we understand. No one needs to explain their reluctance to anyone. If ERP is not an option, that’s perfectly valid. Instead, the following treatment modalities can help people with OCD:

Psychotherapeutic approaches:

  • Cognitive behavioral therapy (CBT)
  • Eye-Movement Desensitization and Response (EMDR)
  • Acceptance and commitment therapy (ACT)

Pharmacological approaches:

  • Selective serotonin reuptake inhibitors (SSRIs)
  • Tricyclic antidepressants (TCAs)

Brain modulation techniques:

  • Transcranial magnetic stimulation (TMS)
  • Deep brain stimulation (DBS)

It’s important for everyone with OCD – as well as their friends and family members – that several different treatment methods can help relieve symptoms. Studies indicate exposure therapy is superior to others. However, if that’s not an option – for personal reasons or otherwise – there are alternative pathways to healing, growth, and symptom reduction for people with OCD.

Finding Help: Resources

If you or someone you know needs professional treatment and support for obsessive-compulsive disorder (OCD), please contact us here at Crownview Psychiatric Institute: we can help. In addition, you can find support through the following online resources:

About Angus Whyte

Angus Whyte has an extensive background in neuroscience, behavioral health, adolescent development, and mindfulness, including lab work in behavioral neurobiology and a decade of writing articles on mental health and mental health treatment. In addition, Angus brings twenty years of experience as a yoga teacher and experiential educator to his work for Crownview. He’s an expert at synthesizing complex concepts into accessible content that helps patients, providers, and families understand the nuances of mental health treatment, with the ultimate goal of improving outcomes and quality of life for all stakeholders.