What is ERP?
ERP stands for exposure and response prevention and it is an evidence-based treatment approach for obsessive-compulsive disorder (OCD). Evidence-based means that this approach has the support of research studies to back its claim of being an effective treatment intervention.
ERP is broken down into two parts; exposure and response prevention. The exposure part means gradually working toward facing one’s fears and triggers. One of the keywords here is gradual. Response prevention means not engaging in compulsions. Response prevention is the most important part of ERP and is necessary in changing the relationship with OCD. See this blog post for more information on response prevention.
How does ERP work?
ERP disrupts the OCD cycle. You can’t think your way out of OCD, you have to behave your way out. With ERP, the focus is on facing fears/triggers and resisting compulsions, which breaks the chains of the cycle. When you do something different (i.e., not do compulsions), there is no longer negative reinforcement of the compulsive behaviors. Through ERP, your brain starts to learn new connections. For a more in-depth look at the relationship between OCD and the brain, check out this video.
Learning goals of ERP:
There are a couple of things we want people living with OCD to learn during ERP. First, the more you do something, the less hard it is. This idea is called habituation. Let’s use an example that could come up with ERP. If an ERP exercise is to hold a knife without giving self-reassurance, and resisting avoidance, we could expect this to be challenging and distressing at first. However, the longer one holds the knife without doing compulsions, ideally this distress is going to come down. If the person holds the knife again while resisting compulsions, their distress may not peak as high and may come down quicker. Habituation also states that frequent and consistent practice will lead to a reduction in how intense and long-lasting distress is. So, the distress experienced on Day 7 of holding a knife shouldn’t be nearly as intense or as long-lasting as it was on Day 1.
Another learning goal of ERP is pulled from the inhibitory learning theory (ILT). Learning goals through this lens focus on distress tolerance and creating new learning pathways. This means learning that one can tolerate distress and discomfort without doing compulsion (which OCD likes to say isn’t the case!) and that the distress usually isn’t as awful as OCD makes it seem like it’ll be. This can sound like “it was tough, but not nearly as bad as I thought it would be.” Finally, there is the violation of the fear expectancy. Participating in ERP will provide new knowledge that the bad thing isn’t likely or as probable to happen (but if the bad thing does happen, you can handle it!) as OCD says it is.
What does ERP look like?
In ERP, the treatment plan is called a hierarchy. A hierarchy is where different ERP ideas are stored and they’re graded based on how distressing they are. Treatment starts on the low-moderate range of ERPs and you work up from there. There is research stating that therapist-led exposures (meaning doing exposures together with a therapist first) lead to better treatment outcomes. This isn’t to say a person can’t make progress on their own, just that doing it with a trained therapist can help with progress.
If you want more information on ERP or are looking to get started with a trained professional, IOCDF has some great resources and a therapist directory!