The Truth About ERP Therapy


by stuart miles

by stuart miles

I recently wrote about how exposure and response prevention (ERP) therapy, the evidence-based psychological treatment for obsessive-compulsive disorder, is anxiety-provoking. Many people with OCD are aware of this fact, and it is often one of the reasons given by those with OCD for not attempting ERP. It’s too scary. Who wants to deliberately expose themselves to intense fear and anxiety?

And the media doesn’t help. I’ve seen television programs that show distraught people with OCD being forced to engage in behaviors most of us would find repulsive; things such as sifting through garbage and then not washing your hands, or licking a toilet seat. Who would willingly expose themselves to such things?

The truth, however, is that ERP, when done properly, is patient driven. Nobody is forced to do anything, only encouraged when appropriate. In addition, most good therapists go by the adage, “I won’t ask you to do anything I wouldn’t do myself.”

That being said, ERP might sometimes include things that most of us don’t typically do. For example, if someone’s obsessions involve contamination, it is possible that as part of ERP therapy, they might go with their therapist to a public bathroom, sit on the floor, and touch the floor with their hands, or perhaps even have a little picnic. You might be thinking, “Isn’t just using a public restroom enough of an exposure?” Well, sometimes yes, and sometimes no. As I understand it, the reason these “over-the-top” exposures are sometimes needed can best be explained by envisioning a bendable pole. We are striving for the pole to stand straight up (which represents “normal” actions and reactions). Those with OCD have bent so far in one direction (fear of contamination, for example) that in order to have the pole stand straight up, it is necessary to bend extra far in the opposite direction (hence our picnic in the bathroom).

Just to be clear, if you’ve never done ERP therapy, you will not walk into a therapist’s office and be whisked away to some public restroom to do exposures on the floor. Remember ERP is patient driven. So how and when is it determined what exposures those with OCD will tackle?

One of the crucial components of good ERP therapy is the creation of a hierarchy, which is basically a list of anxiety-provoking situations created by the person with OCD. At the bottom of the hierarchy will be the least distressing events and at the top will be the most triggering sources of anxiety. For example, someone struggling with fear of contamination might have “picking up a spoon that fell on the floor” lower down on his hierarchy and “using a public restroom” at the top. This hierarchy is used as a guide for the person with OCD and his therapist.

Typically therapists will start by having their clients tackle situations that cause mild to moderate distress and then work their way upwards. As you can see this is a very individualized approach, and good therapists will work closely with those with OCD – coaching and encouraging, but never forcing, until the top of the hierarchy has been reached.

So the truth about exposure and response prevention therapy is that it is not easy, but it is indeed doable if you are willing to commit to it. And it works. The pay off is huge – a life no longer dictated by obsessive-compulsive disorder. Seems like the way to go to me.




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18 Responses to The Truth About ERP Therapy

  1. Reblogged this on gemmabrandyboyd and commented:
    Some much-needed encouragement with my self-directed ERP journey.

  2. Thanks for this, Janet. I read this at just the right time: I’ve just completed my Anxiety / Exposure Master Hierarchy and am about to start my self-directed ‘ERP’ journey:

  3. Awesome post. I love the bending pole analogy! That makes a lot of sense to me. And I can use that to help my kids.

  4. 71 & Sunny says:

    Excellent post! So much truth here. My psychologist gave me a similar analogy about over-stretching a bit, so that I could bounce back to normal. It’s funny, because my psychologist did indeed sit on the bathroom floor, and at one point, I was dropping my fork on the restaurant floor as an ERP exercise! But you are also right in that I was never, ever forced to do something I did not want to do, and my psychologist was always personally willing to do any ERP that she assigned to me. I saw her as a kind of coach whose job was to encourage me and show me how to go further, faster, and higher than I ever thought I was capable of (just like any great athlete). ERP was literally some of the hardest work I have ever done in my life – but it really was worth it.

    • Thanks for sharing Sunny, and I love the analogy of your therapist being your coach – encouraging you to do more than you ever thought you could. It’s always great to hear from someone with OCD who has gone through ERP so that others can hear firsthand how worthwhile it is.

  5. Thank you for keeping us all informed, Janet. Blake went through this treatment, and, while it was very tough at times, he was always a part of choosing what was next. It was incredibly humane. I also use ERP as the primary intervention for my patients with OCD. I usually begin with the question, “Would you be willing to…?” My patients always choose what they will do and often surprise themselves at what they are ABLE to do. And I get to be there to cheer them on! I am inspired and humbled by bravery on their parts almost daily. – Angie 🙂

  6. Charley Tan says:

    Some people have courage!

  7. maria says:

    I have a dear friend that is suffering of a weird way of obsession, his obsessions are about the eyesight and hearing. He says that his eyesight problem is growing as he is not wearing glasses, that when he wears them he feels stressed and doubt about what he sees, then he forces his vision and his eye hurt. When he told the doctor, he was asked a few questions included, “do you have any other obsession like that, like, for instance, the hearing” and after that he is obsessed with the hearing. He says that when he wears glasses his ear hurt so much that he has to stop it.
    He found an OCD therapist and they gave him a cocktail of medications and started ERP, washing his chin (another obsession or compulsion, not to wash his face, was that if he wash his face he won’t see normal), but that made him enter into another crisis.
    If the obsession makes physical effects in his body, pain in the eyes and ears,… how will be possible to make the Exposure therapy?

    • Hi Maria, I’m not a therapist and of course I don’t know your friend’s entire story, but in general, ERP has you do “the opposite” of what OCD wants you to do. So, for example, if OCD is telling your friend not to wear his glasses or to take them off – for whatever reason – then part of his ERP would be to keep his glasses on and live with the anxiety and uncertainty of how he feels and what is happening to him. It seems to me that ERP can definitely work in his case if he has a good therapist. I wish you both all the best!

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