Exposure Therapy
Exposure and Response Prevention (ERP) is an active and challenging form of behavioral therapy that is often used to treat obsessive-compulsive disorder (OCD), a condition in which a person is preoccupied by obsessions (thoughts, images) and compulsions (repetitive behaviors that help reduce the anxiety caused by the obsessions). ERP is considered the gold standard for OCD and for good reason: it works. Exposure therapy has been shown to result in changes to the amygdala (1), a part of the brain involved in fear response and emotional learning. ERP is not evidence-based/recommended for generalized anxiety, but it can be effective for treating phobias and Panic Disorder.
How does ERP work?
In ERP, clients are exposed to their anxiety triggers and anxious thoughts while refraining from completing compulsive rituals or any other unhealthy learned actions whose purpose is to reduce their anxiety. Over time, these exposures help improve the client’s tolerance of discomfort in the long term and reduce the association of these triggers with anxiety.
What do ERP sessions look like?
ERP is tailored to each individual client's needs, but here is a common example of an approach that might be used by a therapist helping a client with OCD.
The therapist starts by teaching the client (aka psychoeducation) about OCD and ERP.
The therapist introduces relaxation exercises to help the client learn strategies to reduce the body's physical symptoms of anxiety. Elements of cognitive behavioral therapy, including cognitive restructuring, are introduced to challenge automatic thoughts that may come up during the exposures that contribute to more anxiety and replace them with coping statements.
Once these fundamentals are mastered, the therapist and client work to create a list of triggers (things, situations, etc.) that increase the client's anxiety. The list will then be arranged in a fear hierarchy, which is a list of feared triggers from least anxiety provoking to most anxiety provoking using a self-report scale.
Think of this list as a staircase. You start at the bottom with exposure exercises targeted at the smaller anxiety triggers, and once those are improved, you take the next step up and so on until you are working through the situations that are most feared or bring about the most anxiety in a client.
Exposure exercises may include actually doing an activity or an imagining exercise in which a person uses visualizations to "expose" them to the feared stimulus. In either type of exposure, anxiety is experienced and worked through. The number of exposures needed at each step in the fear hierarchy varies.