Exposure Therapy for OCD: How Does Exposure & Response Prevention Work?

OCD is a rising concern

Around 2.5 million adults in the U.S. are affected by obsessive-compulsive disorder (OCD). Women are three times more likely to have OCD symptoms than men, and this condition affects people of all ages – with a quarter of all OCD cases beginning by age 14^[1]. Health care providers noted an increase in OCD-related obsessions and compulsions when the coronavirus pandemic began in 2020^[2,3], with increased fears of death and excessive hand washing.

When we talk about exposure therapy for OCD, we are often talking about exposure and response prevention (ERP), a highly effective treatment that can help individuals find long-term and even permanent relief from OCD symptoms. Exposure therapy is commonly used in eating disorder treatment and multiple other therapy settings. Here we’ll explore exposure therapy for OCD, including what it is and how it works.

What is OCD?

Many individuals with eating disorders also have a diagnosis of OCD. OCD is a mental health condition that includes:

• Obsessions: Uncontrollable, recurrent and distressing thoughts, images and urges
• Compulsions: Behaviors repeated over and over again to reduce distress related to the obsessions

Compulsive behaviors start as a way to reduce one’s worries, fears and anxiety associated with obsessive thoughts. Unfortunately, that relief is short-lived. Over time, and without effective treatment, obsessions and compulsions can get more severe and more difficult to live with.

Unfortunately, many people feel ashamed about their symptoms and do not seek help. Some people live with OCD for years, decades or a lifetime^[2]. With the help of ERP, individuals from all walks of life can recover from OCD.

Learn more about OCD.

Common OCD symptoms

The most common OCD symptoms are as follows:

• Fear of contamination or exposure to germs (such as by touching a trash can)
• Fear of causing harm to self or others (such as by hitting someone with a car)
• Needing to have everything neat, “just right” or “in its place”
• Seeking reassurance to reduce anxiety

For individuals with eating disorders, OCD symptoms may show up before meals, after meals and during mealtimes.

View more examples of OCD symptoms.

What is exposure therapy?

Exposure therapy stems from cognitive behavioral therapy. When it comes to exposure therapy for OCD, ERP is considered the gold standard as it has helped many people permanently resolve their OCD symptoms.

• The American Psychiatric Association has identified ERP as one of the most effective therapies for OCD^[4] because it provides long-term symptom relief in a short time.
• ERP for OCD has been supported by multiple research studies and endorsed by millions of individuals with OCD worldwide ^4].
• To gain the most benefit from exposure therapy, one must be fully committed to the process.

The exposure therapy approach for OCD looks similar for people of all ages. The therapist individualizes treatment based on each person’s unique pattern of obsessions and compulsions. This pattern of symptoms can change from childhood into adolescence and through adulthood.

Exposure and response prevention for OCD

ERP can be life changing for people with OCD. Here at Eating Recovery Center and Pathlight Mood & Anxiety Center (ERC Pathlight), experienced clinicians offer ERP in all treatment programs. Some ERC Pathlight locations offer focused ERP-intensive programs for OCD, staffed by some of the most experienced OCD clinicians in the country.

How does exposure therapy for OCD work?

We spoke with Ellen Brandenburg, LCSW-C, primary therapist with ERC Pathlight, about exposure therapy for OCD. Here’s what she shared with us.

“Exposures begin during individual therapy sessions. Initially, individuals work with their primary therapist to create an exposure hierarchy, deciding when and how to complete the exposures. While the work can be challenging, over time people often feel more comfortable with exposures as they can better manage their distress around the exposures and/or they are gaining access to the life they want after completing the exposures.”

So, what does this look like in practice? Let’s break it down.

At the start of therapy, your therapist will focus on building trust and creating a safe environment.  At the same time, you will be building your commitment to the process.

1. With the help of a therapist, you will identify the OCD symptoms (obsessions and compulsions) that are the most challenging.
2. Working together, you will create an exposure hierarchy with your therapist. One by one, you will choose which obsessions and compulsions to be “exposed” to. Examples include:
   • Touching perceived “unclean” items (touching a trash can for a certain length of time)
   • Going on a walk and purposefully stepping on cracks
   • Limiting the number of reassurances the therapist will give during the session
3. During the exposure, you will be asked to stop yourself from engaging in behaviors (compulsions) usually associated with the obsessions (e.g., not washing hands after touching a trash can). This part of therapy is “response prevention,” since you are not engaging in a compulsive behavior in response to the exposure.
4. The therapist will measure any distress occurring during the exposure and discuss any avoidance/accommodation behaviors occurring in the session.
5. This process is repeated across multiple sessions. You will be encouraged to complete exposures during and in-between group therapy sessions. When ERP for OCD is done in a group setting, peers can encourage and cheerlead each other’s accomplishments.
6. As you move through exposures, you may practice relaxation techniques (breathing, mindfulness, grounding) to help you manage anxiety and distress. This is all individualized based on your needs. Shares Brandenburg, “If you are distracting yourself, for example, by listening to music during the exposures, it may disrupt the therapeutic value of the exposure. Your therapist will work one-on-one with you to help you get the most out of therapy.”
7. Over time, the frequency of exposures may be increased. Response prevention should also improve over time.

Repeated exposures in a supportive environment “teach” the brain that obsessions do not have to be followed by compulsions. The brain starts to create new thought and behavior patterns.

A sample session of ERP for OCD

Now that you understand the basics of ERP, here is an example of how ERP for OCD would work in real life.

Let’s say that Jennifer, who has OCD, has a negative thought about herself (e.g., “I’m worthless, I can’t do anything right”). She compulsively seeks reassurance from others when she has such thoughts, as a way to reduce her anxiety. In Jennifer’s ERP session:

1. The therapist asks her to engage in a situation that would normally evoke some doubt about herself, like speaking or singing in front of a group.
2. As the feelings of self-doubt come up, instead of relying on her preferred behavior of asking for reassurance, the therapist would encourage Jennifer to not ask for reassurance.
3. The therapist would offer support to Jennifer, who now feels anxious without reassurance, to stay with that feeling of anxiety until it mostly or completely goes away.
4. Over time, Jennifer learns that anxiety doesn’t last forever, and the uncomfortable feelings and thoughts will eventually end.

As you can see, exposure therapy can be challenging, but also very effective. With regular communication and support provided by the therapist, the exposures are done in partnership. Individuals can choose to engage or not engage in these exposures at any time.

Typically, people start with less intense (less challenging) exposures, working their way up to more challenging exposures.

Types of exposures for OCD

Some of the exposure methods we use at ERC Pathlight include:

• In vivo exposure: Direct exposure to the item they fear (e.g., touching a trash can in session, for individuals who have germ OCD and fear becoming contaminated by touching a dirty trash can)
• Imaginal exposure: Imagining the stimuli when it is not possible or safe for a person to directly confront a fear trigger (e.g., imagining holding a razor, for individuals who have harm OCD and fear that they will hurt self or others with sharp objects)
• Interoceptive exposure: Confronting the physiological symptoms associated with anxiety, including increased heart rate and shortness of breath (e.g., intentionally becoming anxious in session, for people who worry that they will die or have a heart attack when they experience anxiety)

“We often see results quickly with ERP for OCD. This usually leads to an empowered individual who becomes even more committed to doing the genuinely hard work associated with completing exposures,” comments Brandenburg.

How does ERP help OCD?

Exposure therapy helps people overcome fear and anxiety in several ways:

• Habituation: There is a natural decrease in anxiety when you are repeatedly exposed to the objects (situations, individuals, etc.) you fear.
• Extinction: The therapy breaks or stops the associations between the object that is feared and the feelings of anxiety and distress.
• Self-efficacy: You are empowered and become skilled at managing feelings of anxiety related to the object you once feared.
• Emotional processing: You develop new, more realistic beliefs about the objects you once feared, becoming more comfortable with the universal experience of fear.

For many, ERP is a valuable treatment modality used in combination with traditional talk therapy.

Family involvement in OCD treatment

Exposure therapy offers your loved one a guided path to emotional wellness—an important step in the journey of recovery from daily anxiety and fear.

“When family is involved, we may use family therapy sessions to practice exposures or talk about how to create exposures outside of programming hours. We find that the frequency of exposures, across more than one environment (e.g., in individual or family therapy sessions, within ERP specialty groups, during programming groups or group breaks, and outside of programming hours, if applicable) creates increased success,” shares Brandenburg.

Caregivers are encouraged to support and even work alongside their loved ones in treatment. If your loved one is receiving exposure therapy for OCD, you may be asked to change how you interact with them. The therapist will discuss the therapeutic principles of exposure therapy with you to help you understand what is going on in treatment and how you can support your loved one.

Exposure therapy for children and teens

At ERC Pathlight, we've seen kids and teens have great success with ERP for OCD. Our team works carefully on exposures for this age group, supporting them through real or imaginal experiences. Working with their therapist, young patients learn the techniques they need to help them accept the distress rather than engaging in avoidant or self-destructive behaviors they would typically use to avoid the distress.

Work with an OCD ERP therapist

We are constantly amazed by the power of the human spirit: the ability to change, learn, grow and find relief from troubling mental health challenges. If you are looking for more support related to OCD, we invite you to give us a call at 866-622-5914 or fill out this form. Our compassionate team is here to speak with you about your concerns, to listen and to help you get matched with the exact support you need.

Related Reading:

What Are the Four Types of OCD?
Exposure and Response Prevention for Compulsive Overeating
Exposure Therapy in Virtual Eating Disorder Treatment