What Is ERP Therapy?
Exposure and Response Prevention (ERP) therapy is a specialized form of cognitive-behavioral therapy primarily used in the treatment of obsessive-compulsive disorder (OCD) and related anxiety disorders. It is considered the gold standard treatment for OCD symptoms, with numerous studies demonstrating its effectiveness in reducing symptoms and improving quality of life for sufferers. ERP therapy typically involves working with a licensed mental health professional who has received specialized training in ERP in structured individual sessions, though aspects of it can be practiced as homework between formal therapy appointments.
Unlike traditional talk therapy, ERP is an active, practical first-line treatment that directly confronts the patterns that maintain OCD and anxiety-related disorders. Rather than focusing extensively on understanding the origins of obsessions, ERP concentrates on changing the behavioral response to them. Many patients report significant improvement in their symptoms after completing a course of treatment using ERP, though the timeline for improvement varies based on individual factors and the severity of symptoms.
To learn more about ERP therapy and how it can positively impact your mental health, please contact our compassionate and skilled ERP therapists at Balanced Mind of New York for a free 15-minute consultation.
How Does ERP Work?
ERP (Exposure and Response Prevention) therapy is effective in treating OCD and uses two fundamental principles: exposure and response prevention. ERP therapy works by gradually exposing individuals to feared thoughts, situations, or objects (exposure) while preventing them from engaging in their usual compulsive behaviors or avoidance strategies (response prevention). Over time, this psychological intervention helps reduce anxiety and symptoms of OCD (including severe OCD) and rewire the brain’s response to fear-based triggers, leading to greater emotional regulation and a decrease in distressing symptoms. The two core interventions of ERP treatment can be summarized as follows:
Exposure
The exposure component involves gradually and systematically confronting the thoughts, images, objects, and situations that trigger obsessions and anxiety. Exposure exercises are done in a controlled, hierarchical manner with your therapist, starting with less distressing triggers and progressing to more challenging ones.
Response Prevention
The response prevention aspect of ERP therapy requires clients to resist engaging in their typical compulsive behaviors or avoidance strategies when anxiety arises during exposure exercises. By remaining in the anxiety-provoking situation without performing compulsive rituals, patients learn that their anxiety naturally decreases over time (also known as habituation), and that their feared outcomes rarely, if ever, materialize, ultimately breaking the reinforcement cycle that maintains OCD.
What is Obsessive-Compulsive Disorder (OCD)?
Obsessive-Compulsive Disorder (OCD) is a chronic mental health condition characterized by intrusive, unwanted thoughts (obsessions) and repetitive behaviors or mental acts (compulsions) performed to reduce distress. These symptoms can significantly interfere with daily life, causing distress and consuming a great deal of time. OCD symptoms vary in severity and presentation, but it often follows a cycle of obsessive fear followed by compulsive rituals aimed at temporary relief.
Symptoms of Obsessive-Compulsive Disorder (OCD)
Although OCD symptoms may vary slightly from person to person, the Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR) details diagnostic symptoms as follows:
Obsessions (Intrusive Thoughts):
- Fear of contamination or germs
- Unwanted aggressive or taboo thoughts
- Excessive concern with order, symmetry, or exactness
- Fear of harming oneself or others
- Persistent doubts (e.g., “Did I lock the door?”)
Compulsions (Repetitive Behaviors):
- Excessive handwashing or cleaning
- Repeated checking of locks, appliances, or switches
- Counting, tapping, or repeating words silently
- Arranging objects in a specific order
- Seeking reassurance or confessing excessively
Subtypes of Obsessive-Compulsive Disorder (OCD)
Although the DSM-5-TR does not list individual subtypes of Obsessive-Compulsive Disorder (OCD), identifying the focus of obsessive thoughts and compulsions is essential to developing a comprehensive Exposure and Response Prevention (ERP) therapy treatment plan with your therapist to manage OCD. While not exhaustive, some of the common subgroupings of OCD and their associated obsessive thoughts and compulsions include:
Contamination OCD
Clients who focus on contamination or germ avoidance may feel dirty or contaminated after touching a public doorknob or a grab rail on a subway. Other fear situations may include crowded public places or shaking hands due to concern of being exposed to germs.
- Obsessions: Fear of germs, illness, bodily fluids, or toxic substances.
- Compulsions: Repeatedly washing hands, cleaning, avoiding certain places or objects, changing clothes frequently.
Harm Obsessions (Checking) OCD
This focus of this type of OCD may involve concerns that someone is being harmed. Examples include worrying that a gas stove was left on, possibly resulting in carbon monoxide poisoning for the household, or feeling an intense urge to intentionally harm themselves or others.
- Obsessions: Intrusive thoughts of harming oneself or others or of someone being harmed
- Compulsions: Avoiding sharp objects, seeking reassurance, mentally reviewing actions to ensure no harm was done.
Symmetry and Order OCD
Symmetry and Order OCD is a subtype of Obsessive-Compulsive Disorder characterized by an overwhelming need for objects, actions, or thoughts to be perfectly arranged, balanced, or aligned. Individuals with this form of OCD experience intense discomfort or anxiety when things feel “off” or asymmetrical, often leading to compulsive behaviors aimed at achieving a sense of completeness or correctness.
- Obsessions: Intense need for objects to be perfectly arranged, fear of things feeling “off” or “not right.”
- Compulsions: Repeatedly arranging, aligning, or balancing objects; counting or repeating actions until it “feels right.”
Obsessive Thoughts Without Observable Compulsions (sometimes called “Pure O OCD”)
Pure Obsessional OCD (“Pure O OCD”) is a subtype of Obsessive-Compulsive Disorder in which individuals experience persistent, intrusive thoughts (obsessions) without visible compulsive behaviors. However, they often engage in mental rituals such as reassurance-seeking, thought suppression, or excessive rumination to reduce anxiety.
- Obsessions: Intrusive, distressing thoughts or images related to morality, religion, relationships, or identity.
- Compulsions: Mental rituals, reassurance-seeking, excessive rumination, thought suppression.
Sexual OCD
Sexual OCD involves intrusive, distressing thoughts or fears related to inappropriate, immoral, or unwanted sexual themes. Individuals may fear acting on these thoughts despite having no desire to do so.
- Obsessions: Fear of being sexually attracted to inappropriate individuals (e.g., family members, children), unwanted thoughts about committing sexual acts that go against personal morals
- Compulsions: Avoiding situations where intrusive thoughts may arise (e.g., avoiding being alone with children), seeking reassurance about sexual identity or morality, mentally reviewing past interactions to ensure no inappropriate behavior occurred
Relationship OCD
Relationship OCD is characterized by persistent doubts and fears about the quality, authenticity, or rightness of a romantic relationship. These worries can cause distress and interfere with emotional intimacy.
- Obsessions: Fear of not truly loving one’s partner or not being in the “right” relationship, doubts about a partner’s love, loyalty, or attraction, or intrusive thoughts about whether a past relationship was better
- Compulsions: Frequently seeks reassurance from the partner or others about the relationship or compares the relationship to others or idealized standards, ends relationships prematurely due to these persistent doubts
Hoarding
Although hoarding was previously classified as a subvariant of OCD, the DSM-T-R acknowledges hoarding as a distinct diagnosis. Its symptoms include:
Obsessions:
- Fear of needing an item in the future and regretting discarding it
- Intense emotional attachment to objects, even those with little or no value
- Fear that discarding items will lead to loss, harm, or a catastrophic mistake
- Feeling overwhelmed or distressed at the thought of organizing or discarding possessions
- Belief that objects hold sentimental or irreplaceable significance
Compulsions:
- Hoarding or excessively collecting items, even when unnecessary
- Avoiding decisions about what to keep or discard
- Rearranging or organizing items repeatedly without discarding them
- Saving items in case they are “useful someday”
- Experiencing distress when others suggest decluttering or removing items
How Is ERP Used to Treat OCD?
Exposure and Response Prevention (ERP) therapy for Obsessive-Compulsive Disorder (OCD) begins with creating a personalized hierarchy of triggers called the “fear ladder,” ranking situations from least to most anxiety-provoking. Working collaboratively with their ERP therapist, patients gradually confront these triggers while refraining from performing compulsions. Throughout the course of this first-line treatment for OCD, therapists provide education about OCD mechanisms, teach anxiety management techniques, and help patients recognize that anxiety naturally subsides without compulsions. Sessions typically occur weekly for 12+ weeks, with patients practicing ERP exercises between sessions to reinforce learning and build confidence.
The effectiveness of ERP lies in its ability to break the OCD cycle through repeated exposure without compulsions. As patients respond to anxiety-provoking situations without negative consequences, their brain forms new neural pathways that don’t associate triggers with danger. This process, called habituation, leads to decreased anxiety responses over time. Patients learn that uncertainty is tolerable, their feared outcomes rarely materialize, and engaging in compulsions actually perpetuates anxiety and other mental health symptoms rather than relieving it long-term.
In Vivo Exposure
In vivo exposure involves being directly exposed to real-world anxiety-triggering stimuli or situations. The ERP treatment plan focuses on ritual prevention after an encounter with the feared stimuli. For someone with contamination OCD, this might include touching doorknobs without washing hands afterward, while someone with checking OCD might leave the house without checking locks repeatedly. These exposures are carefully planned and implemented gradually, with therapist guidance ensuring they’re challenging yet manageable. The power of in vivo exposure comes from its concrete, tangible nature that directly challenges OCD beliefs in real-world contexts.
Imaginal Exposure
Imaginal exposure targets feared scenarios that cannot be ethically or practically recreated in real life. Clients write detailed scripts about their worst fears (like accidentally causing harm) and read them repeatedly, often recording and listening to them between sessions. This technique is particularly useful when fears revolve around unacceptable thoughts rather than external triggers. OCD treatment may also use virtual reality to encounter the situations of concern with guidance from the therapist. By repeatedly confronting these distressing thoughts without neutralizing them, patients learn that thoughts themselves are harmless, reducing the anxiety and distress they previously caused.
Settings for ERP Therapy
Although ERP may be offered in an inpatient or partial hospitalization setting, ERP is most commonly offered in an outpatient therapist’s office. Exposure and Response Prevention (ERP) therapy is typically conducted in individual sessions through structured, gradual exposure to feared thoughts or situations while preventing compulsive behaviors. The therapist collaborates with the client to create a hierarchy of anxiety-provoking triggers, starting with less distressing exposures and progressing to more challenging ones.
During ERP sessions, the client confronts these fears in a controlled, supportive environment, learning to tolerate discomfort without engaging in compulsions. The therapist provides guidance, encouragement, and cognitive strategies to help the client recognize that their anxiety decreases over time through repeated exposure. Between sessions, clients are assigned homework to practice exposures in their daily lives, reinforcing progress made in therapy. ERP in an outpatient setting allows individuals to build confidence in managing their OCD while responding their usual routines with increased confidence, leading to an overall improved quality of life.
Exposure and Response Prevention (ERP) Therapy Versus Exposure Therapy
While often confused as identical cognitive-behavioral therapy approaches, ERP (Exposure and Response Prevention) differs from traditional exposure therapy in several key ways. The primary distinction lies in the “response prevention” component, which is specific to ERP and critical for treating OCD and related mental health symptoms.
In standard exposure therapy, patients are gradually exposed to feared stimuli to reduce anxiety through habituation while under supportive supervision of the therapist, but there’s no explicit focus on preventing ritualistic behaviors. ERP treatment, however, the inhibitory learning approach deliberately combines exposure with strict prevention of compulsions or safety behaviors that would otherwise provide temporary relief. This crucial difference directly targets the compulsion cycle unique to OCD, where the disorder is maintained by negative reinforcement each time a ritual reduces anxiety.
For example, in exposure therapy for a phobia, someone might gradually approach a feared object until anxiety subsides. However, in ERP treatment for OCD, someone would not only confront a trigger but also resist performing the accompanying ritual (example: handwashing or checking). This combined approach is specifically designed to break the reinforcement pattern of Obsessive-Compulsive Disorder by teaching patients that they can tolerate anxiety without performing compulsions and that their feared consequences rarely materialize.
How Do I Find an ERP Therapist?
Finding a qualified ERP therapist requires careful research and consideration. Start by looking for practitioners with specific training in ERP treatment and experience treating OCD, as not all therapists are adequately trained in this specialized technique. You can ask for referrals from your primary care physician, psychiatrist, or local mental health clinics. Major academic medical centers with anxiety disorder programs often have specialists in ERP therapy.
When evaluating potential therapists, don’t hesitate to ask about their specific training in ERP, experience treating OCD, typical treatment approach, and for some examples of efficacy and benefits for previous clients. Additionally, if you experience comorbid disorders, such as post-traumatic stress disorder (PTSD), are they trained in other forms of cognitive-behavioral therapy or related techniques, such as EMDR? Many therapists offer initial consultations where you can assess their expertise and your comfort level with them. Balanced Mind of New York offers a free, 15-minute consultation to learn more about the real-life benefits of individual therapy with a highly skilled ERP therapist.
If in-person treatment isn’t accessible, consider teletherapy options, which have become increasingly available and have shown effectiveness for ERP. Some specialized OCD treatment centers also offer intensive outpatient treatment programs that provide concentrated ERP therapy over a shorter timeframe. Balanced Mind of New York is pleased to offer both in-person and telehealth sessions for ERP treatment for OCD and other mental health conditions, so contact us to learn more about ERP treatment for OCD.
How Do I Pay For ERP Therapy?
At Balanced Mind of New York, we offer multiple payment options to fit your needs and budget.
In-Network Insurance Provider: Balanced Mind of New York is proud to be an in-network provider for clients covered by Aetna insurance plans.
Out-of-Network Insurance Provider: For all other insurances, we provide superbills for reimbursement. We will contact your insurance company to confirm your eligibility and benefits, including the reimbursement rate for each session. We will also guide you through the process of sending superbills to your insurance.
If you have an out-of-network plan, any reimbursements will be sent directly to you from your insurance provider. Insurance typically reimburses 50-80% of the fee, but note that each policy is different.
Self-Payment Options: If no insurance coverage is available, clients may choose to pay for services out of their own pocket. If you need to pay out of pocket, we offer a sliding scale as part of our commitment to providing affordable care.
We accept Visa, MasterCard, Discover, American Express, and HSA/FSA cards.
Contact Balanced Mind of New York to learn more about your payment options and take the next step on your healing journey.
