What Is Exposure and Response Prevention?

Exposure and response prevention (ERP) is a form of cognitive behavioral therapy considered the gold standard for treating obsessive-compulsive disorder (OCD). It is also used to treat anxiety, phobias, and eating disorders.

Read on to learn how ERP works, what it treats, how to find a specialist, and more.

What Is Exposure and Response Prevention?

Exposure and response prevention is a two-step process. ERP starts with exposure to the very things that cause you discomfort. Then, with the help of a trained specialist, you learn how to prevent your ritualized or compulsive response via a process called habituation (becoming more comfortable with the stimuli), as follows:

• The exposure phase of ERP refers to purposely putting you in direct contact with the discomfort-inducing stimuli (germs, public places, elevators, etc.) that typically trigger obsessive thoughts, ritualized compulsive behavior, fear, or anxiety.
• The response prevention phase of ERP involves getting used to and not engaging in compulsive behavior when exposed to the stimuli. It also allows you to let go of intrusive thoughts after being triggered by exposure.

Exposure immediately followed by response prevention makes ERP a unique and highly effective treatment for OCD.

History of ERP

ERP's roots can be traced back to the 1960s, when a British psychologist, Vic Meyer, developed a successful treatment for helping people with OCD stop compulsive rituals. Throughout the late 1970s and early '80s, clinical psychology professor Edna Foa and colleagues at the University of Pennsylvania fine-tuned ERP techniques and gave exposure and response prevention its name.

ERP Therapy vs. Talk Therapy

As its name suggests, talk therapy helps people gain insights into their problems by speaking with a mental health professional. ERP is a behavioral therapy that takes a different approach.

Instead of just talking about obsessive behaviors or anxiety-inducing situations, ERP therapy exposes people to their fearful stimuli in a safe environment. At the same time, the therapist coaches and teaches the patient how to cope in real time.

Although ERP can be performed using one's imagination (imaginal exposure) or with virtual reality technology, it usually takes place in real-world situations. Unlike talk therapy—which generally takes place in an office setting, on the phone, or via video chat—ERP patients are encouraged to face a fear-inducing situation, object, or activity in real life.

How Does ERP Therapy Work?

ERP exposes people to situations that trigger intrusive thoughts or obsessions. As the triggering situation is experienced, patients learn new coping skills that prevent them from acting on their compulsions. With practice and gradual habituation, ERP reduces anxieties and prevents compulsive responses.

ERP therapy starts with a consultation and assessment by a trained professional who gathers detailed information about a patient's unique triggers and comes up with a personalized treatment plan.

Throughout this process, the patient works closely with their provider to identify specific external stimuli (places, situations, objects, etc.) and internal stimuli (intrusive thoughts, panicky feelings, etc.) that trigger behavior related to OCD, severe anxiety, phobias, or eating disorders.

After someone's obsessions, compulsions, or aversions are cataloged, the patient is asked to share intimate details of a feared outcome if a ritual or avoidance behavior isn't performed.

During the exposure phase of each session, the patient is exposed to discomfort-inducing stimuli that typically provoke obsessive behavior or trigger anxiety. With an ERP professional by their side, people face the problem head-on and learn skills that prevent them from acting on their impulses or panicking.

Over time and with each new exposure, the patient learns how to avoid responding in maladaptive (negative) ways.

What Can ERP Therapy Treat?

ERP therapy can be used to treat people with:

• OCD
• Eating disorders
• Generalized anxiety disorder (GAD)
• Panic disorder
• Social anxiety disorder (SAD)
• Other anxiety-related disorders

Obsessive-Compulsive Disorder

ERP is the first-line behavioral therapy for OCD. An older 2005 study found that 62% of people with OCD responded to their initial ERP treatment sessions. If they completed the 12-week program, success rates jumped to 86%.

ERP remains the gold standard for treating OCD.

Anxiety and Phobias

As part of ERP therapy, patients create a list that ranks anxiety-provoking triggers and phobias from most distressing to least distressing. With the help of a trained specialist, patients are exposed to things that trigger anxiety or phobias and become better at coping with varying degrees of distress as they realize that feared stimuli are safe.

Eating Disorders

When using ERP to treat eating disorders, a patient might create a fear of food hierarchy and gradually be exposed to specific foods or situations that typically trigger ritualized behaviors. A 2020 review found that ERP was slightly more effective than other CBT treatments for preventing unhealthy responses to binge and purge cues.

How to Find an ERP Specialist

The International OCD Foundation has a resource directory of therapists who use ERP in their practice. Visit the IOCDF's homepage to get help and learn more about ERP specialists.

Summary

Exposure and response prevention therapy is the gold standard for treating obsessive-compulsive disorder. It's also an effective way to cope with social anxiety, phobias, and eating disorders.

Unlike talk therapy, which doesn't require exposure to triggers, ERP usually takes place in real time. ERP forces people to face what they fear most. Being exposed to things that trigger obsessive thoughts or compulsions isn't easy, but it gets easier as patients learn response-prevention techniques and master new coping skills.

A Word From Verywell

ERP isn't an easy or quick fix for OCD and other mental health disorders; it's hard work and takes dedication. Facing what scares you most or triggers obsessive behaviors or phobias is scary. It's important to stay committed and do your ERP exercises regularly and with the guidance of a mental health professional. Don't get discouraged if you don't see immediate results. ERP therapy can take a while to work but can make a notable difference.

Frequently Asked Questions

ERP is one form of CBT. Cognitive-behavioral therapy may sound like a single type of therapy, but it's actually a mix of cognitive therapies (CT) and behavioral therapies (BT). Under the CBT umbrella, exposure and response prevention is one of the behavioral therapies.

Excessive hand washing is a compulsion that's often treated with ERP. Some compulsive handwashers scrub their hands until they're raw after contact with any surface touched by others. During an ERP therapy session, the patient might start by touching a public surface with one finger and not immediately washing their hands. Over time, exposure to surfaces gradually increases. And, as part of response prevention, the patient learns to gently wash their hands only when necessary, while no longer scrubbing compulsively.

When someone with obsessive thoughts does ERP therapy, they purposefully expose themselves to situations that trigger these thoughts but learn not to act on them. ERP won't completely void intrusive thoughts. However, over time, it's possible to master coping skills that make these thoughts less invasive, and habituation makes them less potent with repeated exposure.

Yes, ERP works for social anxiety. People with social anxiety disorder (SAD) often start the ERP process by making a fear hierarchy list of specific social situations they fear most. Then, with the help of a trained specialist, they gradually expose themselves to these situations while a therapist gives them tips on response prevention. Over time, social anxieties dissolve as people with SAD realize there's nothing to fear in most social situations.

Verywell Health uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read our editorial process to learn more about how we fact-check and keep our content accurate, reliable, and trustworthy.

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By Christopher Bergland
Bergland is a retired ultra-endurance athlete turned medical writer and science reporter. He is based in Massachusetts.

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