Exposure therapy can seem kind of mysterious and edgy, but the approach is actually very straightforward and does not have to be scary, extreme, or complicated. Since therapy is an art and a science, each experience will be unique based on the training and style of the therapist and the relational dynamic between client and therapist.
Exposure and Response Prevention (ERP) sessions generally involve psychoeducation on OCD and how exposure therapy works. After this review, clients will do a pre-planned exposure exercise with the support of the trusted therapist. After exposure, the client and therapist will process the experience and the therapist will give guidance on suggested homework practice. The goal of ERP is to stop compulsions and avoidance, so sessions are focused on this aim. Therapists may incorporate techniques from other types of therapy like ACT, DBT, and depth-oriented therapies. Although variations in ERP exist, all types of ERP will include exposure and response prevention.
- Exposure: intentionally approaching obsessional triggers.
- Response Prevention: not engaging in any type of compulsion or avoidance when triggered by unwanted thoughts, images, or urges (ie. obsessions).
Your Role in ERP Therapy
Clients in ERP play an active role in their recovery, so sessions involve collaboration between the therapist and person with OCD. Collaboration looks like curiosity from the therapist and client in attempts to understand the client’s struggles. Collaboration also involves co-creation of the Exposure Hierarchy and shared treatment planning including details of exposure practice.
In each session, the therapist offers a non-judgmental space, bringing their knowledge and support while clients come with a willingness to be open to new experiences with commitment to ERP practice both in session and outside of session.
ERP sessions are typically 1-2 times per week. Each sessions builds on the last as clients approach triggers without using mental or physical compulsions. Week by week exposures become more challenging as the client works their way up the hierarchy they designed with the therapist. Clients learn to stop compulsions and refrain from avoidance while developing an empowered relationship with anxiety. Symptom relief and emotional processing are targets for lasting recovery.
Rumination-Focused ERP Restores Agency
In Rumination-Focused ERP (RF-ERP) sessions emphasize learning to stop compulsive rumination. Compulsive rumination is active mental engagement with obsessions and sometimes referred to as the ‘Pure O’ subtype. Rumination is present in all types of OCD.
Learning to stop rumination’s anxiety spiral restores the person with OCD’s agency so they are no longer hostage to their triggers. Clients learn to direct their attention on purpose to unhook from the overthinking rollercoaster that prolongs anxiety.
What happens during an RF-ERP session depends on the stage of treatment, personal style of the therapist, and the individual circumstances of each client. After clients have developed the basic skill of learning to stop ruminating, they practice exposures in session with the therapist. Topics of rumination, areas of avoidance, physical compulsions performed, and anxiety triggers guide exposure planning.
A Typical ERP Therapy Session
Sessions will typically begin with a check-in about how the previous week’s practice went. The therapist will process the experience with the client, trouble shooting areas of difficulty and reinforcing the client’s courage to approach what feels scary without the use of neutralizing compulsions. In RF-ERP, deeper exploration of emotional and relational patterns is welcome to foster increased self-understanding and psychological health.
Items on the Exposure Hierarchy are targeted for in-session practice after reviewing the previous week’s homework practice. During exposure, clients approach the trigger while not ruminating or doing any other form of compulsion. The therapist will be a source of support the entire time, periodically inquiring about the client’s level of anxiety, trouble shooting difficulties, and encouraging the client to stay present. Without compulsive rumination during exposure, anxiety decreases and clients get a little closer to their goals. With repeated practice, clients reclaim their agency and develop a greater capacity to tolerate the full spectrum of human experiences.
After in-session exposure practice, the therapist and client will process the experience verbally, discussing insights and areas of new learning. Post-exposure processing is followed by a discussion of expected home practice outside of therapy. Clients are invited to ask questions and share reflections on their experience.
Starting ERP Treatment for OCD
If you would like to try OCD treatment with ERP, reach out to a licensed therapist trained in Exposure and Response Prevention. The International OCD Foundation has a directory where you may search for therapists in your area. If you are in California, I offer in-person ERP in Ventura County and secure online therapy across the state.