Exposure and Response Prevention (ERP)If you are interested in counseling using ERP, call OakHeart at 630-570-0050 or 779-201-6440 or email us at [email protected]. We have counselors, psychologists, and social workers available to help you at one of our locations in North Aurora, IL, Sycamore, IL, and/or via Telehealth Online Therapy Services serving Kane County, DeKalb County, Dupage County, and beyond.
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What is Exposure and Response Prevention?Exposure and Response Prevention, or ERP, is the gold-standard treatment for obsessive-compulsive disorder (OCD). Numerous studies have demonstrated that ERP is an extremely effective treatment for OCD and is superior to all other available psychological and behavioral interventions. ERP is a form of Cognitive Behavioral Therapy (CBT) that addresses the thoughts, behaviors, and cognitive patterns that maintain obsessions and compulsions in a structured, skills-based format.
While ERP is most commonly associated with the treatment of OCD, exposure-based treatment is actually the core mechanism underlying effective treatment for all anxiety disorders. Whether the fear involves intrusive thoughts, specific situations, physical sensations, social judgment, or concerns about health and illness, the fundamental principle is the same: systematic, supported confrontation with feared stimuli without engaging in avoidance or safety behaviors. At OakHeart, exposure-based approaches are used across a wide range of anxiety-related conditions including OCD, specific phobias, panic disorder, social anxiety disorder, health anxiety, generalized anxiety disorder, and body dysmorphic disorder. To learn more about how these conditions are treated, visit our specialty pages. What Does This Evidence-Based Treatment Entail?In ERP, the goal is to learn that thoughts are just thoughts and that they do not contribute to behavioral or situational outcomes without intention. OCD is considered by some to be a thought phobia in which a phenomenon called thought-action fusion occurs. Thought-action fusion is the belief that whatever thoughts come to mind will result in behavior or action in the world (Grayson, 2014). In other words, OCD is often considered a thought phobia because individuals with OCD are afraid of their thoughts and the perceived power of those thoughts.
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How will you learn that thoughts are not as powerful as they feel? By sitting with anxiety and intrusive thoughts without neutralizing them or trying to eliminate them in any way (Foa et al., 2012). You will learn to sit with anxiety and intrusive thoughts using a variety of techniques that allow you to confront the stimuli that trigger anxiety and distress, both mentally and physically. With enough exposures to the feared thought or related stimuli, you will eventually learn that you can tolerate the trigger, that nothing bad or dangerous will happen, and that the anxiety will subside if you do not engage in a compulsion.
What Exactly Does This Treatment Consist Of?
An exposure exercise entails repeatedly and systematically encountering a feared situation or thought using a variety of exposure techniques until the fear diminishes. In treatment, your clinician will help you create what is called a hierarchy of feared triggers so that you can gradually confront your fears in a structured and supported way. For example, if you are afraid of driving due to fear of harming someone while driving, a very common obsession in individuals with OCD, your hierarchy might look like sitting in the car in a parking lot, driving in an empty parking lot, driving in the parking lot when it is busy, driving around the block, driving on a main road, and so on. Your clinician will assist with developing a plan that is tailored to your specific fears and goals.
ERP is systematic and gradual. You will not typically move onto the next item on your hierarchy until the anxiety, distress, and perceived level of danger regarding the thought or situation have significantly reduced during the previous step. Eventually, you will start to see that an intrusive thought is just a thought, that you do not need to be afraid of your thoughts, and that your feared outcomes are highly unlikely. We all have intrusive thoughts. One of the most important components of ERP is learning to accept uncertainty. We cannot eliminate all uncertainty from our lives, and we cannot live our lives trying to prevent every possible risk we could encounter without sacrificing our ability to live at all. In ERP, you will not be asked to take risks that most people would not take or that could cause serious harm to yourself or others. However, you will be asked to accept the small amounts of uncertainty that we all must accept as part of living a full life.
In sum, the goal of ERP is to help you take back control of your life from OCD. The skills and techniques learned in treatment are designed to be used both during and after the formal treatment process. The end goal is for you to become your own exposure therapist -- someone who can recognize an intrusive thought for what it is and respond to it without fear or compulsion. Because intrusive thoughts are a universal human experience, the aim is not to eliminate them but to learn to react to them the way you did before OCD took hold: a thought is just a thought, and thoughts do not have power over you unless you give them power.
Here is a blog written by the owners Dr. Kat Harris and Vanessa Osmer on Exposure and Response Prevention for OCD
ERP is systematic and gradual. You will not typically move onto the next item on your hierarchy until the anxiety, distress, and perceived level of danger regarding the thought or situation have significantly reduced during the previous step. Eventually, you will start to see that an intrusive thought is just a thought, that you do not need to be afraid of your thoughts, and that your feared outcomes are highly unlikely. We all have intrusive thoughts. One of the most important components of ERP is learning to accept uncertainty. We cannot eliminate all uncertainty from our lives, and we cannot live our lives trying to prevent every possible risk we could encounter without sacrificing our ability to live at all. In ERP, you will not be asked to take risks that most people would not take or that could cause serious harm to yourself or others. However, you will be asked to accept the small amounts of uncertainty that we all must accept as part of living a full life.
In sum, the goal of ERP is to help you take back control of your life from OCD. The skills and techniques learned in treatment are designed to be used both during and after the formal treatment process. The end goal is for you to become your own exposure therapist -- someone who can recognize an intrusive thought for what it is and respond to it without fear or compulsion. Because intrusive thoughts are a universal human experience, the aim is not to eliminate them but to learn to react to them the way you did before OCD took hold: a thought is just a thought, and thoughts do not have power over you unless you give them power.
Here is a blog written by the owners Dr. Kat Harris and Vanessa Osmer on Exposure and Response Prevention for OCD
How Does ERP Work? Habituation and Inhibitory Learning
For many years, ERP was understood primarily through the lens of habituation. Habituation refers to the natural process by which anxiety gradually decreases when a person is repeatedly exposed to a feared thought or situation without the feared outcome occurring. Under this model, the measure of a successful exposure was a reduction in anxiety. If your anxiety came down during or between sessions, the treatment was working. Habituation is a real phenomenon and remains a useful concept, but research has increasingly suggested that it is not the whole story.
One important challenge to the traditional habituation model is that many people show clear habituation of anxiety during ERP and still do not improve, while others improve without showing much habituation at all. This inconsistency has led researchers, including Dr. Michelle Craske, to develop what is now called the inhibitory learning model, a more nuanced and clinically powerful way of understanding why ERP works and how to maximize its effects.
The inhibitory learning model proposes that ERP does not erase or overwrite the original fear. Instead, it creates a new, competing learning experience alongside it. When someone has OCD or an anxiety disorder, the brain has learned to associate certain thoughts, situations, or sensations with danger. The goal of exposure is not simply to reduce that danger signal through repeated contact, but to actively build new safety learning -- new associations that communicate to the brain that the feared thought or situation is not actually dangerous, that the distress it produces is tolerable, and that engaging in a compulsion or avoidance behavior is not necessary for safety. In this way, the feared stimulus ends up carrying two competing meanings: the original danger association and the new safety association. The work of ERP is to strengthen the safety association until it is powerful enough to inhibit, or block out, the original danger signal -- which is where the term inhibitory learning gets its name.
This shift in understanding has meaningful practical implications for how ERP is conducted. Rather than measuring success by how much anxiety decreases during an exposure, the inhibitory learning approach focuses on how much new safety learning has occurred. This means working to clearly disconfirm feared predictions -- for example, identifying what you feared would happen, doing the exposure, and explicitly noting that the feared outcome did not occur. It means introducing variety into exposures so that safety learning generalizes across different contexts and situations rather than being limited to a single setting. It means tolerating and even welcoming some degree of anxiety during exposures rather than waiting for it to subside, because anxiety itself is not the problem -- the belief that anxiety is dangerous or intolerable is. And it means embracing uncertainty rather than seeking the false sense of safety that compulsions temporarily provide.
Importantly, focusing on habituation as the goal can actually be counterproductive. If the aim of an exposure is to reduce anxiety, then anxiety becomes the enemy; something that must be eliminated. The inhibitory learning model reframes this entirely. Anxiety during an exposure is not a sign that something is going wrong. It is the very context in which new safety learning occurs. The goal is not to feel less afraid in the moment. The goal is to learn something new about the feared thought or situation that fundamentally changes your relationship with it going forward.
At OakHeart, our clinicians are trained in both the traditional habituation model and the more contemporary inhibitory learning approach, and will tailor exposure work to what is most clinically meaningful for your specific presentation and goals. For a deeper dive into inhibitory learning and how it applies to anxiety disorders, OCD, and PTSD, visit our blog post on the topic written by Hillary Gorin, PhD, LCP.
One important challenge to the traditional habituation model is that many people show clear habituation of anxiety during ERP and still do not improve, while others improve without showing much habituation at all. This inconsistency has led researchers, including Dr. Michelle Craske, to develop what is now called the inhibitory learning model, a more nuanced and clinically powerful way of understanding why ERP works and how to maximize its effects.
The inhibitory learning model proposes that ERP does not erase or overwrite the original fear. Instead, it creates a new, competing learning experience alongside it. When someone has OCD or an anxiety disorder, the brain has learned to associate certain thoughts, situations, or sensations with danger. The goal of exposure is not simply to reduce that danger signal through repeated contact, but to actively build new safety learning -- new associations that communicate to the brain that the feared thought or situation is not actually dangerous, that the distress it produces is tolerable, and that engaging in a compulsion or avoidance behavior is not necessary for safety. In this way, the feared stimulus ends up carrying two competing meanings: the original danger association and the new safety association. The work of ERP is to strengthen the safety association until it is powerful enough to inhibit, or block out, the original danger signal -- which is where the term inhibitory learning gets its name.
This shift in understanding has meaningful practical implications for how ERP is conducted. Rather than measuring success by how much anxiety decreases during an exposure, the inhibitory learning approach focuses on how much new safety learning has occurred. This means working to clearly disconfirm feared predictions -- for example, identifying what you feared would happen, doing the exposure, and explicitly noting that the feared outcome did not occur. It means introducing variety into exposures so that safety learning generalizes across different contexts and situations rather than being limited to a single setting. It means tolerating and even welcoming some degree of anxiety during exposures rather than waiting for it to subside, because anxiety itself is not the problem -- the belief that anxiety is dangerous or intolerable is. And it means embracing uncertainty rather than seeking the false sense of safety that compulsions temporarily provide.
Importantly, focusing on habituation as the goal can actually be counterproductive. If the aim of an exposure is to reduce anxiety, then anxiety becomes the enemy; something that must be eliminated. The inhibitory learning model reframes this entirely. Anxiety during an exposure is not a sign that something is going wrong. It is the very context in which new safety learning occurs. The goal is not to feel less afraid in the moment. The goal is to learn something new about the feared thought or situation that fundamentally changes your relationship with it going forward.
At OakHeart, our clinicians are trained in both the traditional habituation model and the more contemporary inhibitory learning approach, and will tailor exposure work to what is most clinically meaningful for your specific presentation and goals. For a deeper dive into inhibitory learning and how it applies to anxiety disorders, OCD, and PTSD, visit our blog post on the topic written by Hillary Gorin, PhD, LCP.
ERP for Children and Adolescents
ERP is not only the gold-standard treatment for adults, it is also the gold-standard treatment for children and adolescents with OCD and anxiety disorders. Research consistently supports the effectiveness of ERP across the lifespan, and the fundamental principles are the same regardless of age. Treatment with younger clients is adapted to be developmentally appropriate, and parents and caregivers are typically involved as active participants in the treatment process.
Parental involvement is not just helpful -- it is often essential. Caregivers play a critical role in supporting exposures at home, avoiding accommodation of OCD and anxiety-driven behaviors, and helping their child build the skills and confidence to face their fears. At OakHeart, our clinicians work collaboratively with children, adolescents, and their families to deliver ERP in a way that is age-appropriate, compassionate, and grounded in the best available evidence.
Parental involvement is not just helpful -- it is often essential. Caregivers play a critical role in supporting exposures at home, avoiding accommodation of OCD and anxiety-driven behaviors, and helping their child build the skills and confidence to face their fears. At OakHeart, our clinicians work collaboratively with children, adolescents, and their families to deliver ERP in a way that is age-appropriate, compassionate, and grounded in the best available evidence.
Frequently Asked Questions About ERP
Is ERP the same as flooding?
No, and this is one of the most common misconceptions about ERP. Flooding refers to an older technique in which a person is exposed to their most feared situation immediately and at maximum intensity. ERP is not flooding. ERP is gradual, collaborative, and systematic. Treatment begins with lower-anxiety items on your hierarchy and progresses at a pace that is clinically appropriate and agreed upon between you and your therapist. You will never be asked to do something you are unwilling to do, and the work is always done with careful clinical guidance and support.
Will ERP make my anxiety worse?
ERP will ask you to tolerate some discomfort, and that is intentional and clinically important. However, the goal is never to overwhelm you. The temporary increase in anxiety that occurs during an exposure is not harmful, and it is precisely in that window of discomfort that new safety learning occurs. Most people find that while individual exposures are challenging, their overall anxiety and quality of life improve significantly over the course of treatment. Research consistently shows that ERP produces meaningful, lasting symptom reduction for the vast majority of people who engage with it.
Do I have to touch things or do things that feel dangerous?
ERP is tailored to your specific fears and your specific presentation. Not all exposures are physical. Many exposures in OCD treatment are imaginal, meaning they involve confronting feared thoughts, images, or scenarios mentally rather than through physical contact with objects or situations. Your therapist will work with you to design exposures that are clinically meaningful and appropriate for your specific obsessions and compulsions.
What is the difference between the "E" and the "RP" in ERP?
The "E" stands for exposure, which refers to deliberately confronting the thoughts, situations, objects, or sensations that trigger your anxiety or obsessions. The "RP" stands for response prevention, which refers to refraining from the compulsive behaviors, mental rituals, or avoidance strategies you would normally use to reduce distress. Both components are essential. Exposure alone without response prevention is significantly less effective, because engaging in a compulsion after an exposure reinforces the belief that the compulsion was necessary for safety and undoes much of the learning that the exposure was designed to create.
How long does ERP treatment take?
The length of treatment varies depending on the severity of symptoms, the number and complexity of obsessions and compulsions, and how consistently exposures are practiced between sessions. Many individuals with OCD see meaningful improvement within 12 to 20 sessions. More complex presentations may require longer treatment. Your therapist will work with you to establish a treatment plan with clear goals and regular progress monitoring.
I have tried ERP before and it did not work. Should I try again?
Yes, in many cases. There are several reasons ERP may not have been effective in a prior course of treatment, including insufficient exposure intensity, excessive therapist accommodation of avoidance, lack of response prevention, or a focus on anxiety reduction rather than safety learning. Advances in our understanding of inhibitory learning have also led to meaningful improvements in how ERP is conducted. If you have had a previous course of ERP that was not effective, it is worth discussing with a clinician who is well trained in contemporary ERP approaches, as a different implementation may produce a very different outcome.
Is ERP available via telehealth?
Yes. ERP is well suited to telehealth delivery and research supports its effectiveness in online formats. Many exposures can be conducted or coached remotely, and telehealth ERP removes practical barriers that might otherwise prevent someone from accessing this specialized treatment. OakHeart offers telehealth ERP throughout Illinois.
No, and this is one of the most common misconceptions about ERP. Flooding refers to an older technique in which a person is exposed to their most feared situation immediately and at maximum intensity. ERP is not flooding. ERP is gradual, collaborative, and systematic. Treatment begins with lower-anxiety items on your hierarchy and progresses at a pace that is clinically appropriate and agreed upon between you and your therapist. You will never be asked to do something you are unwilling to do, and the work is always done with careful clinical guidance and support.
Will ERP make my anxiety worse?
ERP will ask you to tolerate some discomfort, and that is intentional and clinically important. However, the goal is never to overwhelm you. The temporary increase in anxiety that occurs during an exposure is not harmful, and it is precisely in that window of discomfort that new safety learning occurs. Most people find that while individual exposures are challenging, their overall anxiety and quality of life improve significantly over the course of treatment. Research consistently shows that ERP produces meaningful, lasting symptom reduction for the vast majority of people who engage with it.
Do I have to touch things or do things that feel dangerous?
ERP is tailored to your specific fears and your specific presentation. Not all exposures are physical. Many exposures in OCD treatment are imaginal, meaning they involve confronting feared thoughts, images, or scenarios mentally rather than through physical contact with objects or situations. Your therapist will work with you to design exposures that are clinically meaningful and appropriate for your specific obsessions and compulsions.
What is the difference between the "E" and the "RP" in ERP?
The "E" stands for exposure, which refers to deliberately confronting the thoughts, situations, objects, or sensations that trigger your anxiety or obsessions. The "RP" stands for response prevention, which refers to refraining from the compulsive behaviors, mental rituals, or avoidance strategies you would normally use to reduce distress. Both components are essential. Exposure alone without response prevention is significantly less effective, because engaging in a compulsion after an exposure reinforces the belief that the compulsion was necessary for safety and undoes much of the learning that the exposure was designed to create.
How long does ERP treatment take?
The length of treatment varies depending on the severity of symptoms, the number and complexity of obsessions and compulsions, and how consistently exposures are practiced between sessions. Many individuals with OCD see meaningful improvement within 12 to 20 sessions. More complex presentations may require longer treatment. Your therapist will work with you to establish a treatment plan with clear goals and regular progress monitoring.
I have tried ERP before and it did not work. Should I try again?
Yes, in many cases. There are several reasons ERP may not have been effective in a prior course of treatment, including insufficient exposure intensity, excessive therapist accommodation of avoidance, lack of response prevention, or a focus on anxiety reduction rather than safety learning. Advances in our understanding of inhibitory learning have also led to meaningful improvements in how ERP is conducted. If you have had a previous course of ERP that was not effective, it is worth discussing with a clinician who is well trained in contemporary ERP approaches, as a different implementation may produce a very different outcome.
Is ERP available via telehealth?
Yes. ERP is well suited to telehealth delivery and research supports its effectiveness in online formats. Many exposures can be conducted or coached remotely, and telehealth ERP removes practical barriers that might otherwise prevent someone from accessing this specialized treatment. OakHeart offers telehealth ERP throughout Illinois.
References
Abramowitz, J. S. (n.d.). The inhibitory learning approach to exposure and response prevention. International OCD Foundation. Retrieved from https://iocdf.org/expert-opinions/the-inhibitory-learning-approach-to-exposure-and-response-prevention/
Abramowitz, J. S., Deacon, B. J., & Whiteside, S. P. H. (2019). Exposure therapy for anxiety: Principles and practice (2nd ed.). The Guilford Press.
Craske, M. G., Treanor, M., Conway, C. C., Zbozinek, T., & Vervliet, B. (2014). Maximizing exposure therapy: An inhibitory learning approach. Behaviour Research and Therapy, 58, 10-23.
Foa, E. B., Yadin, E., & Lichner, T. K. (2012). Exposure and response (ritual) prevention for obsessive-compulsive disorder: Therapist guide (2nd ed.). Oxford University Press.
Freeman, J. B., & Garcia, A. M. (2008). Family-based treatment for young children with OCD: Therapist guide. Oxford University Press.
Grayson, J. (2014). Freedom from obsessive-compulsive disorder: A personalized recovery program for living with uncertainty (Updated ed.). Berkley.
Jacoby, R. J., & Abramowitz, J. S. (2016). Inhibitory learning approaches to exposure therapy: A critical review and translation to obsessive-compulsive disorder. Clinical Psychology Review, 49, 28-40.
Abramowitz, J. S. (n.d.). The inhibitory learning approach to exposure and response prevention. International OCD Foundation. Retrieved from https://iocdf.org/expert-opinions/the-inhibitory-learning-approach-to-exposure-and-response-prevention/
Abramowitz, J. S., Deacon, B. J., & Whiteside, S. P. H. (2019). Exposure therapy for anxiety: Principles and practice (2nd ed.). The Guilford Press.
Craske, M. G., Treanor, M., Conway, C. C., Zbozinek, T., & Vervliet, B. (2014). Maximizing exposure therapy: An inhibitory learning approach. Behaviour Research and Therapy, 58, 10-23.
Foa, E. B., Yadin, E., & Lichner, T. K. (2012). Exposure and response (ritual) prevention for obsessive-compulsive disorder: Therapist guide (2nd ed.). Oxford University Press.
Freeman, J. B., & Garcia, A. M. (2008). Family-based treatment for young children with OCD: Therapist guide. Oxford University Press.
Grayson, J. (2014). Freedom from obsessive-compulsive disorder: A personalized recovery program for living with uncertainty (Updated ed.). Berkley.
Jacoby, R. J., & Abramowitz, J. S. (2016). Inhibitory learning approaches to exposure therapy: A critical review and translation to obsessive-compulsive disorder. Clinical Psychology Review, 49, 28-40.
