ERP: The Most Effective Treatment for OCD

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People sometimes toss around the phrase “I’m so OCD” to describe personality traits like a need for order, organization, and routines. But obsessive-compulsive disorder (OCD) goes well beyond that. OCD is characterized by persistent unwanted thoughts or obsessions that lead to repetitive behaviors or mental acts called compulsions. These obsessions can trigger intense anxiety or feelings of discomfort, and the compulsions are performed in order to alleviate this anxiety or discomfort or to prevent a feared event or situation from happening.

The most effective way to treat OCD is with exposure and response prevention (ERP). ERP involves facing fears or obsessions (the exposure part) without engaging in the compulsive behaviors or rituals that typically follow (the response prevention part). ERP helps us confront our fears in a controlled way, breaking the cycle of obsessions and compulsions. It’s like teaching our brains that the feared outcomes are unlikely and the anxiety and discomfort are tolerable and manageable without needing to engage in compulsive behavior.

We’re going to look at some general descriptions of how ERP can help manage four main subtypes of OCD, and then we’ll learn how to practice ERP in more detail. This was an example of ERP for contamination-based OCD. With responsibility for harm-based OCD and checking compulsions, we might find ourselves constantly worried that we left the stove on and that it could potentially cause harm like burning down the house. With ERP, we would deliberately resist the urge to check the stove repeatedly after turning it off and learn to tolerate the anxiety that arises without going back to check. By doing so, we teach ourselves that our fears are exaggerated and that we can tolerate the anxiety and uncertainty without resorting to compulsive checking.

With symmetry, order, and arranging OCD, we have a compelling need for things to be just right, and we feel discomfort or unease when items aren’t arranged precisely as we think they should be. In ERP, we disrupt this need for perfection. We intentionally place objects in a slightly disordered fashion and then resist the urge to rearrange them to achieve symmetry. Through this process, we learn to manage the discomfort that arises from things not being ordered perfectly and to tolerate these feelings without the need to compulsively rearrange things.

In taboo or forbidden thoughts OCD, we might experience distressing and intrusive thoughts that go against our values, like thinking about harming a loved one, creating significant anxiety. Compulsions often involve mental rituals like trying to stop ourselves from having these thoughts or trying to neutralize them with good thoughts. With ERP, we invite these thoughts in and then resist the urge to engage in mental rituals or seek reassurance. By facing these thoughts, we learn that they’re just thoughts, they’re not dangerous, and they don’t define our character or intentions.

In theory, ERP sounds quite simple – we just prevent ourselves from engaging in our compulsive behaviors. But that’s much easier said than done, or we’d already be doing it. Reducing the strength of our obsessions can help make ERP more manageable, and I talk about how to do this in another video. I also have a video that describes the theory and practice of exposure therapy in general in detail, which can help with ERP.

So the first step in ERP is to come up with a list of about 8 to 10 exposure situations that trigger our obsessions and provoke compulsive behaviors. The items on the list should be as specific as possible and include things that cause a range of anxiety or distress, from situations that seem somewhat manageable to situations that might feel almost impossible. Everyone’s lists will be different, but here are some sample situations for an exposure list for contamination-based OCD. You’ll find a full sample list on my website that I link to in the description, along with sample lists for other subtypes of OCD.

The traditional way of doing exposure therapy is to start with the situation that causes us the least amount of distress and then work our way up through the list to the one that causes us the most distress. But more recent research suggests it might be more effective to go through the list in a quasi-random fashion, making sure to include some of the most anxiety-provoking situations towards the start.

Now, there are four things we want to learn from our exposure exercises. We want to violate our expectations about what we think will happen and learn that our feared outcomes are less probable or severe than we predict. We also want to learn that anxiety is a natural human emotion that is both safe and tolerable, as are things such as discomfort arising from uncertainty, lack of perfection, and so on. And we want to learn that we don’t need to rely on compulsive behaviors to tolerate anxiety or discomfort or provide us with safety, and that we’re able to function in our daily lives despite feeling anxiety or discomfort.

For this example, we’re going to use a high distress exposure. So, the situation is to spend a day at work without avoiding touching things I fear could be contaminated or avoiding shaking hands, and so on. Refrain from washing my hands or using sanitizer throughout the day and then come home and prepare and eat dinner with my family without first washing my hands.

So, before starting the exposure, we ask ourselves: What do I expect or predict will happen by not avoiding contaminated objects at work? I will bring it home and infect myself or my family.

What am I most worried about or fear the most? I worry that my family members might get sick because of my actions.

Is there anything I’m worried I won’t be able to tolerate? I’ll feel guilt, anxiety, and intense worry about my family’s health, and I won’t be able to stand feeling this way, and I’ll end up giving in and washing my hands. How likely do I think it is that what I’m worried about will happen on a scale from 0 to 100?

Then we do the exposure exercise and afterwards ask ourselves: What happened during the exposure? Did my fears come true? Throughout the day, I forced myself to refrain from compulsive behaviors. I touched doorknobs, shared office equipment, shook people’s hands, and even went to the restroom without washing or sanitizing my hands afterwards. After work, I prepared and ate dinner without washing my hands first, and nobody felt sick after dinner, and the next morning everyone was still healthy.

Was I able to tolerate the distress, and if so, how? It wasn’t quite as bad as I expected. While some anxiety and discomfort arose, especially at the start of the exposure every time I came into contact with something that might have been contaminated, and just before we ate dinner, I noticed these feelings gradually diminished without me having to do anything about them. I practiced some mindfulness techniques and acknowledged the anxiety but resisted the urge to give into compulsions.

How was this outcome different from what I expected? I thought that not avoiding contaminated objects and especially not washing my hands afterwards would lead to someone in my family falling seriously ill. But everyone was fine and there were no signs of illness.

What did I learn from this? I learned my fears were exaggerated. I realized that my anxiety, while intense at times, was tolerable and I could manage it without resorting to compulsions. I learned my OCD tends to blow things out of proportion, and my anxiety doesn’t always match the actual level of risk. The experience reinforced the idea that my OCD fears aren’t based in reality. It showed me my family wasn’t in imminent danger due to my actions, which allows me to challenge future OCD-driven thoughts more effectively.

These exposure and response prevention situations can be more effective when combined with the exercises in my video about obsessive thoughts and challenging beliefs that contribute to OCD. And these exercises can also help give us the courage to engage in ERP if we’re finding it difficult to get started. But what if I do ERP and someone in my family does get sick? Well, first, we can’t be sure they caught it from us. If there’s an illness going around, they could have caught it from a lot of different sources.

And even if they did catch it from us, people spread germs all the time and catch illnesses from other people all the time. There’s no way to prevent ourselves from ever transmitting germs, and if we have OCD, our compulsive attempts to do so have a very negative impact on the quality of our lives. ERP isn’t about putting ourselves or others in irresponsibly risky or dangerous situations. It’s about learning to live our lives in ways comparable to most people without the burden of debilitating compulsions.

Now, let’s talk about Purely Obsessional OCD, often known as Pure O. This form of OCD involves taboo, forbidden, or unacceptable intrusive thoughts about violence, causing harm, sex, religion, or fear of making mistakes. Unlike traditional OCD, Pure O doesn’t manifest in overt compulsive behaviors but instead involves mental acts and rituals.

Compulsions in Pure O include mental rituals like neutralizing bad thoughts, mentally praying, checking, and incessant mental replaying. The goal is to control and prevent these intrusive thoughts from arising. However, despite the name Pure O, it also involves compulsions, although they’re harder to distinguish from obsessions as both occur in our minds.

An exposure exercise for Pure O might involve deliberately thinking about harming a loved one, allowing the thought without suppression, and resisting mental compulsions. Practicing mindfulness, acknowledging the thoughts without fighting them, and allowing them to pass can be part of the exposure.

If we find ourselves repeating neutralizing thoughts or prayers, changing the words can disrupt the usual ritual. Writing a detailed script of feared scenarios, reading it out loud, or recording and listening to it can also be helpful exposures. By preventing mental compulsions, we learn that the feared consequences linked to these thoughts seldom occur.

In Pure O, there are also overt behavioral compulsions like seeking reassurance or avoiding triggering situations. An exposure could involve confronting these situations directly, such as going to the kitchen with knives present, resisting compulsions, and learning that thoughts alone aren’t dangerous.

For more strategies on managing Pure O and obsessive thinking, check my video on OCD and obsessive thoughts available on my website.

Contamination-Based OCD Exposure Exercises

• Use a pen that other people have used without cleaning or wiping it first. Resist the urge to wash or sanitize hands immediately afterwards.
• Go shopping and hold the cart handle without gloves. Don’t sanitize or wash hands until I’m home, and don’t avoid touching my face or other objects out of fear of contaminating them.
• Use a public restroom and put my bag on the floor rather than looking for a place to hang it, and avoid cleaning it afterwards.
• Shake hands with someone without sanitizing afterward. Touch my face with unwashed hands.
• Touch items in a dumpster with bare hands. Resist urge to wash hands until before my next meal.
• Walk barefoot inside a public restroom, and touch the floor with my hands. Don’t wash hands until next time I eat. Don’t clean feet until the next time I shower.
• Use a public restroom without washing my hands afterwards. Don’t avoid touching doors or anything else in the restroom. Eat some snacks with my hands before washing or sanitizing them.
• Spend a day at work without avoiding touching things I fear could be contaminated or avoiding shaking hands, etc. Refrain from washing or sanitizing hands during the day. Go home and prepare and eat dinner with my family without first washing my hands.

Checking Compulsion Exposure Exercises

• Leave a kitchen appliance plugged in (e.g., toaster) without checking it multiple times to make sure it’s off. Leave it plugged in and walk away without going back to check.
• Make a low-stakes decision without second-guessing it multiple times, and resist the urge to keep revisiting the decision excessively. If doubt creeps in, notice any discomfort but stick with what I already decided instead of changing my mind back and forth.
• Have a conversation with a friend without analyzing it afterward for mistakes. Don’t replay it back in my head to see if I may have said something wrong or embarrassing.
• Close and lock the front door as I leave the house. Once I’ve locked it, resist the compulsion to check again. Go shopping for an hour and any time I start to worry I might have forgotten to lock the door, resist any urges to turn the car around and check, or leave the store early.
• Turn off the stove after cooking breakfast and resist the compulsion to check repeatedly. Go to work without checking to see if it’s off before leaving. Don’t ask anyone else to check while I’m at work.
• Lock the car once and resist the urge to check multiple times, and then go in to work without checking on the car for the rest of the day. Trust my initial action and tolerate any anxiety without giving in to the compulsion to go back to the car to check that I did lock it.
• Leave the house without going back to check that all lights and appliances are turned off. Resist the urge to return and check. Notice the discomfort but trust my initial actions and manage any anxious thoughts or feelings with mindfulness.
• Send a work email without rereading it obsessively. Check it over once and then resist the compulsion to keep checking it over and over. Send the email and then resist the urge to reread it to make sure I didn’t make any mistakes.
• Drive to a destination and resist the urge to go back and check if I’ve harmed anyone on the way. I will trust my driving skills and decision-making without returning to the scene. I will resist mentally reviewing my entire driving route after reaching my destination. I will refrain from replaying the journey in my mind to search for potential mistakes or incidents.

Symmetry, Order, and Arranging OCD Exposure Exercises

• Mix various types of utensils (forks, spoons, knives) in a kitchen drawer. Resist the compulsion to sort them into separate compartment.
• Wear intentionally mismatched socks. Resist the urge to change into matching pairs.
• Place items on my desk in a random pattern without any specific order. Resist the need to arrange them symmetrically.
• Place books or items on a shelf in an intentionally uneven or disorderly manner without categorizing them by size or genre. Resist the urge to create ordered sections or keep rearranging them until they feel “just right.”
• After doing laundry, quickly fold clothes once and place them in drawers in the order they were folded. Resist the urge to refold anything that isn’t perfectly neatly folded, or to rearrange them in a more organized manner.
• Cook a meal using ingredients placed haphazardly on the kitchen counter. Resist the compulsion to organize them systematically before starting to cook. Set the table using mismatched plates, glasses, and utensils and resist the urge to match them symmetrically before eating.

Taboo, Forbidden, or Unacceptable Thoughts OCD Exposure Exercises

• Spend 10 minutes deliberately visualizing taboo thoughts without analyzing or trying to suppress them. Allow the thoughts to come and go without judgment. Avoid trying to neutralize the thoughts with “good” thoughts.
• Write down an obsessive thought in detail. Describe the thoughts, emotions, and fears associated with them. Read back what I’ve written without seeking reassurance or resorting to any neutralizing mental rituals.
• Record the obsessive thought in detail. Listen to the recording multiple times without seeking reassurance or resorting to any neutralizing mental rituals.
• Engage in a conversation with a friend about a taboo or uncomfortable topic. Discuss it openly without changing the subject. Resist engaging in any mental rituals to neutralize the effect of what we’re talking about or any taboo thoughts I’m having related to the topic.
• Watch a movie or read a book that includes themes related to my taboo thoughts. Allow myself to experience the discomfort without turning away or seeking distractions.
• Put myself in situations that could trigger my taboo thoughts (e.g., driving, visiting crowded places, attending social events, being in the kitchen with my partner, putting my baby down to sleep). Resist the urge to avoid these situations and tolerate the anxiety.
• Bring to mind a taboo thought and then go shopping to show myself I can carry out daily tasks even when I’m anxious about something I’m thinking about. Resist the urge to perform any mental rituals to ease my anxiety or discomfort.

Abramowitz, J. S., Deacon, B. J., & Whiteside, S. P. H. (2019). Exposure Therapy for Anxiety: Principles and Practice (2nd ed.). The Guilford Press.