Breaking free from the OCD cycle with ERP therapy

Exposure and Response Prevention (ERP) is an evidenced-based therapy approach that is considered the first line of treatment for OCD and other anxiety disorders.  If you’ve recently been diagnosed with OCD, you’ve probably been recommended Exposure and Response Prevention therapy. As a licensed therapist trained in ERP, I’m here to go over the pros and cons of this approach so you can decide if it’s the right fit for you.

ERP therapy is an experiential approach that teaches you how to sit with your own anxiety without avoiding it or relying on compulsions. The foundation of this approach is that exposure to the triggering thoughts and feelings will ultimately teach your brain that your worst fears won’t come true. Over time, your anxiety becomes less intense and your OCD thoughts become background noise. They may not go away entirely, but they don’t control your life anymore. Effective ERP also teaches you how to handle OCD flair-ups beyond therapy so you can better cope.

Understanding the OCD Cycle

OCD operates on a feedback loop that can feel impossible to escape. It typically begins with an intrusive thought, image, or urge that triggers intense anxiety or distress. The core themes of these thoughts are fear of harming someone else, fear of something bad happening to you, fear that your anxiety will overwhelm you, or fear that you are a bad person. The fears tend to be extreme and rooted in the future.  

 When these obsessions arise, the anxiety you feel can be unbearable. Compulsions are the behaviors or mental rituals you perform to get rid of that anxiety. You might wash your hands repeatedly, check things repeatedly, and seek reassurance from others. Mental compulsions might be reviewing situations to make sure nothing bad happened, or avoiding certain places, people, or activities that trigger your obsessions.

 Here's the cruel irony of OCD: the compulsions that seem to help in the moment make everything worse in the long run. Every compulsion teaches your brain that your obsessive thoughts are real, even though a large part of you knows that it’s not. This strengthens the OCD cycle and makes it more likely that similar obsessions will trigger even more intense anxiety next time. Over time, the compulsions tend to expand and escalate, demanding more of your time and energy while providing less relief.

How ERP Therapy Interrupts This Cycle

Fear Hierarchy List

The genius of ERP lies in its direct approach to breaking this self-reinforcing cycle. Instead of continuing to feed the OCD through avoidance and compulsions, ERP systematically teaches your brain a new response. The process involves intentionally exposing yourself to the thoughts, situations, or objects that trigger your obsessions while simultaneously resisting the urge to perform compulsions.

First Exposure Exercise

When I work with someone using ERP, we don't just dive into their biggest fears on day one. The approach is collaborative where we first talk about what ERP is, and how it could potentially help your OCD. I’ll complete an assessment of your OCD symptoms to determine the level of impact they have on your life. You’ll be asked to track your obsessive thoughts and compulsions over the course of the week and note the level of stress they cause. Together, we create a list of situations that trigger OCD symptoms, ranked from least to most stressful.  

The next step would be to create an exposure exercise together based on one of the fears at the bottom of your list. This process is collaborative so you have a lot of input on what that exercise could be. The exercise can be done in my office or at your home, if we’re doing telehealth. Some OCD fears require that we write a story to trigger anxiety, if there is no safe way to do an exposure exercise. This process is also collaborative where we will write the script together.

The first exposure exercise we create together will occur in session. I will be there to act as your ERP coach by helping you stay present with our anxiety. While the exposure is happening, you’ll also be asked to avoid doing your compulsions to the best of your ability. There will be about 10-20 minutes at the end of each session to debrief your experience. We’ll also be tracking your anxiety level before, during and after the exposure exercise.

ERP Homework

You’ll be asked to practice exposures at home for at least 20 minutes a day, while always working on resisting your compulsions. We’ll check in on how homework is going every session.

Ongoing Sessions

We’ll continue to track your anxiety levels around your fear list. When your anxiety level goes down, and you feel ready, we can move onto the next fear on your list. Sessions have an exposure exercise and a chance to debrief afterwards.

The Downsides of ERP

ERP is challenging work, and you’ll experience an uptick in your anxiety at first. ERP can feel like it goes against every instinct that OCD has told you. It also requires a lot of time and energy, due to completing daily homework. ERP can be potentially harmful if not implemented correctly. This can happen if you move too quickly through the exposure list or start with an exposure that is too distressing.

ERP and Neurodivergence

ERP has some valid critiques when working with neurodivergent minds. Here are the ways I adapt ERP to be more neurodivergent affirming.

Consent and Client-Driven Goals.

A major component of ERP is understanding how it works and how it can help your OCD. I take time to talk about this with you and won’t move forward with ERP until you’re fully on board. Goals will be set by you that are aligned with your needs, rather than trying to fit into society. Together, we’ll talk through what that looks like and how to notice when those societal pressures are interfering with your goals.

Sensory Needs

Some neurodivergent folks have sensory needs and stims that need to be considered in ERP. We’ll discuss what your sensory needs with a focus on accepting them, rather than getting rid of them. We’ll work together to incorporate these needs into treatment. We’ll be constantly checking in throughout treatment and making adjustments as needed.

Trauma-Informed Care

If you hold a marginalized identity, you may have experienced minority stress and discrimination. Past trauma can lead to anxious thoughts that make sense considering your past experiences. Instead of approaching these thoughts as irritational, we explore the impact they have on your life and whether you want to keep those habits, change them, or reduce them.  

OCD in the LGBTQ+ Community

OCD can hit different for queer and trans people. OCD thrives on uncertainty and can latch on to identity-related fears because sexuality and gender are fluid processes. Exploring your identity naturally involves questioning which can get muddy when you have OCD. This can look like questioning if you’re bisexual because you’re in a straight-passing relationship or asking yourself if you’re really trans. There can be a fear that you’re faking it or just looking for attention. As a queer therapist, I help people separate their OCD from identity exploration. We identify and address the core fears that underlying the gender or sexuality OCD presentation.

Life After ERP

The skills that you develop from ERP will become useful even after completing therapy.  Learning to tolerate uncertainty, sit with discomfort, and act according to your values rather than your fears proves valuable in countless life situations. You will become your own ERP coach and know exactly what to do when your ERP flairs up.

Taking the First Step

I offer specialized ERP therapy for OCD at my Philadelphia practice, with options for both in-person and online sessions. Whether you're in Philadelphia or elsewhere in Pennsylvania, I'd love to hear from you and see if we’re a good fit.

To schedule a free 20-minute consultation and learn more about working together, please reach out through my website. I look forward to connecting with you.

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Frequently Asked Questions

• How long does ERP therapy typically take to see results?

  The timeline for ERP varies depending on the severity of your OCD, how consistently you practice between sessions, and other individual factors. Many people begin noticing changes within the first few weeks of active exposure work, though substantial improvement typically occurs over three to six months of consistent treatment or longer. I work with each person to determine the right pace and duration for their unique situation.

• Will ERP make my anxiety worse before it gets better?

  Exposure work involves intentionally triggering your anxiety so it can feel worse in the beginning. This is why we start with fears that are low on your fear hierarchy list and gradually work our way up. There can be some relief in knowing that OCD thoughts are not reflective of who you are and if anything, are in direct conflict with your values. We’ll continue to work on separating OCD from your core self, which can help the anxiety feel more manageable (without using compulsions).

• What if my thoughts are too disturbing to share with a therapist?

  This concern is incredibly common among people with OCD, and it's one of the reasons many people delay seeking treatment. OCD often generates thoughts that feel shameful, disturbing, or completely contrary to your values and identity. I want to assure you that there is nothing you could share that would shock me or change how I view you. You can share as little or as much as you want about your intrusive thoughts. I won’t pressure you to share more than you’re ready to. Talking about your intrusive thoughts is an exposure and I take that seriously.

• Can ERP therapy be combined with other therapeutic approaches?

  Absolutely. In my practice, I combine ERP with Acceptance and Commitment Therapy (ACT) which can help you accept your intrusive thoughts while making choices that are more aligned with your values. The goal isn’t to get rid of these thoughts, but to learn to live with them without them controlling your life.

• Is ERP effective for all types of OCD?

  ERP has been shown to be effective across all subtypes of OCD, including contamination fears, harm obsessions, relationship OCD, sexual orientation or gender identity OCD, religious or moral scrupulosity, perfectionism, and checking compulsions. The specific exposures are tailored to your symptoms, but the underlying principles remain the same regardless of what your OCD latches onto. During our work together, we'll design exposures that directly address your specific obsessions and compulsions.

• What's the difference between ERP and regular talk therapy for OCD?

  Talk therapy that focuses on exploring the meaning of thoughts or processing past experiences typically isn't effective for OCD and can sometimes make symptoms worse. ERP is a specialized, behavioral approach specifically designed to treat OCD by changing your response to obsessive thoughts. Rather than analyzing why you have certain thoughts or trying to reason them away, ERP helps you build tolerance for the thoughts while eliminating the compulsive behaviors that maintain the cycle.

• How is online ERP therapy different from in-person sessions?

  Online ERP therapy is highly effective and follows the same principles as in-person work. Many exposures can be conducted just as well through video sessions, and having sessions in your own environment can sometimes be advantageous for practicing real-life exposures. Some exposures might require creativity in an online format, and we work together to design practices that fit your situation. I offer both in-person sessions in Philadelphia and online sessions throughout Pennsylvania, and we can discuss which option might work best for you.

• Can ERP help with OCD that focuses on my identity or relationships?

  Yes, ERP is effective for OCD that targets aspects of identity, including sexual orientation, gender identity, and relationship concerns. These subtypes of OCD can be particularly distressing because they create doubt about things that feel core to who you are. As an LGBTQ+ affirming therapist, I'm skilled at distinguishing between genuine identity exploration and OCD-driven doubt. We work together to address the OCD symptoms while honoring and supporting your authentic self, whatever that looks like for you.

• How do I know if I have OCD versus just being an anxious person?

  While anxiety and OCD share some features, OCD is characterized by the specific cycle of intrusive, unwanted obsessive thoughts followed by compulsive behaviors or mental rituals performed to reduce distress. If you spend significant time each day dealing with repetitive thoughts you can't shake and feel compelled to do certain things to feel okay, OCD may be present. During our initial sessions, I conduct a thorough assessment to understand your symptoms and determine the most appropriate treatment approach. If you're unsure whether OCD is the right fit, I encourage you to schedule a consultation so we can explore your experience together.