Obsessive Compulsive Disorder Therapy

Those with OCD might have trouble finding the right kind of therapy. Cognitive Behavioral Therapy (CBT) is often suggested as the most effective treatment, but there are some aspects of CBT that can actually make the condition worse. However, one kind of CBT has been used very successfully to treat OCD, which is Exposure and Response Prevention Therapy (ERP).

Exposure and Response Prevention Therapy (ERP) is an evidence-based treatment during which a person with OCD is purposefully exposed to the trigger or fear that causes their obsessive thoughts and compulsive behaviors. While this might seem counterintuitive, being exposed to the situation in a controlled environment with the help of a trained therapist can allow a person with OCD to confront the things that aggravate their obsessions.

Once a person is exposed to the trigger, they respond with a certain behavior. In most cases, they would engage in compulsive action, but the goal behind ERP is to help the client choose a different response, where they do not act in a compulsive way in response to the trigger. Thus, they are choosing response prevention when they do not engage in their compulsive action.

Rumination-focused ERP is another form of treatment that is now being used to treat OCD. In this form of ERP, the focus is on helping clients avoid rumination or overthinking, as some believe that rumination is the root cause of the obsession and therefore OCD.

The goal of Exposure and Response Prevention Therapy is to help people with OCD develop coping mechanisms to deal with triggers in a safe setting. These new coping strategies can help people with OCD choose not to engage in compulsive behaviors as a response to those triggering situations.

A trained therapist will make sure the client encounters stressful situations in a safe setting, a little at a time. A client may be asked to confront their fears directly or even just imagine they are addressing their triggers. Other methods include inducing the feelings a person has when confronted with the triggering situation without including physical stimulus.

Even when done correctly, ERP will cause some discomfort. A person will usually go through the following steps during an exposure session, according to the International OCD Foundation:[1]

• An increase in obsessive thoughts and anxiety.
• A realization that although the thoughts are distressing, those thoughts ultimately have no true power.
• A choice to not fight the obsessive thoughts with compulsive behavior. This choice will eventually become a habit the more often a client is able to prevent the compulsive response.
• A realization that one’s fears are less likely to happen than originally thought as habituation increases.
• The ability to manage everyday fears more easily without getting overwhelmed.

Research shows that ERP is extremely effective at treating OCD. In their comprehensive review, Clara Law and Christina Boisseau note that “Numerous clinical trials support the efficacy of exposure and response prevention (ERP) for the treatment of obsessive-compulsive disorder (OCD).”[2] They also assert that ERP is more effective than medications for treating OCD in adults.

A meta-analysis by Cloe Ferrando and Caroline Selai that includes twenty-four studies published between 1997 and 2018 shows that, across the studies, there was a decrease in OCD symptoms and a decrease in cognitive elements after a person received ERP therapy.[3]

In another review, Dianne Hezel and H. Blair Simpson explain that “…studies indicated that… ERP was effective in both a hospital and outpatient setting, and a majority of patients experienced significant improvement … up to two years post-treatment.”[4]

ERP is now considered the foundational treatment for OCD. New work, especially with rumination-focused ERP, continues to be done in therapeutic settings.

Exposure and Response Prevention therapy begins with a conversation between the client and therapist. The therapist will seek to understand the client’s particular triggers for obsessive thoughts and their corresponding compulsive behaviors.

Once the OCD symptoms are established, the therapist will direct the client to engage with their triggers in a purposeful manner. The sessions may start with the patient imagining themselves in certain situations and escalate until the patient confronts those situations directly. Sessions usually take place in a therapist’s office, but may move to other locations if needed to confront specific triggers.

For instance, if a patient fears germs, the therapist may begin therapy in their office but eventually move the client to the public bathroom to have the client practice touching the door handle without immediately washing their hands. In time, the therapist will encourage the client to confront situations without resorting to compulsive behavior on their own.

Generally, clients engage in at least a dozen sessions of ERP. ERP is goal-focused, so it is not ongoing once the desired outcome is reached, but reducing the anxiety, obsessive thoughts, and compulsive behavior brought on by certain triggers may take some time.