Treating obsessive-compulsive disorder (OCD) is critical. While specific obsessions and compulsions differ, people with OCD have regular and persistent anxiety that impacts their ability to function at home, work, and in social situations. One of the best OCD treatments to ease symptoms is exposure therapy for OCD.

Whether experiencing fears of contamination, overt concerns of perfectionism, or worries about harm coming to a loved one, exposure therapy for OCD can help.

In this article, we cover how and why exposure therapy works for OCD, the benefits of response prevention, the differences in conducting it online or at home, and examples of what an exposure therapy session for OCD may look like.

If you or someone you know is experiencing the debilitating symptoms of OCD, the providers on the Klarity Health platform can help. On Klarity Health, you can find a mental health therapist trained and experienced in OCD treatment.

What is exposure therapy for OCD?

Exposure therapy is also referred to as exposure and response prevention (ERP) therapy for OCD or simply ERP therapy. It’s a type of cognitive behavioral therapy (CBT). And it’s the gold standard in OCD treatment because it focuses on the disorder’s 2 components — distress tolerance of the obsessions (exposure) and behavioral changes for the compulsions (response prevention).

OCD is categorized by persistent and intrusive thoughts, urges, or images that lead to extreme anxiety — these are the obsessions or fears. For example, “Were there germs on that doorknob? Is my apartment door locked? Can I drive without crashing into somebody?” The compulsions or rituals, such as intense hand washing, repeated checking, or mantras, are used to alleviate the anxiety of the obsessions.

In ERP therapy for OCD, a trained professional teaches a client about OCD through psychoeducation, before slowly and strategically increasing exposure to a client’s fear to help them process the anxiety that is triggered without performing the compulsion. Starting with lower anxiety obsessions, the client begins to learn that they can manage the anxiety without the compulsion, which is the first step in breaking the debilitating cycle of OCD.

The importance of response prevention as part of exposure therapy for OCD

Some argue that the response prevention part of ERP is more important than the exposure part, and this has to do with the cyclical nature of OCD. It also has something to do with our ability to control our behaviors better than we can control our thoughts and feelings.

The compulsion, or response to the anxiety of the obsession, is developed to alleviate the anxiety, but it also reinforces the behavior of reacting and gives credibility to the obsession. In other words, the compulsion ensures that the OCD cycle continues. “I was worried about the germs from that public bathroom making me sick, and washing my hands for 5 minutes took away that fear, so my worry was correct.”

Additionally, when it comes to making changes, the thoughts and feelings of the obsessions are a lot harder to control than the behaviors of the compulsion. And changing the behavior can help support changes in thoughts and feelings. By not responding to the anxiety with a compulsion or ritual, the bond between obsession and compulsion is broken, and the fear and anxiety can be processed.

How is exposure therapy different for OCD?

Exposure therapy is used with other disorders, such as phobias, post-traumatic stress disorder (PTSD), panic attacks, and social anxiety. The similarities in treating these disorders and OCD with exposure therapy involve confronting the fear. The exposure to anxiety-provoking stimuli — whether spiders, airplanes, or a birthday party — increases the person’s distress tolerance, desensitizes the stimulus, and lowers anxiety overall.

But exposure therapy is different for OCD because of the response prevention part, or stopping the compulsions. Response prevention is critical in exposure therapy for OCD because it is the only way to break the cycle of obsessions and compulsions.

How does exposure therapy work for OCD?

In the simplest terms, exposure therapy for OCD works by increasing a person’s anxiety tolerance of a fear (the obsession) and eliminating the need for a response (the compulsion). For example, a person with contamination OCD may be exposed to items that the person considers dirty — car keys, money, a door knob — and then coached by a therapist to talk about their anxiety and fears instead of reacting to them by washing their hands.

In an ERP session, the therapist’s goal is to create a safe space to explore the uncomfortable feelings brought on by the obsession or fear, while encouraging the client to not respond to those feelings with a compulsion. Not responding can be scary for people with OCD as the compulsion is their coping skill.

That’s why after building rapport, discussing the client’s specific obsessions and compulsions, and answering questions about ERP, a therapist’s next step is to work with the client to create an exposure hierarchy.

The exposure hierarchy

The exposure hierarchy is a list of fears and obsessions from least to most distressing. It’s also called a “fear hierarchy” or “fear ladder.” To create an exposure hierarchy, the therapist and client work together to identify external stimuli and situations as well as internal thoughts and feelings that trigger obsessions.

The therapist then has the client organize the list using the subjective units of distress scale (SUDS), with 0 for no anxiety, 20 for low anxiety, 35 for moderate anxiety, 50 for significant anxiety, 75 for severe anxiety, and 100 for extreme anxiety. For example, someone with contamination OCD might find shaking hands moderately anxiety provoking but using a public restroom a severe anxiety situation.

With the exposure hierarchy complete, the work of being exposed to an obsession without responding starts.

It’s important to note that the exposures can be real, imagined, or virtual depending on logistics. Starting with a lower anxiety obsession, the therapist offers support and validation as the client experiences the uncomfortable feelings of fear and anxiety without reacting. The therapist also helps the client process the experience post-exposure, talking about how it felt and what was learned. The client and therapist decide together when to move on to a higher anxiety exposure.

Habituation and inhibitory learning

Habituation and inhibitory learning are 2 models or theories of ERP.

Habituation means a person gets used to something they don’t like so that it is less noticeable. In the case of OCD, the exposure to the obsession or fear in a safe space without engaging in the compulsion helps to eventually reduce the fear. Habituation lets the person trust their ability to cope with the anxiety and uncertainty of the obsession, which can also reduce the anxiety of the obsession over time.

Inhibitory learning relates to gaining new information that overrides the obsessional fear. In the case of OCD, learning new safety information can inhibit or lower the obsessional fears and lead to more lasting results. For example, if someone with contamination OCD is afraid they’re going to get sick if they touch door knobs, the clinician can challenge that fear by illustrating ways that germs are spread and teaching the person new ways to avoid getting sick.

After the client and clinician work together to create an exposure hierarchy, habituation and/or inhibitory learning may be used in an ERP therapy session either in person or online.

Does ERP therapy work online?

As with many therapeutic interventions, ERP therapy can work in person and online. Some clinicians prefer online work for ERP as it may allow the client a more direct connection with the external stimuli and situations that trigger the obsessions compared to meeting in a therapist’s office.

A study in the Journal of Medical Internet Research found that online video sessions for ERP for OCD were effective in reducing OCD symptoms as well as depression and anxiety symptoms, 2 common comorbid (co-occurring) disorders.

As with other forms of online therapy, the convenience, cost savings, and comfort of being in your own surroundings can make the difficult work of therapeutic change more engaging and motivating.

But what exactly does an ERP session look like?

Examples of exposure therapy for OCD

While early ERP sessions include building rapport, psychoeducation about ERP, and creating an exposure hierarchy, future sessions involve actually practicing the exposures without responding, discussing new triggers, problem-solving, and reflecting on what was learned.

The following are 2 examples of what a session of exposure therapy for OCD can look like.

Example #1: contamination OCD and ERP

Imogene has had OCD traits for years, and her symptoms manifested in contamination OCD with the onset of COVID-19. There were a dozen fears on her exposure hierarchy, starting with the fear of public spaces, which was rated a 20 using the SUDS or low anxiety, to fear of touching a communal pen, which was rated a 50, to fear of using the bathroom at work, which was a 100 or extreme anxiety. While Imogene had several compulsions, depending on the obsession, her most time-consuming and disruptive compulsions were hand washing and changing her clothes.

Because ERP was done online, the therapist encouraged Imogene to imagine herself in a public space that she frequented. She chose the lunchroom at work and was encouraged to visualize the space and talk about what she did and how she felt in that space.

Imogene explained that before heading to lunch, she would put on her “public” sweater, something that she could easily take off when she returned to her cubicle. She said that her anxiety increased when she entered the lunchroom, and the thought, “Don’t touch anything,” was on a loop in her head. Her first step was to grab 3 napkins to use when she opened the refrigerator door. She noted an increase in anxiety if she had to move someone else’s lunch to get to her own. She typically looked for a place to sit away from everyone else and ate as quickly as possible. She was angry with her company’s policy against eating at your desk.

The therapist supported Imogene in how she was feeling throughout this visualization and encouraged her to revisualize the experience without one of her compulsions — the “public” sweater, the three napkins, the “don’t touch anything” mantra, or the isolation.

With time, Imogene was able to tolerate the anxiety of this experience without her compulsions and was able to try it at work. She then moved on to a higher anxiety obsession on her exposure hierarchy.

Example #2: symmetry OCD and ERP

Mateo was always a neat and organized person, but since college, his need for order has become debilitating. He was diagnosed with symmetry OCD. In the course of a normal day, Mateo spends more than 2 hours organizing and reorganizing his space, which has led to difficulty with his roommate and missed deadlines at work.

After talking about his obsessions and compulsions with his therapist, Mateo creates an exposure hierarchy. At the moderate anxiety level of his obsessions were drawers and doors that weren’t shut properly. At the severe end was the need for items in his immediate space to be at right angles and organized by size.

At his desk, for example, without this order, Mateo said his anxiety skyrockets. He also acknowledged that once he’s achieved “order”, he repeatedly checks it and makes small adjustments until his anxiety decreases. According to Mateo, this takes upwards of 20 to 30 minutes every time he sits down at his desk.

Because Mateo works from home, his therapist recommends they start with a moderate anxiety-provoking trigger — exposure to doors and drawers. Mateo moves his computer into the kitchen, and the therapist asks him to look at the cabinet doors and drawers and only shut the ones that are open. She also asks Mateo to talk about what he’s doing before he does it.

Mateo commented that he wasn’t confident that any of the drawers or doors were shut properly, but identified one drawer that was slightly open because a dish towel was in the way.

The therapist encouraged Mateo to correct that one drawer and do nothing else. Mateo reported that it felt good to tuck in the dish towel, but said he was feeling anxious and uncertain about not checking the other doors and drawers. The therapist encouraged Mateo to talk more about his anxiety and what “having order” meant to him. In this discussion, Mateo touched on feelings of control and self-worth.

In a relatively short amount of time, Mateo and his therapist move on to the next obsession on his hierarchy. Mateo continues to make progress in tolerating anxiety without his compulsions to order and recheck.

As he continues with exposure therapy for his OCD, his symptoms are decreasing, his relationship with his roommate is improving, and he’s performing better at work. He also has learned how to reinforce his ERP therapy at home, outside of therapy.

How to do exposure therapy for OCD at home

Because most ERP therapy sessions occur just once or twice a week, working to change behaviors, or your compulsions, on your own at home is likely something a therapist may suggest as homework.

Using your exposure hierarchy, you choose lower anxiety exposures and introduce them slowly. This is particularly important as experiencing anxiety without performing your rituals or compulsions feels strange and uncomfortable at first — perhaps even more so without the immediate support of a professional.

While conducting exposure therapy for OCD at home may work with lower anxiety triggers, it will become increasingly difficult as you move up your exposure hierarchy. Without validation and support, you might run the risk of getting discouraged and losing motivation, or increasing symptoms of anxiety and depression, which often co-occur with OCD.

Another potential downfall of conducting exposure therapy for OCD at home, without the guidance of a professional, is that despite your intense personal experience of the disorder, you might not be aware of all your compulsions. And eliminating the compulsions — response prevention — is the most important part of exposure therapy.

In addition to support and expertise, being able to work with a professional who specializes in ERP therapy for OCD gives you the benefit of a customized treatment plan. As the therapist helps you work through exposures on your hierarchy, you benefit from post-exposure processing, which gives you space to talk about how you felt and what you learned. This ability to make meaning from the experience of facing your fears and resisting compulsions is a deeper form of learning that can lead to real change.

Does exposure therapy work for OCD?

ERP therapy is one of the most effective treatments for OCD and has been in use for decades. And regardless of the type of OCD you have, including contamination OCD, rumination OCD, checking OCD, false memory OCD, or another type, ERP therapy is proven effective.

A meta-analysis of ERP studies published in the Journal for Obsessive-Compulsive and Related Disorders, found that ERP reduced compulsions and moderate dysfunctional beliefs. Another meta-analysis of the effectiveness of ERP combined with medication published in Frontiers in Psychiatry found that ERP combined with medication, such as serotonin reuptake inhibitors (SRIs), delivers statistically better results than treating OCD with medication alone.

Additionally, there are many social media sites, blogs, and podcasts where people with OCD write and talk about their personal experiences of the effectiveness of ERP.

ERP isn’t the only therapeutic option for OCD though.

Alternatives to exposure and response prevention therapy for OCD

ERP is a form of cognitive behavioral therapy (CBT), which focuses on thoughts, feelings and behaviors. While there are other subsets of CBT, such as dialectical behavior therapy (DBT), mindfulness therapy, acceptance and commitment therapy (ACT), and rational emotive behavior therapy (REBT), ERP is the gold standard for treating OCD.

Medications have also been used to treat OCD. The most common medications used in the treatment of OCD are SRIs. While these types of drugs are typically classified as antidepressants, they have been used to treat OCD for decades. SRIs that are most helpful for OCD symptoms, include Prozac, Luvox, Zoloft, Paxil, Lexapro, and Anafranil.

Get help and take control of OCD today on Klarity Health

If you or someone you know are ready for relief from OCD symptoms and want to try ERP or another option, finding help is easy on Klarity Health. Klarity Health provides a fast, flexible way to find a therapist who meets your specific needs and can create a tailored OCD treatment plan. Find a provider on Klarity Health today and take control of your OCD, so it stops controlling you.

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