![A path through a garden leading toward an open gate](https://viacara.com/img/content/approaches-erp-feature-light.webp) # Exposure and Response Prevention (ERP) Learn how ERP works, what sessions involve and where it sits in the NICE guideline for OCD. ## What is ERP? Exposure and response prevention (ERP) is a specific form of [CBT](https://viacara.com/approaches/cbt/) designed for obsessive-compulsive disorder (OCD). NICE recommends CBT that includes ERP as the psychological treatment for OCD. The principle is straightforward: you gradually face the situations that trigger your obsessions (exposure) while choosing not to perform your usual compulsive responses (response prevention). Over time, your brain learns that the feared outcome does not happen and the anxiety naturally reduces. ## How it works OCD operates as a cycle. An intrusive thought triggers anxiety. A compulsive behaviour temporarily relieves that anxiety. But the relief is short-lived, and the cycle strengthens each time it repeats. ERP breaks this cycle. Your therapist will help you: 1. **Map your OCD**: identify your obsessions, compulsions and avoidance behaviours 2. **Build a hierarchy**: rank feared situations from least to most anxiety-provoking 3. **Begin exposures**: start with manageable challenges and work upward 4. **Prevent the response**: resist the urge to perform compulsions during and after exposure 5. **Process the experience**: discuss what happened and what you learned The key insight is that anxiety peaks and then naturally falls on its own, without the compulsion. Each successful exposure teaches your brain something new. ![Gradually approaching what feels difficult](https://viacara.com/img/content/approaches-erp-mid-light.webp) ERP works by gradually facing fears in a safe, supported way The two parts of *ERP* - **Exposure** You face an agreed situation, thought or object that brings up fear. - **Response prevention** You practise resisting the compulsion you would usually use to reduce that fear. Your therapist supports the work. ERP combines exposure with response prevention; exposure alone is only one part. Source: [NICE: OCD full guideline](https://viacara.com/approaches/erp/#ref-5) ## What sessions look like ERP typically runs for 12 to 20 sessions, though complex OCD may need more. Sessions last 60 to 90 minutes, longer than standard therapy, because exposures need enough time for anxiety to rise and begin falling naturally. Early sessions focus on understanding your OCD and building your hierarchy. Your therapist will explain the rationale thoroughly before any exposures begin. Nothing is forced on you, and the pace is collaborative. Exposures can be: - **In vivo**: facing real-life situations (touching a doorknob without washing, leaving the house without checking the lock) - **Imaginal**: vividly imagining feared scenarios when real-life exposure is not possible or ethical - **Interoceptive**: deliberately triggering physical sensations associated with anxiety Between sessions, you will practise exposures on your own. This homework is essential. The skills need to transfer from the therapy room into your daily life. ## Who is it best suited to? ERP is specifically designed for OCD, but it is also used for: - Health anxiety (hypochondria) - Body dysmorphic disorder (BDD) - Specific phobias - Some anxiety disorders with avoidance patterns - Hoarding disorder It is particularly important to seek an ERP-trained therapist if you have OCD, because NICE recommends CBT that includes ERP rather than general therapy. Öst and colleagues (2015) pooled 37 trials of CBT for OCD and found very large effects against waiting lists and placebo, and no significant difference between ERP and cognitive therapy. ## How it differs from other approaches ERP is more targeted than general [CBT](https://viacara.com/approaches/cbt/). While CBT might explore the thoughts behind your anxiety, ERP focuses on changing your behavioural response to those thoughts. The learning happens through direct experience, not through cognitive restructuring alone. Unlike [psychodynamic therapy](https://viacara.com/approaches/psychodynamic/), ERP does not explore the origins of your OCD. The question is not why you have these intrusive thoughts but how you respond to them. Most people have bizarre or disturbing intrusive thoughts; OCD is about the meaning you attach to them and the compulsions that follow. If the intrusive thoughts began after a frightening event and come with flashbacks or nightmares, the pattern may be trauma rather than OCD. Our [trauma and PTSD page](https://viacara.com/support/trauma/) and [trauma-focused CBT](https://viacara.com/approaches/trauma-focused-cbt/) cover that route. ERP can feel challenging because it involves deliberately facing discomfort. A good therapist will move at your pace and stay within what you have agreed to. ## The evidence ERP has a large evidence base for OCD. The foundational work by Foa and Kozak (1986) on emotional processing of fear established the theoretical basis. Öst and colleagues' 2015 meta-analysis of studies spanning two decades found very large effect sizes for CBT against waiting lists and placebo. NICE recommends CBT that includes ERP as the psychological treatment for OCD, and it is available through NHS Talking Therapies in England. Modern research by Craske and colleagues (2014) on inhibitory learning has refined how exposures are designed. The field continues to improve how ERP is delivered. On this page [What is ERP?](https://viacara.com/approaches/erp/#what-is-erp) [How it works](https://viacara.com/approaches/erp/#how-it-works) [What sessions look like](https://viacara.com/approaches/erp/#what-sessions-look-like) [Who is it best suited to?](https://viacara.com/approaches/erp/#who-is-it-best-suited-to) [How it differs from other approaches](https://viacara.com/approaches/erp/#how-it-differs-from-other-approaches) [The evidence](https://viacara.com/approaches/erp/#the-evidence) Related [Cognitive Behavioural Therapy (CBT)](https://viacara.com/approaches/cbt/) [Dialectical Behaviour Therapy (DBT)](https://viacara.com/approaches/dbt/) [Understanding Different Approaches](https://viacara.com/guides/understanding-approaches/) [Therapy for OCD](https://viacara.com/support/neurodivergence/ocd/) [Trauma and PTSD](https://viacara.com/support/trauma/) [Trauma-Focused CBT](https://viacara.com/approaches/trauma-focused-cbt/) Thanks for your interest. We're not taking on new clients at the moment. ## Looking for *OCD* support? We ask what matters to you, then find professionals who fit. Leave your email and we'll let you know as soon as we're ready for you. This conversation helps us find you the right support. What you share helps us understand what you're looking for and find someone who fits. Your email keeps you updated on what's happening next and isn't shared with anyone we introduce you to. [Privacy policy](https://viacara.com/privacy/) [Terms of service](https://viacara.com/terms/) ## References 1. Foa, E. B. & Kozak, M. J. (1986). *Emotional processing of fear: Exposure to corrective information*. Psychological Bulletin. [doi:10.1037/0033-2909.99.1.20](https://doi.org/10.1037/0033-2909.99.1.20) 2. Öst, L. G., Havnen, A., Hansen, B. & Kvale, G. (2015). *Cognitive behavioral treatments of obsessive-compulsive disorder: A systematic review and meta-analysis of studies published 1993-2014*. Clinical Psychology Review. [doi:10.1016/j.cpr.2015.06.003](https://doi.org/10.1016/j.cpr.2015.06.003) 3. NICE (2005). *Obsessive-compulsive disorder and body dysmorphic disorder: treatment (CG31)*. [nice.org.uk](https://www.nice.org.uk/guidance/cg31) 4. Craske, M. G., Treanor, M., Conway, C. C., Zbozinek, T. & Vervliet, B. (2014). *Maximizing exposure therapy: An inhibitory learning approach*. Behaviour Research and Therapy. [doi:10.1016/j.brat.2014.04.006](https://doi.org/10.1016/j.brat.2014.04.006) 5. NICE (2006). *Obsessive compulsive disorder: full guideline*. [nice.org.uk](https://www.nice.org.uk/guidance/cg31/evidence/full-guideline-194883373) ## Related ### [Cognitive Behavioural Therapy (CBT)](https://viacara.com/approaches/cbt/) Learn how CBT works, what happens in sessions and what NICE says about it, and read about its forms for sleep, pain and self-help. ### [Dialectical Behaviour Therapy (DBT)](https://viacara.com/approaches/dbt/) Learn how DBT works, what its four skill modules teach and what NICE says about it for people with borderline personality disorder. ### [Understanding Different Approaches](https://viacara.com/guides/understanding-approaches/) A plain-English guide to the main therapeutic approaches including CBT, person-centred therapy, psychodynamic and integrative methods. ### [Therapy for OCD](https://viacara.com/support/neurodivergence/ocd/) OCD is not tidiness. It is intrusive thoughts and the exhausting compulsions that follow, and NICE names the therapy it recommends for it. ### [Trauma and PTSD](https://viacara.com/support/trauma/) Trauma can keep a frightening event alive long after it ended. PTSD is common and treatable. Find a professional who works with trauma. ### [Trauma-Focused CBT](https://viacara.com/approaches/trauma-focused-cbt/) Learn how trauma-focused CBT works, what happens in sessions, how it differs from EMDR and what NICE says about it and its main forms.