A Guide to Exposure and Response Prevention (ERP)

Exposure and Response Prevention, also known as ERP, is an evidence-based form of therapy used to treat a variety of mental health diagnoses. It is derived from Cognitive Behavioral Therapy (CBT) and can be highly effective in managing previously uncontrollable fears, worries, and anxieties. ERP is often misunderstood and can be intimidating, so this guide will give you an overview of what to expect as you prepare to start your therapy journey.

What is Exposure and Response Prevention?

Many people benefit from Exposure and Response Prevention, especially individuals dealing with OCD, phobias, social anxiety, and eating disorders as it aims to gradually decrease the anxiety and overwhelm caused by specific triggers. ERP therapists assist clients in confronting these triggers and fears while resisting compulsions and safety behaviors in order to reduce anxiety to a tolerable level. Just like other forms of therapy, ERP does not make our worries disappear, however; it reduces the impact of them and teaches us how to cope with triggers.

What does ERP entail?

1. The first step to Exposure and Response prevention is making a list of triggers and responses, also known as compulsions in OCD. Triggers can be a variety of things including thoughts, events, other people, and external stimuli- anything that elicits a reaction of anxiety or worry. In people with OCD, triggers typically occur before or with an obsessive thought. Responses are how we respond to triggers and look different for everyone. They can be behaviors like hand washing, checking, or isolation; or mental rituals such as counting or praying.
2. After creating an extensive trigger and response list, you and your therapist will work together to create an exposure hierarchy. This is a list of specific triggering situations or stimuli, ranked from least to most anxiety-provoking. Each individual item on your hierarchy is considered an exposure. Your hierarchy may include a variety of different exposures such as imaginal exposures, in-vivo exposures (where you directly face the trigger), or interoceptive exposures (an exposure that mimics the physical sensations of anxiety). You will be given a numeric anxiety scale by your therapist and will rate each exposure on your hierarchy based on how much anxiety you think it will cause you.

It is important to break each one of your triggers down into smaller steps, rather than just jumping ahead into something that will cause extreme levels of anxiety. For example, someone with a fear of spiders may break down this trigger into the following exposure hierarchy:

• imagine what a spider looks like
• imagine yourself touching a spider
• look at a picture of a spider
• look at a picture of a spider crawling on someone
• be in the same room as a spider
• look at a spider from a few feet away
• hold a box with a spider in it
• let the spider out of the box near you
• poke the spider with a glove
• poke the spider with your bare hand
• let the spider crawl on you.

Once your hierarchy is created, you are ready to start exposures! You will begin by engaging in the exposures lower on your hierarchy that are intended to evoke a manageable level of anxiety. You will typically focus on one exposure at a time, and complete multiple trials of it.

After each exposure trial, you need to sit with whatever anxiety comes up, as this is the response prevention component. Your therapist will ask you to rate your anxiety directly after the exposure and monitor how long it takes for the anxiety to go down. It is imperative that you do not engage in compulsions or safety behaviors; which are behaviors intended to avoid or reduce anxiety such as distraction or reassurance seeking. Many people find this to be the most difficult part of ERP as compulsions and rituals often become automatic and hard to resist.

It is recommended that you sit with the anxiety until it reduces by at least half. If you find that your anxiety is higher than expected and unmanageable, you may engage in a mindful coping skill and let your therapist know that the exposure was too difficult, as this is a sign that you are too high up on your hierarchy.

1. After completing exposure trials, the next portion of ERP is called habituation. This is when you begin to habituate or get used to the anxiety caused by a specific trigger. Habituation occurs when your anxiety no longer increases significantly during an exposure and means that you are ready to move on to a more difficult exposure. It often takes many exposure trials to reach habituation, and that is okay, ERP takes time.
2. Repeat! You will continue this process with each exposure on your hierarchy. ERP is often not a linear process and you may find yourself going back on your exposure hierarchy occasionally. Do not let this discourage you as this is a completely normal and expected part of treatment.
3. Although ERP is not intended to completely make anxieties go away, many people master some of their exposures. This is when your brain no longer views a certain exposure as a trigger and you can encounter it without thinking twice.

The end goal of ERP is that you will be able to encounter different triggers without experiencing intense anxiety or having to engage in compulsions or avoidance. Another important part of treatment is generalization of ERP skills so that you can encounter various triggers in the future and manage them effectively. Anxieties and fears change over time, so it is imperative that you are able to take the tools you gained from ERP treatment and use them in everyday life.

Next Steps

If you find yourself overwhelmed with anxiety or worry or struggling with any of the diagnoses listed above, you would likely benefit from some form of Exposure and Response Prevention. At Serengeti Wellness, we use ERP in conjunction with other forms of therapy in order to best meet your needs. Reach out if you’d like to learn more about how we incorporate ERP in our work or if you are ready to take the next step in tackling your anxiety! If you would like to book a session with me as your therapist, click here to access our online booking site. I look forward to working with you!