What It Is, How It Works, and Why It’s the Gold Standard for OCD & Anxiety Disorders
Understanding OCD and Anxiety Disorders
Obsessive Compulsive Disorder (OCD) is made up of two parts: obsessions and compulsions.
- Obsessions are intrusive thoughts, urges, or images that cause distress and leave you feeling compelled to do something to relieve the anxiety or discomfort.
- Compulsions are the behaviors, either mental or physical, that follow in efforts to relieve distress. Sometimes people can see them (like washing your hands, checking a lock, or asking for reassurance), and sometimes they happen silently in your mind (like mental reviewing, praying, or repeating phrases).
Compulsions are voluntary, but they feel anything but optional. They show up to try to relieve powerful emotions, most commonly anxiety, shame, guilt, or disgust. The problem is, they only work for a moment. Compulsions actually keep OCD alive by teaching the brain: “Yes, this was dangerous, good thing I did the ritual to prevent the bad thing from happening.”
That cycle is what made OCD rank as one of the top ten most debilitating conditions in the world (according to the World Health Organization). Without proper help, OCD can seriously interfere with someone’s ability to function.
To learn more about OCD and how we treat it, visit our page on Obsessive Compulsive Disorder. For additional education, see the International OCD Foundation.
Alongside OCD, many people also struggle with complex anxiety disorders, such as:
- Social anxiety (children and adults)
- Separation anxiety (more common in kids, but occurs in adults too)
- Panic disorder (suffering from reoccurrent panic attacks, seemingly without a trigger and oftentimes, someone with panic disorder becomes fearful of sensations associated with panic attacks).
- Agoraphobia (when someone struggles to leave home or other safe places/people)
- Phobias (emetophobia – fear of vomiting, dog phobia, blood phobia, spider phobia, etc.).
- Generalized anxiety disorder (GAD) (ongoing worry about daily life stressors like the future, relationships, finances, or death).
- Illness anxiety disorder (fears of developing or already having a serious illness).
Learn more on our pages about Separation Anxiety, Social Anxiety & Other Phobias and Panic Attacks, Panic Disorder & Agoraphobia.
So, What Exactly Is ERP?
ERP stands for Exposure and Response Prevention. Here’s the simplest way to understand it:
- The exposure part means gradually and thoughtfully facing your fears and triggers through activities with your therapist or at home.
- The response prevention part means practicing reducing (and eventually eliminating) the safety behaviors, compulsions, or avoidance that normally follow for relief of the anxiety or distress. The problem is that compulsions typically only relieve distress for a few moments and often grow the anxiety or OCD overall.
ERP starts with creating a hierarchy or exposure menu– listing out all triggers and then listing out all safety seeking behaviors or compulsions, rating each trigger on how challenging it would be for you to face and each safety seeking behaviors on how difficult it would be for you to refrain from doing. Hierarchies are an important step in ERP because it allows clients to envision what their life could look like free of fear of compulsions and free, yielding better results for clients long-term.
Well-trained therapists will also assess using the Y-BOCS II for OCD and with other measures for anxiety, followed by educating clients on what is occurring in the brain and the ERP Process.
could look like touching a surface like public door handles (if you struggled with a fear of getting sick or dying and resisting the urge to wash your hands, to ask for reassurance, to distract yourself, or even to mentally replay an event over and over. It also means reducing other “safety” strategies like avoiding places, distracting with substances, or rituals that temporarily relieve distress.
There are a few different types of exposures therapists may use:
- In vivo exposures: Facing real-life triggers in the moment (like touching a doorknob or giving a school presentation).
- Imaginal exposures: Creating written or verbal scenarios (for example, a worst case scenario) of feared events and practicing sitting with the uncertainty (“What if I lose control and hurt someone I love?)
- Interoceptive exposures: Purposely bringing on feared body sensations, like a racing heart or dizziness, so your brain learns those feelings aren’t dangerous (learn more in our blog: The Science Behind Panic Attack Sensations).
The goal of ERP isn’t to make fear disappear overnight. It’s to help you learn, in your body, not just in your head, that you are safe to experience discomfort or uncertainty. Over time, your brain learns the worst-case scenario usually doesn’t happen, and even if discomfort shows up, you can tolerate it.
ERP helps people shift from living a small life (trying to prevent every bad thing) to living a big, values-based life, one where you can show up how you want, spend time with who matters, and pursue your actual goals and dreams.
See the IOCDF’s ERP page about ERP as a first line treatment and about modern second-line treatments and NIMH’s OCD article to learn about risk factors for developing OCD.
Why Is ERP Considered the Gold Standard for OCD Treatment?
ERP has been studied for decades, and across hundreds of clinical trials, it continues to come out on top as the most effective treatment for OCD. When people say it’s the “gold standard,” they mean it’s the treatment with the most scientific evidence behind it and the highest rate of success compared to other approaches.
Here’s why ERP stands out:
- Directly targets the OCD cycle. ERP rewires the brain by showing: “I can face this fear and nothing catastrophic happens.”
- High success rates. About 60–70% of people with OCD experience significant symptom reduction with ERP, much higher than with medication alone or talk therapy without exposure.
- Durable results. ERP doesn’t just provide short-term relief, the improvements last because you’ve built new learning.
- Widely recommended. The APA, NIMH, IOCDF, not to mention any OCD specialist you speak to, all recommend ERP as the frontline treatment.
ERP Compared to Other Treatments for OCD
Here’s how ERP stacks up:
- ERP (Exposure and Response Prevention): The gold standard dating backs to the 1960s that can stand alone at a 60–70% success rate. Our therapists have had the privilege to be a part of the journey and radical improvements for our clients with ERP.
- CBT (Cognitive Behavioral Therapy): ERP is a form of CBT. Traditional CBT without exposures isn’t usually effective for OCD. How we describe this as ERP therapists in session is that CBT is like the mama bear, and ERP and ACT are types of CBT, but without ERP, OCD and some anxiety disorders will not be treated effectively.
- Medication (SSRIs): Helps reduce symptoms and is often paired with ERP. The way we like to think about medication for OCD and anxiety is that it helps to lower the volume on the anxiety and OCD symptoms, but true healing is in the behavioral and cognitive changes from ERP.
- ACT (Acceptance & Commitment Therapy): An amazing supplement to ERP, and in our opinion at Outsmarting Anxiety & OCD, a necessary add-on to the whole-person approach. ACT aids in helping humans to better understand their values, who they are as people and how they want to show up in the world, which allows ERP to be completed with meaning, purpose and value-based living in mind.
- I-CBT (Inference-Based CBT): While ERP remains the gold standard and first line treatment, I-CBT is the first evidence-based alternative treatment to ERP. Deep dive here: ERP vs. I-CBT.
ERP for Kids vs. Adults
ERP is adapted for every age:
- Children: ERP is playful, developmentally appropriate, and with parent involvement. Child therapists often utilize SPACE (Supportive Parenting for Anxious Childhood Emotions). Parents are taught that true support = acceptance + confidence. Learn more about SPACE and how we use SPACE in our therapy for kids at Outsmarting Anxiety & OCD in our blog, Parenting a Child with Anxiety & OCD. Additionally, our child therapists may bring in therapies such as play therapy or expressive arts therapy as an adjunct to ERP to get your child comfortable with your therapist, help them process how anxiety and OCD impacts them through play or art, and to help make ERP fun and interesting.
- Teens: At this age, exposures are tailored to teen worldviews, their language, and weaving in and out of supporting mental health topics that naturally come up for teens like studying for final exams and friend group drama with ERP for their anxiety and OCD. Their exposures are also set up to match their current values. For example, since friends and school are a huge part of a teen’s world, social anxiety exposures may focus more on those topics than interview prep or networking.
- Adults: ERP can be more direct and explicit, with exposures that may include writing, saying, or visualizing intrusive thoughts, OCD themes, anxiety topics or phobias in detail. Like teens, adults bring life stressors to therapy, and our therapists will pause ERP on days where it feels more important for the client to process a life stressor than move on in their ERP treatment. And other days, your therapist may challenge you to stay locked into ERP to continue making progress with the goals our clients set.
What ERP feels like in real life: ERP for OCD and anxiety disorders
ERP also helps with panic, social anxiety, phobias, and more.
- OCD: Exposures for OCD will be based on themes of fears, triggers and compulsions. For example, if someone has contamination OCD, exposures amy include touching door handles, sitting on the floor, using public restrooms and reducing washing compulsions. If someone struggles with harm OCD, exposures may include writing out worst case scenario scripts, practice cutting meat or veggies if avoidant of knives for example, driving without checking that something bad didn’t happen, etc. If someone struggles with moral OCD, exposures may involve excessive and compulsive prayer reduction, reducing confessing compulsions, etc.
- Social Anxiety: Exposures include starting conversations, accepting compliments, interview prep, ordering food out in public, saying no and setting boundaries, accepting or extending invitations to friends, etc. Response prevention targets safety behaviors like phone use (distraction), always bringing a “safe person” (reassurance seeking), or simply going to the event you want to say no to (avoidance).
- Panic Disorder: Exposures involve intentionally recreating interoception sensations felt in a panic attack (like jogging in place to create racing heart or spinning in a chair to create dizziness or nausea). Exposures can also look like playing basketball like you enjoyed before panic attacks but have since avoided because it felt too similar to a panic attack. Learn more in our blog, The Science Behind Panic Attack Sensations and on our page about Panic Attacks, Panic Disorder & Agoraphobia.
- Phobias: With phobias, your therapist will make a hierarchy of your triggers and safety behaviors with you. For example, if you have a fear of throwing up (emetaphobia), you may start with saying or writing words like “throw up” or “vomit”. From there, you may begin looking at photos of cartoon-y vomit, followed by photos or real vomit, followed by video clips of people throwing up, engaging in written worst-case scenario scripts and eventually working your way up to making your own fake vomit and pretending to throw it up in a toilet or outside. Keep in mind that every exposure experience is tailored to the client’s experience of their phobia.
- Separation Anxiety: Typically when working with children, we start with educating our clients and their parents on how we can help them feel safe, even when separated from their parents. We practice in incremental steps, sometimes with the first one being parents sitting in the waiting room. Many kids will practice sharing stories or drawing pictures of being separated from mom or dad and discuss their related fear. At some point, kiddos typically practice sleeping in their own bed, going to playdates without mom or dad present, sleeping over at Grandma’s going to school for half days if they previously have avoided school, etc.
- Agoraphobia: Here, our clients are slowly practicing re-entering avoided places, often public places. Many clients who suffer from this type of anxiety want to start with telehealth therapy, as simply going to an office can feel highly anxiety-producing. So, exposures tend to start with baby steps. Taking a walk around the block, sitting on the porch, walking to the mailbox, followed by exposures like going to therapy in-person or attending an avoided medical appointment. Therapists will also highly concentrate on reducing anxiety around panic attacks, which can often be a contributing factor to agoraphobia symptoms.
- Illness Anxiety: Exposures embody challenging fear of illness and ultimately, death. This and health ocd are potentially interchangeable, depending on how safety seeking behaviors present and if other OCD symptoms are present. Reducing safety behaviors like getting several second medical opinions, making too many phone calls to doctors, excessive somatic checking and internet searching. Our main goal is to reduce fear and anxiety and increase value-based living.
Learn more on our pages about Separation Anxiety, Social Anxiety & Other Phobias, Panic Attacks, Panic Disorder & Agoraphobia, and Obsessive Compulsive Disorder.
Myths & Misunderstandings About ERP
- Myth: ERP is flooding. Reality: It’s gradual and collaborative.
- Myth: Therapists make clients do unsafe things. Reality: Trained ERP therapists should never make you feel unsafe.
- Myth: My therapist will make me do things I don’t want to do. Reality: You are always in the driver seat of your own treatment.
- Myth: I could be asked to do something dangerous if I have OCD. Reality: Your therapist should never ask you to do something that goes against your values. Therapists will always respect your no and boundaries.
Why We Use ERP at Outsmarting Anxiety & OCD
At Outsmarting Anxiety & OCD, ERP is warm, friendly, and collaborative:
- We go at your pace.
- We challenge in empowering ways.
- You’re the expert on yourself; we’re experts in OCD, anxiety, and ERP.
- ERP can even be fun- we use lightness and humor to make the hard work feel safe and doable.
Schedule your free consultation with us, today, by filling out our contact form.