Overcoming Obsessive Compulsive Disorder (OCD) through Exposure and Response Prevention (ERP) by Shoshana Levie, LCSW

Updated: Jul 26

When someone always seems to have their home immaculately clean and organized or they are more particular about how tasks are completed, others may say, “She is so OCD.” However, Obsessive Compulsive Disorder (OCD)- is not a useful personality quirk. Rather, it is a type of anxiety disorder that can cause severe, debilitating symptoms.

Understanding Obsessive Compulsive Disorder (OCD)

OCD is characterized by distressing thoughts, images, or urges (obsessions) that cause a person intense anxiety and torment. These unbidden obsessions tend to target what we care for the most and are typically in direct opposition to how we see ourselves as a person. To dispel the distress associated with these obsessions, people with OCD will begin to engage in different sorts of behaviors to try and minimize anxiety (compulsions). Compulsions can be directly related to intrusive thoughts or be seemingly random. They can also be either behavioral or mental.

We have all seen the more stereotypical portrayals of OCD on television or in movies: worry about germs so intense that a person cleans excessively and will not touch doorknobs; distress about causing something bad to happen so one develops a need to check and re-check the locks and stove; a need for things to match and be in a specific order to the point of re-doing and fixing until it is “just right.”

All of the above are true examples of OCD. However, they are not the only ways in which OCD can show up in a person’s life. Far more stealthy are those who excessively ruminate or engage in other mental compulsions like “undoing” a negative thought with a positive one. Some rely on prayer to neutralize a “bad thought” or simply avoid certain actions or places to not risk the obsessional intrusion.

At its core, OCD is a doubting disease. Those with OCD have tremendous difficulty accepting the uncertainty in daily life. So, the disorder urges them to try and seek certainty through compulsive behaviors. While the compulsions may provide some temporary relief, it is short-lived and results in more compulsions. This will eventually take up a lot of time and energy and cause more distress.

Introduction to Exposure and Response Prevention (ERP)

OCD was previously considered to be treatment-resistant as the modalities of therapy in use at the time- such as more traditional psychodynamic “talk therapy”- were not effective in addressing the core symptoms of OCD. Exposure and Response Prevention (ERP) is a cognitive behavioral approach that is designed to address obsessions without resorting to avoidance or rituals.

ERP is specifically designed to provide gradual, methodical exposure to triggers without engaging in any sort of compulsion. By doing so, individuals can learn that their distress will not last forever and will decrease on its own without any rituals. This approach shows that it is possible to sit with and tolerate discomfort or uncertainty without relying on compulsive behaviors.

ERP consists of several components: in-vivo exposure, imaginal exposure, ritual prevention, and cognitive processing. Combined, these pieces of treatment work to reduce OCD symptoms. In-vivo exposure (or real-life exposure) means to deliberately approach a feared object or situation and stick with it for a time without engaging in any compulsions. An example of this type of exposure would be purposefully touching all of the doorknobs at your local Target for those with contamination OCD.

In some cases, because of the type of intrusive thought, in-vivo exposures are not possible. In those situations, imaginal exposures are used to approach the fears. Imaginal exposure involves allowing yourself to picture and try to immerse yourself in the worst-case scenario of that which OCD is scaring you, again without ritualizing. The final two components of treatment are ritual prevention, which means refraining from doing compulsions in your day-to-day life, and cognitive processing to fully explore and examine the changes in distress levels and beliefs during and after exposures.

Early sessions of ERP focus on assessment and psychoeducation about OCD and how it functions. Once that foundational learning is complete, the clinician will help you brainstorm exposure tasks that will become the basis of your hierarchy. Each task is assigned a number rating to describe the level of distress that would be associated with it and then put into ascending order. Exposures start slowly and steadily. ERP is not the “throw you into the deep end” approach, but instead has a focus on building momentum and remaining consistent throughout treatment to address these compulsions.

Sample Contamination Hierarchy Tasks

Exposure task	Distress rating
Touch toilet bowl and seat at work	10/10
Touch toilet bowl and seat home home	9/10
Take public trans, sit on couch	8.5/10
Take out the garbage, eat a snack	7/10
Handle raw meat while cooking	6/10
Eat unwashed banana	5/10
Use a fork that has fallen on the floor	5/10
Touch doorknobs at local mall	4/10

ERP sessions can be conducted once or twice per week ranging from 50-80 minutes. Early on in treatment, an ERP clinician will encourage you to monitor OCD symptoms as “homework” throughout the week. Once exposures begin, you will do the exposure in session with the therapist first and then practice daily for homework. While ERP can feel demanding, putting in the time and effort is key to achieving lasting, positive results.

The Benefits of ERP in Overcoming Obsessive Compulsive Disorder (OCD)

ERP is the gold standard of treatment for OCD and for those who fully engage and work the model, there is a substantial reduction of OCD symptoms. Overcoming OCD requires a person to accept uncertainty. When we engage with a compulsion, we are telling OCD that it is right, that we cannot possibly function in the unknown and it is this OCD story that causes crippling anxiety and distress. While the compulsions may temporarily make us feel better, they truly only serve to exacerbate our core fears.

ERP does the opposite. It encourages us to accept the fact that there are things in this world that we cannot control, while simultaneously helping us recognize the flaws in OCD thinking. Take for example a case of contamination OCD: is it possible that touching doorknobs at the local grocery will result in a drug-resistant virus and death? Yes, it is possible. But is living your life worried about this negligible risk what is best for you? No. ERP allows you to accept the unknown. It helps you to ride out anxiety and distress instead of being scared of it and to reclaim the parts of your life that you value the most.

Choosing ERP: How to Determine If It’s Right for You

ERP may be a good fit for you if you have ever been diagnosed with obsessive-compulsive disorder and other therapies or medication management have not significantly reduced your symptoms. If you suspect that you may have any of the symptoms described above, it is worth having a formal assessment completed by a licensed clinician.

If you are looking for more information about OCD, ERP, or how to find an ERP clinician, visit the International OCD Foundation website.

At Lukin Center, we specialize in evidence-based treatments like ERP. Our team provides expert support to help you overcome OCD. Contact us today to begin your journey toward a healthier, more fulfilling life.

Shoshana Levie, LCSW is a psychotherapist at Lukin Center for Psychotherapy, specializing in the treatment of anxiety and related disorders, such as social anxiety, specific phobias, and obsessive-compulsive disorder, in adolescents and adults.

Shoshana uses a warm, collaborative, and person-centered approach with her clients, with the aim of creating a trusting therapeutic alliance. Her treatment approach integrates elements of cognitive behavioral therapy (CBT), dialectical behavioral therapy (DBT) and psychodynamic work to formulate an individualized path forward for each of her clients.

Shoshana has completed advanced training at the Ackerman Institute for the Family, as well as intensive trainings in both DBT and ERP. She has extensive therapy experience working at both outpatient mental health programs and group private practices.

Shoshana holds a BA from the University of Maryland and a Master of Social Work from the Silberman School of Social Work at Hunter College.