Exposure and Response Prevention (ERP) therapy is one of the most effective therapeutic modalities for relieving the symptoms of obsessive-compulsive disorder (OCD). ERP therapy works by interrupting the cycle of obsessions and compulsions that characterizes this disorder. Hence, it provides relief from distressing and intrusive thoughts, as well as the repetitive behaviors associated with OCD.
In this guide to ERP therapy for teens and children, we’ll look at how ERP works for OCD and examples of ERP therapy. In addition, we’ll explain how Exposure and Response Prevention therapy works alongside other modalities, as part of an integrated model of care for teen OCD.
Key Takeaways
- Exposure and Response Prevention therapy works to interrupt the cycle of OCD obsession and compulsions.
- Research shows that ERP therapy is the most effective treatment for OCD, leading to significant improvements for about 80 percent of patients.
- The components of ERP therapy include psychoeducation, ranking triggers in terms of the distress they cause, exposure to triggers, and practicing response prevention techniques.
- The most effective OCD treatment includes ERP therapy in addition to other therapeutic modalities to address underlying causes and co-occurring mental health issues.
What Is Exposure and Response Prevention Therapy?
ERP therapy is a type of Cognitive Behavioral Therapy that gives people with OCD greater insight into their obsessions and compulsions. In addition, ERP gives patients skills for preventing the compulsive behaviors they typically use in response to obsessions.
Research on ERP has shown it is extremely effective for OCD, and it is now considered the gold standard of care for this disorder. One study found that 80 percent of ERP patients experienced relief from OCD symptoms.
Stanley Robinson created ERP therapy for OCD in the 1970s, drawing from past studies in this area, including research on classical conditioning—the link between distress. Robinson drew primarily from the work of behavioral scientists such as Ivan Pavlov, John Watson, and Joseph Wolpe.
In fact, Wolpe’s method of systematic desensitization forms the basis of ERP therapy. Wolpe’s technique exposed patients to anxiety-provoking situations, and used relaxation skills to reduce distress and reduce sensitivity to these triggers.
How ERP Therapy Works for Teen OCD
Children, adults, and teens with OCD experience cycles of obsessions and compulsions. When a situation, person, or object triggers an obsessive thought, people with OCD react by using compulsive behaviors in an attempt to ward off the dread, distress, or fear related to the obsession.
Common obsessions include germs, fear of themselves or someone they love being hurt, taboo thoughts about sex or violence, and dread of hurting someone by accident.
Compulsions for people with OCD include counting, repeated handwashing, checking things (such as lights being off or doors shut), and specific repetitive thoughts to ward off fears. While these compulsions may provide temporary relief from anxiety, they ultimately keep the cycle of obsessions and compulsions going.
Exposure and Response Prevention therapy works to interrupt this OCD cycle. In ERP therapy for teens, adolescents with OCD are exposed to triggering situations and then practice responding to them with new, healthy strategies. Rather than removing triggers, ERP therapy helps teens learn to stop avoiding potentially distressing situations. Instead, teenagers with OCD gain skills for coping with the distress and discomfort of their obsessions, without resorting to compulsive behaviors.
On the surface, teen ERP therapy appears to address compulsive behaviors, but not the obsessions that trigger those compulsions. But over time, as teens practice ERP, their obsessive thoughts begin to have less power over them. Because they now have tools to cope with the obsessions, the intrusive thoughts no longer seem overwhelming. Hence, the obsessions gradually begin to fade in both frequency and intensity.
An Example of ERP Therapy for OCD
An example of how ERP therapy works involves fear of germs and contamination—a common OCD obsession—and repeated handwashing, the compulsive behavior typically triggered by this fear. An ERP therapist would have the patient touch a doorknob, dishwashing sponge, bathroom sink, or other object that they view as a contaminant. Then the therapist might ask the patient to touch their face to make the situation slightly more triggering.
Next, the therapist guides the patient to use response prevention techniques to resist washing their hands repeatedly. Instead of defaulting to this compulsive ritual, they learn to tolerate the anxiety of having potentially exposed themselves to germs. And with repeated practice, they learn that they can resist compulsions and nothing terrible will happen.
Components of ERP Therapy
Let’s break down the various parts and steps in ERP therapy:
Psychoeducation
In the psychoeducation component of ERP, people with OCD learn more about the disorder and how their obsessions and compulsions work. The therapist will also share information about how ERP works, including the goals of ERP therapy and the different components of the process.
Creating an Exposure Hierarchy
At the start of ERP therapy, patients work with their therapist to make a list of the sources of anxiety that trigger them. Using a system called the Subjective Units of Distress Scale (SUDS), they rate the severity of each obsession in terms of how distressing it is for them. An ERP therapist will begin the process using a trigger that is lower in the hierarchy and thus less intense for the patient. As ERP continues, therapist and patient work with triggers higher in the hierarchy—those that provoke more extreme anxiety and distress.
Exposure
The exposure part of ERP therapy involves exposing the patient to a trigger that typically creates obsessive thoughts, distress, and discomfort. Types of exposure in ERP Therapy include:
- In vivo exposure: directly facing an actual feared object or situation
- Imaginal exposure: vividly imagining the anxiety trigger, such as a past traumatic experience
- Interoceptive exposure: inducing physical symptoms that create distress, such as spinning around to induce the dizziness that a patient may feel during a panic attack
- Virtual reality exposure: facing OCD anxieties using simulations of the feared experience, such a flying or driving on a highway
Response Prevention
Following the exposure, the next part of ERP therapy is response prevention. This refers to stopping the compulsive behavior that the person with OCD typically resorts to following a trigger. The therapist gives clear instructions on how to prevent these compulsive rituals. Response prevention strategies include:
- Learning to tolerate anxiety
- Delaying OCD rituals
- Modifying the rituals
- Avoiding rituals completely
Exposure Homework
ERP therapy can be provided in both individual and/or group sessions. Once a patient is able to use response prevention techniques in therapy sessions, they start practicing them outside of sessions. Exposure homework involves exposure to triggers and resisting rituals afterward.
Relapse Prevention Planning
As ERP therapy concludes, an essential part of the process is relapse prevention planning. This includes establishing ways to keep OCD symptoms from returning and making a plan for addressing any relapses.
Why Does ERP Therapy Work?
There are a number of theories about why ERP works for OCD. It appears to work on a variety of levels, including the neurobiological level. Exposure and response prevention techniques disrupt the neural circuit between the processing part of the brain and the action part of the brain.
In addition, Exposure and Response Prevention therapy works through habituation. Habituation is the gradual decrease in fear and anxiety that happens as a person undergoes repeated exposures.
Inhibitory learning is another mechanism in ERP therapy. This refers to the process in which fear-based beliefs are inhibited by new experiences. In other words, ERP patients find out that bad things don’t happen to them when they resist compulsive behaviors. Therefore, it becomes gradually easier for them to resist the compulsions.
Ultimately, ERP therapy empowers people with OCD by giving them the skills they need to face their fears. Moreover, they learn to accept and live with some level of uncertainty rather than constantly trying to avoid it.
“Within the span of about 20 years, the prognosis for individuals with OCD has changed from poor to very good as a result of the development of ERP.”
Canadian Journal of Psychiatry
How Do I Know If My Teen Needs ERP Therapy?
If your teen does not have an official OCD diagnosis, the first step is a full OCD assessment with a mental health professional. A psychiatrist or other mental health clinician can determine whether a child or teen is struggling with OCD or another type of anxiety, using criteria listed in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). OCD is also associated with anxiety issues such as severe generalized anxiety and social anxiety, panic disorders, body dysmorphia, agoraphobia, skin-picking, and trichotillomania (hair-pulling).
The following signs indicate that a child requires an OCD assessment:
- Trouble sleeping due to obsessive imaginings and intrusive thoughts
- Taking an excessive amount of time to complete homework, due to starting over repeatedly or rechecking all the answers
- Needing to check lights, doors, and windows before leaving the house
- Repeated handwashing, sometimes to the point that their skin becomes raw and bleeds
- Substance use—using drugs or alcohol as a way to cope with the distress caused by OCD symptoms
- Tic disorder, such as repeatedly blinking, shrugging, or throat-clearing
How Do I Find an ERP Therapist Near Me?
Should your child receive an OCD diagnosis, the doctor or clinician may be able to recommend a therapist who specializes in treating OCD using ERP. In addition, the International OCD Foundation maintains a database of OCD specialists throughout the country. Exposure and Response Prevention therapists who work with teens should be highly trained and experienced in using this modality.
Newport Academy offers teen mental health assessments at no charge, and also provides specialized programming for OCD that includes 4.5 hours of ERP therapy daily. Contact us today to schedule an assessment, in person or virtually, and learn more about our approach to OCD treatment.
Exposure and Response Prevention as Part of an Integrated OCD Treatment Model
ERP therapy is one of the most effective approaches for treating obsessive-compulsive disorder. However, teens and children with OCD are more likely to find long-term, sustainable recovery when ERP therapy is part of a treatment plan that addresses OCD symptoms while also supporting whole-person well-being.
That’s why Newport Academy’s OCD programming for adolescents addresses both OCD and common co-occurring mental health issues, such as trauma, depression, and generalized anxiety disorder. In addition, our program addresses anxiety-related conditions including severe social anxiety, body dysmorphia, agoraphobia, trichotillomania, and panic disorders.
Find Out More About Newport’s Specialized Teen OCD Programming
Our teen OCD treatment include a wide variety of modalities, provided by a multidisciplinary treatment team. Each teen’s treatment plan for OCD includes 4.5 hours daily of ERP therapy, delivered in individual sessions, group sessions, and exposure homework.
In addition to ERP, our OCD treatment for adolescents incorporates psychiatric care and medication management, family therapy, experiential activities like art and music therapy and outdoor adventures, and a robust academic component.
Contact us today to learn more about our specialized adolescent OCD treatment and schedule an assessment for your teen.
Frequently Asked Questions
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