Approaches / Cognitive and behavioural
Exposure and response prevention (ERP)
A behavioural method in which a person gradually faces feared situations or thoughts without carrying out the usual ritual.
Overview
Exposure and response prevention is a form of cognitive behavioural therapy used mainly for obsessive compulsive disorder. A person approaches what triggers their distress while agreeing not to carry out compulsions or other rituals.
Core ideas
The method rests on the idea that rituals can bring short-term relief but keep the fear going. Staying with a trigger without the ritual gives a chance to learn what happens, and for the distress to change over time.
The plan is made with the person, and exposures are usually graded from less to more difficult.
What a session can involve
Early sessions usually map the person's triggers, rituals and avoidance. Later sessions can include agreed exposures, planned practice between meetings and review of what was noticed. Pace and intensity are set together.
Formats and settings
ERP can be offered individually, in groups, online or with family members involved, and in intensive or weekly formats. Families sometimes receive guidance on how to respond to rituals.
How it relates to other approaches
ERP is closely related to prolonged exposure, which applies exposure principles to trauma. Both belong to the exposure tradition within cognitive and behavioural therapy. They differ in the problems they were developed for and in what the exposure involves. See the comparison page for a side-by-side summary.
Limits and open questions
ERP can be demanding, and some people stop treatment or prefer another approach. Questions include how to adapt it for children, for people whose obsessions are mainly mental, and across cultures where the content of obsessions differs.
NICE recommends CBT including ERP for adults with obsessive compulsive disorder, with treatment intensity and options depending on functional impairment and preference. Its guidance also addresses children and young people. In the United States, the American Psychiatric Association describes ERP as a first-line therapy for OCD. These sources concern OCD and should not be taken as guidance for every condition.
History
Exposure methods grew from behaviour therapy in the mid twentieth century. Joseph Wolpe's work on reciprocal inhibition was an early influence on exposure-based work. Edna Foa and Michael Kozak's 1986 paper on emotional processing of fear became an influential account of why exposure might work.
Key people
Edna Foa is a leading figure in exposure research and in its use for obsessive compulsive disorder and post-traumatic stress. Joseph Wolpe is associated with earlier behavioural work on anxiety.
Sources and inspection notes
NHS, Treatment for obsessive compulsive disorder (OCD)
Supports: That therapy for OCD is usually a type of CBT with exposure and response prevention, as described for NHS services (UK).
NICE, Obsessive-compulsive disorder and body dysmorphic disorder: treatment (CG31)
Supports: Recommendations on CBT including ERP for OCD, with options depending on age, functional impairment and preference (England and Wales).
American Psychiatric Association. What are obsessive-compulsive and related disorders?
Supports: US patient information describes ERP as a first-line therapy for OCD and outlines exposure and response prevention.
Supports: The theoretical account of emotional processing of fear that is often cited in exposure-based therapies.