What Is Exposure and Response Prevention Therapy?

When someone is struggling with an anxiety disorder or OCD, exposure and response prevention therapy (ERP) is considered the best way to treat these disorders. McLean’s Abigail Stark, PhD, explains ERP so anyone can understand it and helps us know when this treatment might be best for a child or teen.

Find resources and more about the expert below.

What Is Exposure?

To explain exposure and response prevention therapy, first we’ll cover the exposure, and then get into response prevention.

Whenever we feel an emotion, there’s an urge that comes with that emotion. For anxiety, the urge tends to be to avoid.

Let’s say it’s the first day of school and you wake up and you feel a ton of anxiety. There tends to be an urge to say, “I can’t go to school today, I have a stomachache; this is too much for me,” and to find some type of way to avoid it.

In the short term, avoidance works really well. If your parent says, “Of course you don’t have to go to school today,” there is immediate relief—it feels better.

But what we know about avoidance is that in the long term, it makes anxiety bigger and bigger and bigger. It reinforces this idea that this is too much for me, that I can’t handle it.

Let’s say you skip that first day of school. The next day, it’s going to be a little bit more anxiety-provoking and a little bit harder to approach.

What we see with anxiety disorders and obsessive compulsive disorders is that this avoidance keeps growing and growing and growing over time until it becomes panic-inducing or overwhelming to approach these things.

What is exposure? It’s basically doing the opposite. It’s approaching in a slow, step-by-step manner to help teach your brain that you can handle this situation or this fearful experience.

With the school-based example, this might look like someone being out of school for a while, sitting in the parking lot for 10 minutes, going to a preferred class, or spending an hour in the school building.

A step-by-step approach helps teach your brain that you can tolerate this and you can get through it.

With obsessive compulsive disorder, this might look like practicing not washing your hands if you feel that urge to wash your hands or feel that you’ve been contaminated.

With social anxiety disorder, it might look like talking with friends and sharing opinions. It can look like all different things, depending on what the anxiety is and the feared situation you’re avoiding.

What Is Response Prevention?

This is the second part of exposure and response prevention. The idea with response prevention is that we find all different ways to increase avoidance in the moment.

We call these safety behaviors.

For someone with OCD, let’s say they’re really worried about contamination or the way it feels on their hands if they touch something that they think is contaminated. The safety behavior would be washing your hands in the moment.

For someone with social anxiety, let’s say they are afraid of talking to other people and judgments. The safety behavior might be never sharing an opinion or always over-apologizing.

Similar to avoidance, these safety behaviors reduce anxiety in the short term, and in the long term, our brain learns, “I can only handle the situation if I do the safety behavior.”

An example is thinking, “I was only safe from that contamination or the OCD feeling because I washed my hands, or my friends only didn’t judge me because I made it a joke that I like this music artist,” or something like that.

One part of exposure and response prevention is avoiding these safety behaviors, making sure we’re doing the exposure, and leaning into the anxiety without relying on those avoidance behaviors.

How Does ERP Work in the Brain?

We tend to look for two different outcomes. This is important to explain to kids and teens in advance, so they fully understand the idea behind ERP.

The first possible outcome is that we learn the feared situation didn’t happen.

For example, you share your opinion in a group, and no one says anything or they agree with you. It feels okay. If you touch something that feels contaminated, and you don’t wash your hands, that feeling goes away and you’re safe.

The other outcome is that the feared situation does happen, and you learn you can tolerate it and still move toward your own goals.

For example, you share your favorite music artist and someone says, “I don’t like them. They’re not that good.” You get through it, and you can still move toward your goal of being a genuine friend and being in the moment with your friends.

Maybe you get a cold after doing a bunch of contamination exposures, and you survive the cold. You’re still able to work toward leaving your house, going to school, and doing the things you want to do without the interfering compulsive behaviors.

There has been research on how exposure learning happens in the brain. We used to think the way it worked was that every time you did an exposure, it undid old learning from the past—that the situation is scary, I can’t handle it, or it’s too much for me.

What we’ve learned over time through further research is that, in what is called the inhibitory learning model, we’re building a new learning pathway in the brain. We’re building a new one, and that old one remains.

This is one of the reasons why we do exposures over and over again—why we really overlearn them—because we actually want to inhibit that other pathway in the brain.

Additionally, we used to think that you had to habituate in the moment—that anxiety had to go down during an exposure in order for it to work. We now know that doesn’t have to happen.

It feels nice if it does, but it doesn’t have to—the learning can occur whether or not anxiety goes down during the exposure itself. Your brain still learns you can tolerate it and that you can get through the moment.

Key Takeaways

Exposure and response prevention tends to be most helpful for people with anxiety and obsessive compulsive disorders—for people who are avoiding a lot of things in their lives because they’re afraid of it or feel like they can’t handle or tolerate it.

ERP has been the gold standard therapeutic treatment for most anxiety disorders, from social anxiety disorder, panic disorder, agoraphobia, and so on, as well as obsessive compulsive disorders.