People who reach out about OCD usually have one question they're a little nervous to ask: what does the exposure part actually look like, and when does it start? Here's the honest answer. It usually starts somewhere between the third and fifth session, we plan it together ahead of time, and you never walk into it blind.
ERP stands for Exposure and Response Prevention. It's the treatment with the strongest evidence for obsessive-compulsive disorder. A full course typically runs 12 to 21 sessions, depending on you and how things progress.
Before the first exposure: mapping your OCD
The first few sessions are an assessment. We look at your obsessions, the unwanted thoughts, images or urges that show up, and your compulsions, the checking, cleaning, counting, replaying or reassurance seeking that brings the distress down for a moment. We also look at what all of it costs you day to day.
Then we build what's called a hierarchy. You rank your obsessions and triggers from least to most distressing. That list becomes the plan for treatment, and you help write it. We start where you're ready to start, not at the top.
What an exposure session looks like
Once the hierarchy is built, exposures begin, and from then on most sessions include one until we reach the goal.
- We pick a step from your list. Something lower on the list comes first.
- We bring on the trigger, on purpose. For about 30 to 40 minutes we set up a situation that brings up that obsession. That might mean touching something you'd normally avoid, leaving something unchecked, or sitting with a thought you'd usually push away.
- You don't do the compulsion. That's the "response prevention" part. No checking, no washing, no asking for reassurance, no mental ritual to cancel the thought out.
- We notice what happens to the distress. I'll ask you to rate how distressed you feel along the way. It usually rises first. Then, without the compulsion, it starts coming down on its own.
That last part is the whole point. Your brain learns from experience, not from being told, that the distress passes without the ritual. Each time it learns that, the next step on the list gets easier.
Where exposures happen
Wherever your OCD shows up. Some exposures happen in my office. Some work better out in public, and some happen in your home, if that's where the obsessions tend to live. We decide on the setting together.
Is it going to be too much?
Exposure sounds intense, and a lot of people worry they'll be pushed into their worst fear on day one. That's not how it works. You helped build the list, you know what's coming, and we move up it at a pace you agree to. Between sessions you practice the steps we've already done, so the progress keeps going during the week.
Not sure it's OCD?
You don't need a diagnosis before you call. It takes an average of seven years for someone with OCD to get an accurate diagnosis, often after treatment for general anxiety that didn't touch it. Evaluating OCD properly is part of what I'm trained to do. You can read more on my OCD and ERP page.
ERP is available in my Wooster office and by telehealth for clients located in Ohio. Every new client starts with a free 15-minute phone call. You tell me what's going on, ask me anything, and I'll tell you honestly whether ERP makes sense for you.
Book a free 15-minute consult or call (330) 439-2157.
If you need support right now: if you are thinking about harming yourself or you're in crisis, call or text 988, the Suicide and Crisis Lifeline. If you are in immediate danger, call 911.