Exposure and response prevention

Domain II · Behavioural & cognitive · Victor Meyer, Edna Foa, Kozak · 1966 · London

What it is

Exposure and response (ritual) prevention (ERP, EX/RP) is the core behavioural treatment for obsessive-compulsive disorder (OCD). It combines two parts. First, the client deliberately confronts the situations, objects, thoughts and images that trigger obsessional distress (exposure: in vivo and…

Format

• Formats documented by the developers' centre (Penn CTSA):
• Intensive: 15 sessions on every weekday for 3 weeks, about 2 hours each, following the Kozak & Foa (1997) manual (Abramowitz et al. 2003). The 2015 Penn intensive programme describes 17 × 90-minute sessions, with up to two therapist home visits and follow-up phone calls over several weeks…

Questions to explore with your client

• What drew you to it, and what are you hoping it will change?
• Is there physical contact? Was it explained beforehand, and do you feel free to say no or stop at any point?
• Does it involve any substance, plant preparation, remedy or supplement? Has your doctor or prescriber been told, especially about any medication you take?
• Does it involve intense or unusual breathing? Have you been told about the medical conditions for which that is not advised?
• Does it involve fasting, a special diet or 'detox'? Have you discussed this with your doctor?
• Who runs it, and what training or registration do they hold?
• What actually happens in a session or meeting, and how often?
• What does it cost, and is there pressure to commit to more?
• How do you feel afterwards, in the hours and days that follow?
• Does it fit with, or clash with, the work we do here?

What practitioners of it watch for

• the cue becoming a ritual or talisman ("I'm safe if I wear it").
• acceptance used as a new ritual ("I'll accept it so it goes away").
• new safety behaviours replacing old ones (ritual substitution, 5.6).
• labelling that turns into reviewing, analysing or reassurance seeking.
• spacing that leads to drift; bring sessions closer again if symptoms rise. Format adaptations

Problems the guide addresses

• Refusal or low readiness to start
• Stuck: stalling on low items, endless intermediate steps, or no change
• Overwhelm: distress far above plan, panic, dissociation, shutdown
• Non-adherence to homework or ritual prevention
• Concealment of symptoms
• Ritual substitution, "unforbidden" avoidance, incomplete abstinence
• Arguments, demands for guarantees, "what if this time it's real?"
• Alliance ruptures
• Depression, suicidality, and crises unrelated to exposure
• Poor insight and overvalued ideas

When to involve someone else

• New or worsening physical symptoms, or advice to stop or change prescribed medication: involve the client's doctor or prescriber.
• Signs of coercion, isolation from family and friends, escalating costs or secrecy: discuss openly and consider safeguarding.
• A crisis or thoughts of suicide: follow your crisis protocol. In the US, call or text 988; in the UK and Ireland, Samaritans on 116 123.

Drawn automatically from the guide's own sections. Stay curious: neither endorse nor dismiss what the client values, and check anything that matters against the full guide and its sources. Not medical advice.