What Does Effective OCD Therapy Actually Look Like? A Closer Look at ERP

For people with OCDFor professionals
Written By Ian O Brien

From Hopeless to Hopeful

Not long ago, OCD was considered untreatable. Psychoanalysis — the primary therapy at the time — showed little success, leading many to believe OCD was a lifelong sentence (Foa, 2010). But the landscape has changed. Thanks to decades of research, we now know that OCD can be treated — and one therapy, in particular, stands out: Exposure and Response Prevention (ERP).

1. What Is ERP?

ERP was introduced by Victor Meyer in 1966 and has since become the gold-standard behavioural treatment for OCD. The idea is deceptively simple: face the things that trigger your anxiety (Exposure), and resist the compulsions your brain demands (Response Prevention). Over time, this breaks the OCD cycle (Rowa et al., 2007).

2. What Does ERP Look Like in Practice?

ERP typically follows a structured format, regardless of the treatment setting (Hezel & Simpson, 2019):

  • Psychoeducation: Learning how OCD operates and why ERP works.

  • Hierarchy Development: Collaboratively building a list of feared situations, from least to most distressing.

  • Exposure Tasks: Starting with manageable triggers and working up the ladder.

  • Response Prevention: Resisting rituals during exposures and in everyday life.

It may involve in vivo exposures (real-life scenarios) or imaginal exposures (mental scenarios or feared thoughts).

3. How Does ERP Work? Different Theories

There are a few ways researchers explain the mechanism behind ERP’s success (Hezel & Simpson, 2019):

  • Cognitive theory: OCD persists due to distorted beliefs — for example, “If I think something bad, it might come true” (Foa & Kozak, 1985; Rachman, 1997; Salkovskis, 1985). ERP challenges these beliefs by disproving them through lived experience. However, this theory is not universally accepted. Some newer research has found that obsessive beliefs may not strongly predict symptom improvement over time (Su et al., 2016), suggesting other processes may be at play.

  • Behavioural theory: ERP breaks the conditioned link between obsession and compulsion. When feared outcomes fail to materialise during exposure, anxiety naturally decreases.

  • Inhibitory learning model: The most current model suggests ERP helps the brain learn new, safer associations. Instead of trying to erase fear, it teaches the nervous system: “I can feel fear — and still be okay.” (Craske et al., 2008; Abramowitz & Arch, 2014). The goal is not to eliminate anxiety altogether, but to build greater tolerance for distress and uncertainty, gradually weakening the power of the OCD cycle.

4. What Makes ERP More Effective?

Not all ERP is equal. Research (McKay et al., 2015, citing Abramowitz, 1996) has uncovered key ingredients that predict stronger outcomes:

  • Therapist involvement: Therapist-guided ERP is more effective than self-directed attempts.

  • Complete response prevention: Avoiding all rituals is more helpful than partial prevention.

  • Combined exposures: Mixing real-life (in vivo) and imagined (imaginal) exposure gives the best results.

  • Longer sessions: A meta-analysis of 39 studies found that longer ERP sessions (average 88 minutes) led to better outcomes (Song et al., 2022).

Even the speed of exposure (gradual vs. rapid) doesn’t seem to matter as much — both approaches are equally effective.

5. It’s Not Just About the Technique

ERP techniques alone account for roughly 68% of symptom improvement — but the remaining 32% is linked to non-specific factors like the therapeutic alliance, client motivation, and emotional safety (Öst et al., 2015; Strauss et al., 2018).

This tells us something powerful: Healing isn't just about doing the exposures. It's about being supported while doing them.

Final Thoughts: Facing Fear with Support

ERP is challenging — it asks us to turn toward what we fear most. But with the right support, it becomes something more than a treatment plan. It becomes an act of courage and self-trust.

Whether it’s facing a fear of contamination or learning to sit with intrusive thoughts, ERP offers a way through. It doesn't erase fear — it helps you build a new relationship with it.

Interested in Starting ERP?

If you're reading this and thinking, “Maybe this is something I need” — you're not alone. ERP can feel overwhelming at first, but with the right guidance, it’s one of the most empowering paths toward change.

I’m a psychotherapist specialising in OCD and anxiety-related conditions. I offer ERP-informed therapy that’s collaborative, trauma-sensitive, and tailored to each person’s needs and pace.

If you're interested in exploring therapy with me, feel free to get in touch here. I’d be happy to answer any questions or help you figure out if ERP might be a good fit for you.

References

  • Abramowitz, J. S., & Arch, J. J. (2014). Strategies for improving long-term outcomes in cognitive behavioral therapy for obsessive-compulsive disorder: Insights from learning theory. Cognitive and Behavioral Practice, 21(1), 20–31. https://doi.org/10.1016/j.cbpra.2013.06.004

  • Craske, M. G., Treanor, M., Conway, C. C., Zbozinek, T., & Vervliet, B. (2008). Maximizing exposure therapy: An inhibitory learning approach. Behaviour Research and Therapy, 46(1), 5–27. https://doi.org/10.1016/j.brat.2007.10.003

  • Foa, E. B. (2010). Cognitive behavioral therapy of obsessive-compulsive disorder. Dialogues in Clinical Neuroscience, 12(2), 199–207. https://doi.org/10.31887/DCNS.2010.12.2/ebfoa

  • Foa, E. B., & Kozak, M. J. (1985). Emotional processing of fear: Exposure to corrective information. Psychological Bulletin, 99(1), 20–35. https://doi.org/10.1037/0033-2909.99.1.20

  • Hezel, D. M., & Simpson, H. B. (2019). Exposure and response prevention for obsessive-compulsive disorder: A review and new directions. Indian journal of psychiatry, 61(Suppl 1), S85–S92. https://doi.org/10.4103/psychiatry.IndianJPsychiatry_516_18 

  • Meyer, V. (1966). Modification of expectations in cases with obsessional rituals. Behaviour research and therapy, 4(4), 273–280. https://doi.org/10.1016/0005-7967(66)90023-4

  • Öst, L. G., Havnen, A., Hansen, B., & Kvale, G. (2015). Cognitive behavioral treatments of obsessive-compulsive disorder. A systematic review and meta-analysis of studies published 1993-2014. Clinical psychology review, 40, 156–169. https://doi.org/10.1016/j.cpr.2015.06.003

  • Rachman, S. (1997). A cognitive theory of obsessions. Behaviour research and therapy, 35(9), 793–802. https://doi.org/10.1016/s0005-7967(97)00040-5

  • Rowa, K., Antony, M. M., & Swinson, R. P. (2007). Exposure and response prevention. In M. M. Antony, C. Purdon, & L. J. Summerfeldt (Eds.), Psychological treatment of obsessive-compulsive disorder: Fundamentals and beyond (pp. 79–109). American Psychological Association. https://doi.org/10.1037/11543-004

  • Salkovskis, P. M. (1985). Obsessional-compulsive problems: A cognitive-behavioural analysis. Behaviour Research and Therapy, 23(5), 571-583. https://doi.org/10.1016/0005-7967(85)90099-2

  • Song, Y., Li, D., Zhang, S., Jin, Z., Zhen, Y., Su, Y., Zhang, M., Lu, L., Xue, X., Luo, J., Liang, M., & Li, X. (2022). The effect of exposure and response prevention therapy on obsessive-compulsive disorder: A systematic review and meta-analysis. Psychiatry research, 317, 114861. https://doi.org/10.1016/j.psychres.2022.114861

  • Strauss, A. Y., Huppert, J. D., Simpson, H. B., & Foa, E. B. (2018). What matters more? Common or specific factors in cognitive behavioral therapy for OCD: Therapeutic alliance and expectations as predictors of treatment outcome. Behaviour research and therapy, 105, 43–51. https://doi.org/10.1016/j.brat.2018.03.007

  • Su, Y.-J., Carpenter, J. K., Zandberg, L. J., Simpson, H. B., & Foa, E. B. (2016). Cognitive mediation of symptom change in exposure and response prevention for obsessive-compulsive disorder. Behavior Therapy, 47(4), 474–486. https://doi.org/10.1016/j.beth.2016.03.003

Ian O Brien
Next

Why Do People Get Stuck in OCD? The Science Behind the Cycle