Therapy Overview: Exposure & Response Prevention (ERP)

About the Authors

Rebecca Sachs, PhD, is a licensed psychologist and an expert in the top recommended treatments for Anxiety, Autism, and OCD. She believes in empowering individuals and their families with knowledge and skills. Board Certified in Behavioral and Cognitive Psychology, she has a private practice in New York and is co-Director of Successful School Transitions, a comprehensive program for school refusal. In addition to these roles, Dr. Sachs is mom to an energetic and determined 6 year old and step mom to the coolest 15 year old around!

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Dr. Alyssa Goodman is a Limited Permit Psychologist, NYS Certified School Psychologist, and Postdoctoral Fellow at E&R Psychology. She has extensive experience working with Autistic youth, adults, and their families, and is passionate about providing neuro-affirming care. With a strong foundation in evidence-based practices, Dr. Goodman specializes in Cognitive Behavioral Therapy (CBT) and Exposure and Response Prevention (ERP) for neurodiverse individuals, supporting individuals in building skills and achieving meaningful goals through compassionate, individualized treatment and care. 

What is Exposure Therapy?

Individuals who struggle with recurring anxiety, anxiety disorders, Obsessive Compulsive Disorder (OCD), and related conditions experience intrusive and unwanted inner experiences (thoughts, images, urges, not-so-right feelings) that are then accompanied by distress and discomfort. These feelings of distress and discomfort may be perceived as intolerable. As a means of self-protection, associated situations are avoided or an individual may do things to try and “get out of” an uncomfortable situation. Additionally, some people do compulsive behavior, rituals, distract themselves in various ways, or seek reassurance to neutralize the trigger or bring relief from the associated discomfort. However, this relief is short-lived and inevitably future situations will bring similar intrusive and unwanted inner experiences and the accompanying distress and discomfort.

Exposure and Response Prevention (ERP) is a well-researched form of Cognitive Behavioral Therapy (CBT) that focuses on helping individuals with anxiety, OCD, and related disorders approach and experience the specific things (situations, thoughts, feelings, urges) that they are avoiding, and that bring distress and discomfort (anxiety, disgust, not-so right-feeling). The goals of ERP are centered around helping the individual gradually reduce their discomfort and compulsive/avoidant behaviors by changing how they respond to distressing thoughts and situations.

• One key goal is to support habituation, which means becoming less sensitive to distress over time by staying in the presence of feared thoughts or situations until the distress naturally decreases. 
• ERP also aims to build distress tolerance, allowing individuals to sit with uncomfortable emotions or urges without trying to neutralize or escape them through compulsions.
• A crucial part of the process involves reducing avoidance behaviors, which often reinforce the fear and keep the cycle alive. ERP helps break this cycle by encouraging people to refrain from compulsions, rituals, distraction and reassurance seeking, even when uncomfortable inner experiences are present.
• Through repeated practice, individuals begin to relearn that feared outcomes are either unlikely or manageable, and they become more comfortable with uncertainty.

Ultimately, ERP works toward improving overall functioning and quality of life, giving people back their time, energy, and ability to live aligned with their values rather than being ruled by what anxiety and OCD are telling them to do.

When modifying and tailoring CBT with ERP For Autistic clients we want to consider the following:

1. Setting-up therapy to so Autistic clients can thrive
   • Set up the environment & session to promote optimal engagement
     • Accommodating communication preferences
     • Making the set up sensory safe
     • Accommodating and supporting executive function needs
   • Increase predictability
     • With virtual communication (visual schedules, social stories)
     • Clear expectations
     • Routines, Advanced Warnings (timers & countdowns)
     • Priming & Previewing
   • Provide choices & agreed upon goals
   • Incorporate special interests & passions
   • Model & prompt helpful behaviors (brave behavior, coping skills communication)
2. Skills that are not part of ERP, but are helpful to teach, practice and develop in therapy
   • Functional communication training & assertiveness training
   • Emotion identification & communication
   • Problem-solving skills
   • Relaxation, mindfulness, and grounding skills
   • When relevant, activities of daily living skills
   • When relevant, social skills
   • When relevant, academic skills
   • When relevant, executive function skills
3. Specific Modifications to CBT with ERP
   • Making exposures more predictable, at least at first and using visuals
     • Incorporating video modeling or live modeling so exposures are more predictable
   • Incorporating special interests into exposures
   • Starting very low on exposure hierarchy and moving at a slower pace when doing exposures
   • Providing prompts and praise almost continuously
     • When relevant, pairing with anti-anxiety stimuli (typically thought of as rewards given after completion) during the exposures
   • Instead of focusing on just response prevention, when relevant focusing on ritual delay & ritual shortening
   • Teaching & simplifying coping self-talk
     • Teaching this skill at first with positive experiences
     • Making sure to acknowledge realistic past learning (for example, bullying & rejection are a real part of social anxiety) 
4. Things to do after an exposure to encourage future exposures and having learning stick
   • Give specific praise on what they did well
   • Reward particle success and attempts to do exposure
   • Give the most powerful reward- favorite thing or activity, especially at the beginning