Will ERP Make my OCD Worse?
What to expect when starting ERP for OCD
Julie Miller, A/LPC-MHSP
Will ERP make my OCD worse? It’s a fair question, and one I get frequently. The answer isn’t as straightforward as “Yes” or “No.” ERP can temporarily make your anxiety feel more intense as you stop using compulsions to cope. But that temporary discomfort is part of the healing process, not a sign that your OCD is getting worse.To really understand how ERP might affect you, it’s helpful to understand how and why it works.
What is ERP?
Exposure Response Prevention (ERP) is the gold-standard treatment for obsessive-compulsive disorder. As the name implies, ERP has two fundamental components: exposure and response prevention.
Exposure is simply facing your fears in a gradual, incremental way that feels challenging but manageable. This is accomplished by creating a list of feared situations, images, and/or thoughts and rating how scary they feel on a scale of 0-10. Now, to be clear, it is never the goal of ERP to start at the top of the exposure hierarchy with the scariest situation you can ever imagine. We don’t push past the threshold of “challenging but manageable.”
Response prevention is the act of resisting compulsive safety behaviors. Response prevention is the essential ingredient that allows a person with OCD to have a new experience of the feared stimuli.
An Example of OCD Exposure
Here’s what this looks like in practice with an obsession related to the fear of dogs resulting in the compulsion of avoidance.
Obsession: Dogs
Compulsion: Avoidance of any stimuli related to dogs (pictures, words, parks, etc.)
Example exposure hierarchy (simplified for brevity):
Write the word “dog” - 2/10
Read the word “dog” - 3/10
Say the word “dog” - 4/10
Look at a drawing of a neural dog - 4/10
Look at a drawing of a scary dog - 5/10
Look at a photo of a neutral dog - 6/10
Look at a photo of an scary dog - 7/10
Go to a park - 8/10
Walk near a leashed neutral dog at the park - 9/10
Stand near a neutral dog at the park - 9/10
Pet dog at the park - 10/10
An exposure hierarchy can have as many incremental steps as needed, with the goal being that while a person with OCD is facing the feared stimuli, it is challenging but manageable to resist compulsive safety behaviors.
How ERP Helps OCD
OCD exists as a cyclical process. First, a person with OCD experiences an intrusive thought, image, or urge. This thought, image, or urge is considered intrusive when it is ego-dystonic, which means that the thought, image, or urge is incongruent with a person’s values. In other words, that intrusive thought, image, or urge is disturbing to the person who experiences it. As a result of being disturbed by the intrusive thought, image, or urge, the person with OCD experiences anxiety. This anxiety is experienced as dangerous, and thus, the person with OCD engages in a behavior that decreases the anxiety. The problem is that the safety behavior that lessens anxiety only works to temporarily decrease anxiety. Because as soon as that intrusive thought, image, or urge returns, so does the anxiety, and the cycle repeats itself again and again and again.
To disrupt this cycle, the response to the intrusive thought must be changed. A revised approach would look like this: the person with OCD experiences an intrusive thought, image, or urge, then experiences anxiety as a result. Instead of engaging in a compulsive safety behavior at that moment, the person with OCD can allow the anxiety to be present while they engage in something else that aligns with their values. In this version of events, the anxiety will be present, but it will rise and fall naturally while the person with OCD continues to engage in activities that are routine, valued, or enjoyable. This experience allows the person with OCD to learn something new about the intrusive thought, image, or urge, their anxiety, and even themselves.
OCD questions what's real, making it hard to trust yourself and your reality. The thought of challenging your OCD can feel overwhelming at best, but you don’t have to do it alone. You deserve the payoff: a deep self-trust and the freedom to choose what’s true and aligned for you.
Julie Miller, A/LPC-MHSP, is an OCD therapist who specializes in ERP, ACT, and IFS for OCD treatment. She serves adults in-office in Nashville and on telehealth across Tennessee.
An Example of ERP In Action
Situation: Going to the park for a family outing
Intrusive thought, image, or urge: Person with OCD experiences an intrusive thought that while at the park, a dog may attack their loved one unexpectedly.
Anxiety: It is not safe to go to the park. Because I had this thought, it is likely to happen and I should protect my family from this danger.
Compulsive safety behavior: Avoid going to the park, do not engage in the valued activity of a family outing.
New Response with ERP: Acknowledges what they are feeling and allows the anxiety to be present while engaging in routine, enjoyable, or valued activity. Self-talk during a situation like this may look like this:
“I’m having the thought that it is dangerous to go to the park with my family, and I am feeling terrified about this.” [allows self to feel anxiety as it rises and falls naturally without intervention from compulsive safety behaviors] “It is in alignment with my values to engage in a family outing to the park. My thoughts are not inherently indicative of factual circumstances.” [allows anxiety to be present while engaging in values-aligned activity]
New Learning: Prior to an exposure, we consider what the feared outcome is. After engaging in the exposure or feared situation, we consider what actually happened? This solidifies new learning for the person with OCD. The person with OCD feared that a dog would attack their family member if they went to the park for a family outing (feared outcome). However, when the person with OCD took their family to the park, what actually happened was they were able to enjoy a family day playing on the swings and slides. Yes, there were dogs present, and yes, the person with OCD experienced some anxiety, but they have potentially learned several things about their anxiety, the feared outcome, and themselves.
New Learning about Their Anxiety: I am able to tolerate situations where my anxiety is high and still enjoy myself even when anxiety is present.
New Learning about Feared Outcome: When I experienced the intrusive thoughts, images, and urges of a dog attacking my family member, I was certain going to the park was too dangerous of an activity for us to do. However, when we went there were dogs at the park and none of them actually attacked us. My thoughts did not cause the feared outcome to occur.
New Learning about Themselves: I do not have to avoid situations where my anxiety is triggered. I can handle being anxious and engaging in valued situations. It is possible to keep going even when anxiety is present. Anxiety doesn’t have to stop me from enjoying my life.
Identifying new learning in the process of facing one’s fears is essential in helping a person with OCD make new choices in response to their anxiety.
The Trade-off of ERP: Discomfort for Freedom
So, back to our original question: “Will ERP therapy make my OCD worse?” Real talk: your anxiety may be temporarily heightened. This is in response to allowing yourself to actually feel the anxiety rather than avoid the anxiety by engaging in compulsions. That being said, as you face your fears and allow anxiety to rise and fall on its own, your body and mind will recalibrate to the feared stimuli with the new learning that is taking place. With repetition, persistence, and courage, the feared stimuli will gradually lose its power to control your life. The goal is not to become fearless (anxiety can be a helpful emotion), but to live your life in spite of anxiety. In doing so, your body and mind will be empowered and anxiety will naturally lessen as distress tolerance increases. The trade-off? You get to stop living life according to OCD and start living life on your own terms.
When to reach out
If any of this sounds familiar, you aren’t broken and you aren’t alone. OCD is highly treatable and our OCD specialist is trained in approaches shown to drastically reduce symptoms. You do not have to keep white-knuckling through your days.
If you are in Nashville and looking for a therapist who specializes in adult OCD, we are here. We offer in-person sessions in Nashville and telehealth across Tennessee. ERP, one of the top OCD treatment modalities, is not about talking through your childhood. It is about learning a new way to respond to your own brain, and it works.
If you’re in Tennessee and looking for support:
Learn more about Julie, our OCD specialist who works with adults across Tennessee
Book your free 15-minute consultation or a full appointment using our easy online scheduling tool
Contact Healing House to see if we’re a good fit
