Exposure and Response Prevention Therapy (ERP), a derivative of Cognitive Behavioral Therapy, offers a powerful approach to address diverse mental health concerns. ERP aims to equip clients with the skills to tolerate distress without resorting to compulsive behaviors. By providing new information that challenges the client’s initial fear response, ERP facilitates effective coping strategies (Hezel, D.M. & Simpson, H.B., 2019). Keep reading to learn 10 ERP Therapy activities and exercises you can do with your clients in therapy sessions.

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Exposure and Response Prevention Therapy (ERP) can be applied across various levels of care, encompassing several common elements. At the outset, clinicians conduct an intake assessment and develop a suitable treatment plan for the client, taking into account their specific needs and circumstances (Hezel, D.M. & Simpson, H.B., 2019). This stage also presents an opportunity to provide psychoeducation about the client’s diagnosis and ERP, ensuring they are well-informed.

Clinicians collaborate with clients in systematically confronting triggers, both internal and external, that evoke distressing reactions (Hezel, D.M. & Simpson, H.B., 2019). These triggers can encompass anxiety symptoms and obsessions. By purposefully abstaining from engaging in compulsive behaviors or distressing responses, clients work towards diminishing the automatic perception of the trigger as a threat. Relaxation strategies are integrated to support clients in effectively managing the distress they encounter. To explore further, continue reading to discover 10 ERP therapy exercises and activities that can be incorporated into your sessions with clients.

Why ERP Therapy?

Exposure and Response Prevention (ERP) therapy is a highly effective treatment for individuals with obsessive-compulsive disorder (OCD) and related anxiety disorders. There are several compelling reasons why ERP therapy may be chosen as a preferred treatment option:

1. Evidence-Based: ERP therapy is considered the gold standard for the treatment of OCD and has a substantial body of research supporting its effectiveness. It is also used for other anxiety disorders, such as specific phobias and social anxiety disorder.
2. Specialized for OCD: ERP is specifically tailored to address the core symptoms of OCD, including intrusive thoughts (obsessions) and repetitive behaviors or mental acts (compulsions). It helps individuals confront their fears and reduce the need to engage in compulsive behaviors.
3. Behavioral Approach: ERP is a behavioral therapy that focuses on changing behavior patterns. It encourages individuals to confront their anxieties through exposure exercises, allowing them to learn that their fears are unfounded or manageable.
4. Exposure to Fears: ERP involves systematically exposing individuals to situations, thoughts, or images that trigger their anxiety or obsessions. This controlled exposure helps desensitize them to their fears over time.
5. Response Prevention: ERP includes response prevention, which means that individuals are discouraged from engaging in compulsive behaviors or rituals that they typically use to reduce anxiety. This helps break the cycle of obsessions and compulsions.
6. Customized Treatment: ERP can be tailored to suit the specific obsessions and compulsions experienced by each individual. It addresses their unique triggers and concerns.
7. Long-Term Benefits: Many individuals who complete ERP therapy report long-lasting improvements in their OCD symptoms, with reduced relapse rates even after therapy has concluded.
8. Empowerment: ERP empowers individuals by teaching them coping strategies to confront their fears and obsessions, ultimately helping them regain control over their lives.
9. Improved Quality of Life: By reducing the impact of OCD symptoms and compulsions, ERP can enhance an individual’s overall quality of life, including their relationships, work, and daily functioning.
10. Less Reliance on Medication: Some individuals with OCD may be able to reduce or discontinue medication use after successfully completing ERP therapy, depending on their specific situation and in consultation with their healthcare provider.
11. Comprehensive Care: ERP therapy is often used in conjunction with other therapeutic approaches or support systems, ensuring a comprehensive treatment plan tailored to the individual’s needs.
12. Transdiagnostic Application: While ERP was initially developed for OCD, it has been adapted for various anxiety-related conditions, making it suitable for clients with comorbid anxiety disorders.

While ERP therapy is highly effective for OCD and anxiety-related conditions, it is essential to consider an individual’s unique needs and preferences when selecting a therapy approach. ERP may be particularly well-suited for those seeking targeted and evidence-based treatment to alleviate distressing symptoms and improve their overall well-being. Keep reading to learn ERP Activities you can do with your clients.

Mental Health Concerns That Can Benefit from ERP

Exposure and Response Prevention Therapy can be used to treat individuals who are struggling with:

• Obsessive-compulsive disorder
• Post-traumatic stress disorder
• Some phobias

A benefit of choosing to use Exposure and Response Prevention Therapy is that it can be used at varying levels of care including inpatient treatment programs, partial hospitalization programs, residential treatment programs, and outpatient treatment programs.

Exposure and Response Prevention Therapy (ERP) can yield numerous positive impacts on clients. Through the effective application of ERP, clients acquire the knowledge and skills to safely manage distress triggered by various stimuli. Although initial engagement in ERP therapy may elicit an increase in distress, clients often discover that their struggle gradually diminishes and, in time, may even subside completely.

It is crucial for clinicians utilizing Exposure and Response Prevention Therapy to possess the appropriate training and experience in ERP techniques. The effectiveness of ERP can be compromised if clinicians employ an incorrect exposure method, such as in vivo or imaginal exposure, fail to address the core fear, or inadequately manage their clients’ mental compulsions (Gilihan, S., Williams, M., Malcoun, et al., 2012).

ERP Therapy Activities

ERP therapy exercises can be used to enhance our client’s clinical experience. ERP exercises can include homework assignments and methods that allow clients to track their experiences outside of therapy sessions, which can then be explored and processed in later therapy sessions.

Examples of Exposure and Response Prevention Therapy Activities include the following:

1. A piece of Exposure and Response Prevention Therapy is having the clients track their experience outside of therapy sessions. The ERP Hourly Tracking Worksheet available from TherapyPatron.com provides clients with a form that encourages them to check in with themselves hourly to rate their subjective unit of distress (SUDS) between 0 and 10. They are able to track their experience for a week with one worksheet, which can be a simple resource for clients to hold onto.  Clients have space at the top of the form to note their exposure task, the time for each exposure, and the behavior they are working to eliminate.
2. Mindfulness meditation can be an effective practice for clients living with obsessive-compulsive disorder. Mindfulness meditation can help our clients become aware of their thoughts without actively pushing them away or judging them. With regular practice, mindfulness meditation can help clients decrease the distress they experience when having troubling or challenging thoughts.
3. A second relaxation strategy that clients could benefit from would be breathing exercises. This can include box breathing, diaphragmatic breathing,  Lion’s breath, breath focus, and long exhale. Allow time to practice these strategies with your client in the session, and explore their experience. Spend time discussing situations in which they can use the various breathing techniques, and encourage your client to use these breathing strategies outside of therapy sessions when they feel distressed.
4. A necessary component of ERP Therapy is to introduce your client to relaxation techniques that can be used to manage the distress they experience during exposures. One relaxation technique that we can introduce to our clients is meditation. Spend time exploring the different forms of meditations, such as progressive muscle relaxation and guided imagery, and allow clients to practice the different meditations. Try to be mindful of mental health concerns that may impact a client’s ability to safely engage in meditation, such as a history of trauma, which can have the opposite effect of what we are looking for. Help your client find times in their day that they can begin practicing meditations. Allow for time in later sessions to follow up on their practices and explore any impact they have noticed from it.
5. A component that can be incorporated into a client’s psychoeducation would be the specific consequences that they have experienced as a result of their obsessive-compulsive disorder. TherapyPatron.com offers an OCD Consequences to Others  Worksheet that can be used to explore the different ways that OCD has impacted the important people in our clients’ lives. This can include ignoring others, hurting others, and embarrassing others. This exploration can help clients recognize the impact that their mental health has on others, and lead to a discussion about the benefits that can occur by addressing their obsessive-compulsive symptoms.
6. Introduce your client to grounding techniques. Grounding techniques utilize our five senses to help us step back from negative or challenging thoughts. Allow for time to walk your client through a grounding exercise, and discuss how they can apply this practice to their daily life outside of their therapy sessions. Encourage your client to use this practice as a way to manage their distress and follow up in subsequent sessions.
7. Introduce your client to Visualization, a common relaxation technique. Begin by teaching your client what Visualization is, followed by exploring what a peaceful or calm place would be for them. Spend time talking to your client through a Visualization exercise. Allow for time to process their experience and any noticeable effects that they experienced.
8. Clinicians who utilize Exposure and Response Prevention Therapy may find that their clients benefit from having worksheets that they can take out of session to remind them of the work they have started in session. Beginning something new can be overwhelming and confusing.  TherapyPatron.com offers an Exposure and Response Prevention Worksheet that provides space for clients to write their exposure hierarchy as well as charts that can be used to track their symptoms and subjective unit of distress. These worksheets can be helpful tools that help clients bring information related to their experience into therapy sessions as they engage in Exposure and Response Prevention Therapy.
9. The Exposure Homework Sheet provides your client with a template that can be used to track their experience during, and after an ERP exposure. At the top of the form available from TherapyPatron.com, your clients have space to note the situation they are practicing. They then have space to write their subjective unit of distress at the beginning of the exposure, 10, 20, 30, 40, 50, and 60 minutes after the exposure. This form can then be reviewed in session to explore the progress that they are making in their ability to effectively manage their distress.
10. Similar to the OCD Consequences to Others Worksheet, the OCD Consequences to Yourself Worksheet can help our clients name the specific harms that their mental health symptoms have had on their lives. This can include the time that they have lost, feeling humiliated or embarrassed, financial losses, damage to interpersonal relationships, negative impacts on their career, and any social or leisure activities that they have missed due to their mental health concern. This can help clients see the benefits of addressing their mental health symptoms if they are not currently in the action stage of change.

Final Thoughts on Choosing Activities from ERP

Thank you for reading this resource on 10 ERP therapy activities and exercises you can do with your clients. These activities can be integrated into therapy sessions and implemented in your clients’ day-to-day lives. Exposure and Response Prevention Therapy can be adapted to address the unique needs of each client, progressing at a pace that aligns with their symptoms.

As emphasized earlier, it is crucial for clinicians utilizing Exposure and Response Prevention Therapy to possess the necessary education and experience to deliver this form of therapy effectively. Specialized training and continued education credits can be pursued to enhance proficiency in this therapeutic approach. If you are eager to learn more about Exposure and Response Prevention Therapy, seeking guidance from your supervisor or consulting with colleagues can provide valuable insights into the practical application of this therapy within your specific area of practice.

TherapyPatron.com helps mental health professionals better serve their clients. Our (editable, fillable, printable PDF) therapy worksheets can help you streamline your practice, effectively deliver different types of therapy, and support your clients be the best version of themselves.

View all of our Exposure and Response Prevention Therapy Worksheets

Resources:

• Gillihan, S. J., Williams, M. T., Malcoun, E., Yadin, E., & Foa, E. B. (2012). Common Pitfalls in Exposure and Response Prevention (EX/RP) for OCD. Journal of Obsessive-Compulsive and Related Disorders, 1(4), 251–257. https://doi.org/10.1016/j.jocrd.2012.05.002
• 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

Author: Kayla VanGuilder, MA, LCMHC

Kayla is a Mental Health Counselor who earned her degree from Niagara University in Lewiston, New York. She has provided psychotherapy in a residential treatment program and an outpatient addiction treatment facility in New York as well as an inpatient addiction rehab in Ontario, Canada. She has experience working with individuals living with a variety of mental health concerns including depression, anxiety, bipolar disorder, borderline personality disorder, and trauma.