Exposure and Response Prevention Therapy, commonly referred to as ERP, has roots that can be traced back to Cognitive Behavioral Therapy. Exposure and Response Prevention Therapy can be used to treat a variety of mental health concerns. ERP works to teach clients how to effectively tolerate distress without engaging in compulsions and other behaviors. This is done by providing new information that challenges the client’s initial fear response (Hezel, D.M. & Simpson, H.B., 2019).   

While Exposure and Response Therapy can be used at different levels of care, there are common elements that can be observed. To start, a Clinician would complete an intake assessment and formulate an appropriate treatment plan for the client (Hezel, D.M. & Simpson, H.B., 2019). This would be an appropriate time to provide psychoeducation about the client’s diagnosis and ERP to ensure that they are informed.  

Clinicians work with their clients as they practice confronting the triggers, both internal and external, that illicit distress (Hezel, D.M. & Simpson, H.B., 2019). This can include anxiety symptoms and obsessions. By continuing to not engage in the compulsive behavior or distressing response, the client works to decrease the automatic response of seeing the trigger as a threat. Relaxation strategies are used to help clients learn to manage the distress they experience.  Keep reading to learn 10 ERP therapy exercises and activities you can do with your clients.

Mental Health Concerns That Can Benefit from Exposure and Response Prevention Therapy

Exposure and Response Prevention Therapy can be used to treat individuals who are struggling with obsessive-compulsive disorder, post-traumatic stress disorder, and 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 can have several positive impacts on our clients. With the effective use of ERP, clients will learn that they can safely manage distress caused by triggers. While they will experience an increase in their distress when beginning ERP therapy, they often find that their struggle decreases, and can eventually subside.

It is important that Clinicians who use Exposure and Response Prevention Therapy have the proper training and experience in ERP. Exposure and Response Prevention Therapy may not be effective when clinicians utilize the wrong exposure method (ie. in vivo or imaginal exposure), failing to address the core fear, and ineffectively manage your client’s mental compulsions (Gilihan, S., Williams, M., Malcoun, et. al, 2012)

Exposure and Response Prevention 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:

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.  TherapyByPro 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.

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.

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. TherapyByPro 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. 

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.

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.

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.

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 TherapyByPro 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.

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.

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 TherapyByPro, 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. 

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. 

Final Thoughts on Choosing Activities from ERP

Thank you for reading this resource on 10 ERP therapy exercises and activities you can do with your clients. ERP therapy activities can be introduced in the session, and used in our clients’ day-to-day lives. Exposure Response and Prevention Therapy can be modified to address our client’s individual needs, and progress at a pace fitting their symptoms.

As noted above, it is important that Clinicians who are utilizing Exposure and Response Prevention Therapy have the education and experience needed to effectively provide this form of therapy. This can be accomplished through specialized training and continued education credits. If you are interested in learning more about Exposure and Response Prevention Therapy, speaking with your supervisor or colleagues can help you see the usefulness of this form of therapy in your niche.

TherapyByPro is an online mental health directory that connects mental health pros with clients in need. If you’re a mental health professional, you can Join our community and add your practice listing here. We have assessments, practice forms, and worksheet templates mental health professionals can use to streamline their practice. View all of our mental health worksheets here.

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

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