OCD
6 Tips for Navigating Resistance to ERP
“I’ve tried exposure and response prevention therapy, and it doesn’t work.”
Posted February 3, 2025 Reviewed by Davia Sills
Key points
- Resistance to ERP is not uncommon; explore client concerns with curiosity rather than defensiveness.
- If a client doesn't have a firm foundation of what ERP is and its goals, there may be increased resistance.
- Resistance is an opportunity to refine ERP, reinforce values, and boost hope and empowerment.
Exposure and response prevention (ERP) therapy is the leading evidence-based treatment for OCD, but what happens when a client tells their therapist that ERP doesn’t work for them? This interaction can leave therapists feeling stuck or lost on how to move forward, and it is important for therapists to explore this concern with curiosity and openness rather than defensiveness. Resistance to ERP is not uncommon, and there are several reasons that a client may feel it is ineffective or that it hasn’t worked in past experiences.
Assess the Client’s Understanding of ERP
Sometimes, when clients say ERP doesn’t work, they might really mean that they don’t understand the process or expectations. ERP is designed to change the relationship with OCD by reducing and eliminating fear-based responses (compulsions) over time, not eliminating intrusive thoughts or distress altogether.
Doing knowledge checks can help therapists gauge their clients’ understanding of ERP. If clients don’t have a firm foundation on the basics, this could contribute to the belief that ERP doesn’t work. Below are some talking points for clarifying the ERP process:
- Clarify that ERP aims to change how clients respond to intrusive thoughts, not stop them.
- Reframe progress as a shift in how distressing the thoughts feel rather than an absence of them. This lends well to the inhibitory learning framework that emphasizes distress tolerance in ERP.
- Normalize the fact that early exposures may still feel distressing and that long-term consistency is key.
Another area to explore is their past experiences with ERP. Were they self-guided or done with a therapist? Was it actually ERP or something else (like traditional CBT, flooding, etc)? Ask for concrete examples of what their treatment looked like (e.g., what exposure exercises they did, what their response prevention goals were, etc.).
Check for Subtle Rituals or Safety Behaviors
Many clients engage in subtle compulsions or avoidance without realizing it, which can hinder ERP from working effectively. Questions therapists can ask to help detect subtle compulsions include:
- “Are there any small things you do to make exposures feel easier?” Make sure to provide examples, such as changing the way one engages with life due to believing the OCD content, telling oneself that the exposures aren’t real, etc.
- “What happens right after you do an exposure?”
- “Do you notice giving yourself reassurance, trying to neutralize the distress, or doing any other sneaky mental compulsions?”
Remember that engaging in compulsions keeps the OCD cycle going. If a client is engaging in compulsions while they are doing exposures, it essentially undoes the hard work of facing their fears. It’s important to share this information with clients and enhance awareness of subtle compulsions and their impact on progress.
Evaluate the Intensity of the Exposures
When doing ERP work, therapists should strive for balance. If an exposure is too distressing, clients may find it overwhelming or white-knuckle their way through, whereas if an exposure is too easy, it may not provide a meaningful learning experience. Some tips include:
- Utilizing a SUDS (subjective units of distress) scale to ensure exposures are in the appropriate distress range
- Adjusting the hierarchy if the exposures are too challenging or not challenging enough
- Encouraging willingness and a collaborative approach to ERP work
Explore the Client’s Relationship With Anxiety
Resistance in ERP may stem from difficulties tolerating distress or uncertainty. It can be easier to say that the treatment doesn’t work rather than face and move through distressing thoughts and feelings. Incorporating ACT principles can help:
- Teach clients to practice willingness rather than trying to force feelings away.
- Help clients identify core values that ERP aligns with. These could include spending more time with family, cooking meals, and expressing love for their partner.
- Encourage mindfulness skills that increase awareness of avoidance or other compulsions and that reinforce observing thoughts without engaging.
Address Motivation and Expectations
Some clients may engage in ERP with the primary goal or expectation to get rid of anxiety or intrusive thoughts. This is not a recipe for success and can lead them to lose faith in ERP.
Therapists can help to set realistic goals and expectations, such as building up a tolerance for discomfort rather than eliminating it. Questions that can be used to explore past or current treatment expectations are:
- “What were your expectations of ERP when you first started?”
- “What would treatment success look like for you?”
- “How can we redefine success based on your values rather than your anxiety?”
Consider Other Factors
There are other factors that should be considered after troubleshooting some of the earlier points if ERP wasn’t successful. These include:
- Comorbid conditions like depression, trauma, or any other co-occurring condition that may impact ERP’s effectiveness or treatment engagement.
- If a client is on medication, it might be helpful to have a conversation with their prescriber to see if any adjustments are needed.
- Just like in any other treatment modality, the relationship between client and therapist in ERP is incredibly important and powerful. If rapport or trust is lacking in the relationship, this could lead to barriers in ERP work.
Wrapping Up
If a client feels like ERP isn’t working or hasn’t worked in the past, it is an opportunity to reassess, adjust, and reinforce core principles. Progress in ERP is often not linear. Validating any frustrations that come up along the way, as well as helping clients navigate through any barriers, can make a huge difference.
Rolling with resistance is a chance to refine the approach, reinforce values, and maintain a collaborative stance. With these tools and tips, therapists can help their clients rediscover how effective ERP can be and regain a sense of hope and empowerment.