
Yay, you're finally ready to try
Exposure and Response Prevention!
Or like 70% ready
You tried regular therapy, half-hearted ERP, medication, meditation, praying, crying, crystals, Reddit, willpower, workbooks, weed, yelling at yourself, and so on.
Let’s discuss actual ERP.

Obsessive-Compulsive Cycles & Your Brain
You can think of us as having two brains: a reptile and a logical brain. They each have their strengths (speed versus accuracy) and sometimes play well together. Other times we feel torn or “of two minds.” When we encounter threats, each brain runs a risk assessment, and sometimes they come to different conclusions. If you have an untreated obsessive-compulsive disorder, your logical brain works normally, but for whatever reason, your reptile brain over-responds to a specific set of threats. When you encounter one of these threats, you feel a powerful urge to engage in “safety behaviors” that are supposed to protect your short-term and long-term survival. If you’re an adult, your safety behaviors include a lot of behaviors you can hide from other people, such as frequently monitoring the threat while pretending you’re not. You do survive the threat, which is awesome, but your reptile brain never gets a chance to learn that you would have survived even without the big physiological reaction or safety behaviors. Because no learning can occur under these conditions, without treatment, the cycle is likely to repeat itself throughout your entire life. Yes, the behaviors take different forms as you grow and change, and of course across different situations. But underneath all the surface-level idiosyncrasies, the same fear cycle remains.
What does treatment look like?
1) A few sessions of information gathering. What are your exact feared outcomes and safety behaviors? What is the logic that ties them together into one neat cycle?
2) One or more sessions practicing the “response prevention” part of “exposure and response prevention.” You learn how to mindfully acknowledge fears, make a rational decision about how to handle the situation, and move on. Symptom relief usually starts when you start practicing consistently.
3) We collaboratively design experiments that let your brain figure out whether your fear beliefs are accurate. I can’t make you do anything, nor does that sound fun. We make too-hard experiments easier until they feel challenging but doable and convert abstract, “untestable” fears to a concrete, testable format.
4) We run the experiments together and problem-solve any barriers to you repeating them at home.
5) Once your brain gathers enough data points to decide for itself, your reaction to your trigger situations starts to look more like everyone else’s.
10% skills / 90% chilling out
We do cover a few cool anxiety management skills, but the process of change is your brain chilling out or learning that “fight or flight” isn’t necessary. Consider past experiences in which you were super afraid of something and then got used to it. Voila! Same process of change brain-wise.

How many sessions will I need?
22…Just kidding! I have no idea.
In all seriousness, a lot of factors impact the number of sessions you will need to cross the finish line. The main one I see is actually under your control: whether you are willing to give ERP a try without any creative modifications.
People often learn the basics and then get creative, often with the goal of making treatment faster or less painful. In reality, ERP works surprisingly fast once you start doing it right. If it feels painful, you are probably doing something ERP-adjacent, and we need to adjust your form so you’re doing actual ERP. It should feel like a mindfulness exercise: observe a fear, allow it to be present, and decide for yourself how you want to proceed. If you are doing ERP, and if we’re treating OCD and OCD only, treatment is often about 20 sessions. The other things I treat usually require fewer sessions, though BDD usually requires more. Again, that number mostly reflects average willingness to try ERP.
If you want to contain therapy time and costs, and you also want to get better, I recommend at least giving ERP a shot. If you don’t like it, you are totally free to stop treatment whenever you want and even bring back all your old compulsions. I’ve never seen someone decide to go back, but life is long and I’m down to be surprised.
ERP isn’t the answer for everything under the sun 🌞
But it’s great for obsessive-compulsive stuff!
Tons of people worry ERP won't work for them. Yet it works for a surprisingly wide range of fears, including every OCD subtype as best we know. Yes, even the most abstract, “untestable” fears (“what if I go to hell after I die because I didn’t say my prayer just right?”). Worried ERP can’t help because your compulsions mostly happen inside your head? That’s adult OCD for you! You don’t want to be weird and do compulsions out in the open. Also, you have learned the art of multitasking. You are a rumination pro while driving, watching TV, scrolling social media, “listening” to your partner or friends, walking the dog, cooking, eating, going to the bathroom…

So many reasons to avoid ERP
A few extra important reasons not to