Biblioteca clínica

Modelos

Entra para guardar tu sesión o suscríbete para abrir la biblioteca completa. Puedes seguir gratis con fichas parciales.

¿Prefieres esperar? Déjame tu correo: te aviso cuando abra el acceso completo y tendrás precio de fundador.

TU MENTOR · ATLASAtlas de la psicoterapia
Vista
Lista Red de afinidades Mapamundi Genealogía
Home

Behaviourism · 1966

Exposure and response prevention (ERP)

The obsessive cycle weakens when the person exposes themselves to the feared uncertainty and stops neutralising it through compulsions.

Exposure and response prevention, usually called ERP or EX/RP, is a specialised behavioural intervention for obsessive-compulsive disorder that identifies the sequence linking obsessions, triggers, anxiety, a sense of incompleteness, compulsions, avoidance and temporary relief, and intervenes on it through deliberate exposure to the cues that activate the problem while blocking overt, mental, interpersonal or avoidant neutralising responses. The model starts from the premise that rituals are maintained because they transiently reduce distress and reinforce the belief that they were necessary to prevent harm, attain certainty or restore a sense of rightness. ERP aims for the person to learn, through repeated and sufficiently prolonged experiences, that they can tolerate anxiety, doubt, the urge to ritualise and the subjective possibility of threat without carrying out compulsions, checking, washing, reassurance seeking, mental neutralisation, avoidance or safety behaviours. Its clinical architecture combines functional assessment of OCD, psychoeducation, self-monitoring, exposure hierarchies, in vivo exposure, imaginal exposure where the feared consequences cannot be safely tested in reality, ritual prevention, processing of the experiences as tests of hypotheses, between-session practice, work on family accommodation, generalisation and relapse prevention.

Theory of change

Change occurs when the person confronts obsessional cues and learns to tolerate uncertainty, distress and urge without carrying out compulsions.

Core ideas

  1. ERP is defined by intervening on the ritual, not merely by exposing the person to what they fear

    Exposure forms part of many behavioural and trauma-focused therapies, but ERP becomes specific to OCD because it joins activation of the obsessional trigger to prevention of the responses that neutralise anxiety, doubt, disgust, guilt or a sense of incompleteness. The decisive clinical target is not simply to experience fear, but to find that contact with the obsession can be maintained without washing, checking, avoiding, seeking reassurance, analysing, counting, praying or correcting. Evidence from component studies indicates that combining exposure with ritual prevention achieves better outcomes than either component alone. Reference: Meyer, V. (1966); Foa, E. B., Steketee, G., Grayson, J. B., Turner, R. M., & Latimer, P. (1984).

  2. Compulsions are maintained because they bring short-term relief

    A compulsion persists not because the person is unaware that it is excessive, but because it produces an immediate reduction in distress and appears to prevent harm, guilt or uncertainty. That temporary relief reinforces the behaviour and makes a ritual more readily available for the next obsession. ERP breaks this contingency by preventing the person from attributing the absence of catastrophe, or the drop in anxiety, to the performance of the compulsion. Reference: Meyer, V. (1966); Foa, E. B., Yadin, E., & Lichner, T. K. (2012).

  3. Uncertainty becomes an explicit therapeutic target

    Many forms of OCD are organised around the demand to be completely sure before acting, leaving a situation, touching an object, making a decision or stopping thinking about a threatening possibility. ERP teaches that absolute certainty is not a necessary condition for living responsibly and that the person can act while a measure of doubt persists. The aim is not to convince the patient that the threat is impossible, but to reduce reliance on rituals designed to eliminate uncertainty. Reference: Foa, E. B., Yadin, E., & Lichner, T. K. (2012); Law, C., & Boisseau, C. L. (2019).

  4. Mental rituals and reassurance maintain OCD just as visible compulsions do

    The clinical presentation of OCD can appear predominantly cognitive where the person does not wash, check or repeat actions observably, but neutralisations such as praying, counting, reviewing memories, arguing mentally, seeking confirmation or repeating reassuring phrases may serve exactly the same function. ERP requires these covert acts to be detected, because an exposure accompanied by mental neutralisation or interpersonal reassurance preserves the very mechanism of relief that maintains the problem. Reference: Foa, E. B., Yadin, E., & Lichner, T. K. (2012).

  5. Exposure functions as an experiential test of obsessive predictions

    ERP does not need to rest on formal cognitive restructuring in order to produce change in obsessive beliefs. The treatment formulates predictions about harm, contamination, loss of control, the intolerability of anxiety or moral responsibility, and tests them against experiences in which the person exposes themselves and does not ritualise. The learning arises from observing that distress can fluctuate and that the predicted consequence is not confirmed by the absence of neutralisation. Reference: Foa, E. B., & Kozak, M. J. (1986); Foa, E. B., Yadin, E., & Lichner, T. K. (2012).

  6. A reduction of anxiety during the session is useful, but it is not the only criterion of learning

    The classic formulation of ERP emphasised fear activation and habituation within and between sessions. Later developments show that clinical improvement can also consolidate when the person carries out effective exposures without experiencing a marked drop in anxiety at each practice. The more robust criterion is that the exposure should activate relevant expectations, prevent rituals and allow the person to learn that anxiety, urge and uncertainty are manageable without neutralisation. Reference: Foa, E. B., & Kozak, M. J. (1986); Law, C., & Boisseau, C. L. (2019).

  7. Imaginal exposure in ERP targets obsessive consequences, not traumatic memory

    Imaginal exposure in ERP is used to confront worst-outcome scenarios that the patient fears if they do not ritualise — falling ill, causing harm, losing control, committing an immoral act, being punished or being defined as a bad person. The imaginal script activates the obsessive meaning and the subjective responsibility associated with the compulsion. This function distinguishes it from the imaginal exposure of Prolonged Exposure, which centres on repetition of the traumatic memory within a protocol specific to PTSD. Reference: Foa, E. B., Steketee, G., Turner, R. M., & Fischer, S. C. (1980); Foa, E. B., Yadin, E., & Lichner, T. K. (2012).

  8. The family can maintain or facilitate change in OCD

    Close relatives can become incorporated into the obsessive system through delegated checking, adaptation of routines, shared avoidance and constant reassurance. ERP does not propose that the family should confront or pressure the patient abruptly, but that they should learn to reduce accommodation gradually, respond consistently to ritualised demands and support the agreed exposures. This modification of the environment helps the learning to generalise outside session. Reference: Foa, E. B., Yadin, E., & Lichner, T. K. (2012).

  9. Relapse prevention means learning to respond differently to new obsessions

    The end of ERP does not depend on eradicating intrusive thoughts entirely, since these may reappear during stress, life changes or with new obsessive content. Relapse prevention consists in recognising early any return to avoidance, reassurance seeking or ritualising, designing autonomous exposures, giving up the search for certainty and using the rules learned to prevent an isolated lapse from rebuilding the compulsive cycle. Reference: Foa, E. B., Yadin, E., & Lichner, T. K. (2012).

Influences

  • Behaviour therapy
  • Classical and operant conditioning
  • Mowrer's two-factor theory
  • The theory of emotional processing
  • Cognitive-behavioural psychology
  • Experimental research on avoidance and extinction

Key references

  • Meyer, V. (1966). Modification of expectations in cases with obsessional rituals. Behaviour Research and Therapy, 4, 273–280.
  • Foa, E. B., y Goldstein, A. (1978). Continuous exposure and complete response prevention in the treatment of obsessive-compulsive neurosis. Behavior Therapy, 9, 821–829.
  • Foa, E. B., Steketee, G., Turner, R. M., y Fischer, S. C. (1980). Effects of imaginal exposure to feared disasters in obsessive-compulsive checkers. Behaviour Research and Therapy, 18, 449–455.
  • Foa, E. B., Steketee, G., Grayson, J. B., Turner, R. M., y Latimer, P. (1984). Deliberate exposure and blocking of obsessive-compulsive rituals: Immediate and long-term effects. Behavior Therapy, 15, 450–472.
  • Foa, E. B., y Kozak, M. J. (1986). Emotional processing of fear: Exposure to corrective information. Psychological Bulletin, 99, 20–35.
  • Goodman, W. K., Price, L. H., Rasmussen, S. A., Mazure, C., Fleischmann, R. L., Hill, C. L., Heninger, G. R., y Charney, D. S. (1989). The Yale-Brown Obsessive Compulsive Scale. I. Development, use, and reliability. Archives of General Psychiatry, 46, 1006–1011.
  • Goodman, W. K., Price, L. H., Rasmussen, S. A., Mazure, C., Delgado, P., Heninger, G. R., y Charney, D. S. (1989). The Yale-Brown Obsessive Compulsive Scale. II. Validity. Archives of General Psychiatry, 46, 1012–1016.
  • Abramowitz, J. S. (1996). Variants of exposure and response prevention in the treatment of obsessive-compulsive disorder: A meta-analysis. Behavior Therapy, 27, 583–600.
  • Foa, E. B., Abramowitz, J. S., Franklin, M. E., y Kozak, M. J. (1999). Feared consequences, fixity of belief, and treatment outcome in patients with obsessive-compulsive disorder. Behavior Therapy, 30, 717–724.
  • Abramowitz, J. S., Foa, E. B., y Franklin, M. E. (2003). Exposure and ritual prevention for obsessive-compulsive disorder: Effects of intensive versus twice-weekly sessions. Journal of Consulting and Clinical Psychology, 71, 394–398.
  • Foa, E. B., Yadin, E., y Lichner, T. K. (2012). Exposure and Response (Ritual) Prevention for Obsessive-Compulsive Disorder: Therapist Guide (2nd ed.). Oxford University Press.
  • Law, C., y Boisseau, C. L. (2019). Exposure and response prevention in the treatment of obsessive-compulsive disorder: Current perspectives. Psychology Research and Behavior Management, 12, 1167–1174.