I can’t speak for every therapist who provides Exposure and Response Prevention therapy and how they structure their sessions, however I am happy to share my own approach when providing this treatment. I hope that this post reduces worries for individuals contemplating connecting to care for OCD treatment.

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The first step in providing any sort of therapy is building a strong rapport with the client. There needs to be trust, open communication and time for the therapist to get to know you! This is incredibly important so that the therapist can pick up non-verbal cues that indicate increased discomfort or anxiety. A strong rapport between the client and therapist is also incredibly important to the overall success in the client meeting their treatment goals!

The first few sessions when meeting with me (when your goals surround OCD treatment), focus on psychoeducation regarding OCD symptoms, assessing what compulsions are present and what obsessional themes you are experiencing currently (harm, scrupulosity, contamination). During these first few sessions, not only is the information important and validating for many clients, during this time the client and I are building rapport.

Before we begin any exposures in session, we will have accomplished these goals:

• You will have a greater understanding of obsessive compulsive disorder and its symptoms
• Treatment options will have been discussed (Exposure and Response Prevention, Inference-based CBT, Acceptance and Commitment Therapy, Medication if appropriate with potential referral options)
• Treatment rational will be explained and consent to move forward with a particular treatment plan confirmed
• We have identified out the core fear that is driving the OCD obsessions and compulsions
• We will begin building a hierarchy of exposures for future sessions and goals outside of session
• Rapport is gained, communication is open and trust between the client and the therapist is present

Now we begin!

When seeking treatment for OCD, the gold standard of treatment is Exposure and Response Prevention. There are other treatment modalities (listed above) that can also be used. Let’s discuss how exposure sessions in particular look.

Once the client and the therapist both feel it is time to move forward with exposures and a hierarchy has begun to be built, it is best to get started! Even if the hierarchy isn’t fully formed (and it is likely going to grow and change over time), exposure-focused session can begin.

Exposure and response prevention sessions may include both in-vitro and in-vivo exposure goals. In-vitro exposures are imaginal exposures and often times we will start with this. These exposures often require closing your eyes and imagining particular images, thoughts or scenarios. In-vitro exposures can also include script writing. This is where you will practice writing about the feared scenario or core fear. It is important to know that any exposure completed will be with your consent and endorsed readiness to begin.

In-vivo exposures are exposures where you are encountering something real and tangible. This could include holding an object, touching different objects or doing particular activities that challenge discomfort and anxiety resulting from OCD. An important part of recovery and healing from OCD are these exposures and being careful not to engage in compulsions during the activity. Due to the nature of outpatient therapy, sessions also may include planning exposures for homework that cannot be achieved in session. An example of this being to purposefully mess up compulsions relating to hygiene routine or going to a public restaurant and ordering a particular food. Everyone’s anxiety and OCD is different and thus every exposure hierarchy and treatment plan is going to look different.

My goal in writing this is to help lower worry surrounding this type of treatment. A therapist trained and specialized in OCD treatment would not approach any of this work unless you give consent and are feeling ready for each step on the hierarchy. Exposures are meant to be a little uncomfortable and anxiety provoking however very manageable and even fun.

I can say without a doubt that although every single exposure session I have led has been challenging for the client, it is always been approachable and we always find ways to laugh at the end. These sessions in my opinion end up being very fun! Often times we anticipate we won’t be able to handle the anxiety or discomfort that exposure sessions bring. I’ve never had a client express that an exposure we completed was too intense. At the end of the day, the exposures are meant to be approachable and achievable even if they are uncomfortable and intentionally anxiety inducing. I also have never had a client have an anxiety attack during an exposure session. This is simply not the goal of this work.

If you are considering finding a therapist who specializes in Exposure and Response Prevention, it might be helpful to ask the therapist ahead of time what their exposure sessions tend to look like. I’m a big believer that we can always find ways to make this work fun. It helps make this treatment easier to commit to and honestly as a therapist, much more enjoyable.

If you have questions about Exposure and Response Prevention therapy, please also consider checking out the IOCDF (International OCD Foundation) website. They are an incredible source of rich information on OCD and specific phobias as well as treatment options. They even have support groups available through their site!