Exposure and Response Prevention (ERP) Therapy: What It Is & How It Works
This podcast episode focuses on Exposure and Response Prevention (ERP) therapy and its effectiveness in treating anxiety in children. Host Tiffany Herlin interviews therapist Mark Rainsdon about how ERP works, including real-world application examples, the importance of parental involvement, and tips for finding qualified ERP therapists. The episode was created with parents in mind, offering insights and strategies to support a child struggling with anxiety. As a treatment approach used at WayPoint Academy, ERP is highlighted as an evidence-based method for helping students develop coping skills and build resilience.
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As a parent, watching your child’s life be ruled by their anxiety is so heartbreaking to see and can make you feel at a loss for how to help them. That is why we created this podcast. This episode focuses on Exposure and Response Prevention (ERP) therapy and why it is considered an effective treatment approach for anxiety. Host Tiffany Herlin, LCSW, interviews Mark Rainsdon, LCSW, about his experience helping teens with anxiety and using ERP therapy with them. They discuss the core principles of ERP, its application in real-world scenarios, and its benefits.
Here are some key points covered in this episode:
- Understanding ERP: The episode explains how gradual exposure and response prevention work to manage anxiety.
- Real-world Application: Mark shares examples of ERP techniques used with students at WayPoint Academy.
- Parental Involvement: The importance of parents in ERP, with strategies like script therapy to address their own fears.
- Finding Help: Tips on locating qualified ERP therapists and resources for parents.
This podcast episode was created with parents in mind, offering valuable insights and practical strategies for supporting a child with anxiety. At WayPoint Academy, we understand the complexities of anxiety and are dedicated to providing comprehensive care for kids who are struggling and their families. Our team of experienced therapists utilizes evidence-based approaches like ERP to help students develop coping skills and build resilience.
Want to Learn More?
This is the second episode in WayPoint's podcast series focused on ERP. Be sure to check out the other episodes in the series to explore more about how ERP supports teens in managing anxiety:
Ep. 3: How to Know If Your Teen Needs ERP Treatment for Anxiety or OCD
Introduction to ERP Therapy
Tiffany: Welcome back to our podcast! I’m Tiffany Herlin, a licensed clinical social worker, and today we’re joined by Mark Rainston, who’s also an LCSW. Mark works with Waypoint Academy, which we mentioned briefly in our last episode. Today, we’re diving into ERP—Exposure and Response Prevention Therapy—and why it’s so effective.
So, Mark, what exactly is ERP?
Mark: Great question and I’m really excited to talk about it! ERP is well-known in name but not always fully understood. A lot of people focus on the “exposure” part and miss the other crucial piece: response prevention.
Exposure tends to get all the attention. For example, if someone has anxiety or OCD—let’s say a fear of snakes—exposure is about gradually facing that fear. I always use the example of Indiana Jones.
Tiffany: Indiana Jones is the perfect example!
Mark: Right? I use that with students a lot. Living in Utah, I’m not a fan of snakes either. My students often ask, “How could you have been a wilderness therapist if you hate snakes?” Well, I went through some ERP myself to manage it.
Exposure can sometimes look dramatic, like throwing Indiana Jones into a pit of snakes—that’s a technique called flooding, where you face the fear head-on all at once. But at Waypoint, we usually take a gentler approach called systematic desensitization.
With systematic desensitization, you work your way up in steps. For example, someone with a fear of snakes might start by looking at pictures of snakes. Then, they’d go to the zoo and look at snakes from a distance. Next, they might enter the room where the snakes are, eventually touching one. The goal is to reduce the fear so it no longer disrupts daily life.
Tiffany: So, it’s about building tolerance gradually?
Mark: Exactly. For me, I don’t need to love snakes, but I do need to handle seeing one without panicking. If I’m camping with my family and see a snake, I don’t want to pack everything up and leave. ERP helps me manage that anxiety functionally.
But exposure is just one part. The other piece, response prevention, is just as critical.
Tiffany: What is that other part of ERP? Most people are familiar with the exposure part and think that’s all ERP is, but there’s another crucial element.
Mark: Exactly—and honestly, I’d argue it’s the most important part of ERP.
Going back to the snake example, exposure is about helping me not immediately jump in my car and drive away the moment I see a snake. That immediate reaction—my response to an anxiety-provoking situation—is what we’re addressing. Instead of letting that fear dictate my actions, ERP works to retrain the brain to respond differently.
I remember a specific experience that shaped my fear. I was camping with my dad once, and as we were driving, he suddenly slammed on the brakes of our old Ford truck. I asked, “What’s going on?” and he said, “There’s a snake!” My dad, being an old cowboy farm boy, backed up to try to hit the snake. It slithered off the road and got away, but that moment stuck with me.
After that, I couldn’t even set up a tent. I thought, “We’re camping in the back of the truck because snakes can’t climb in there, right? And Dad, let’s park by the creek so we can fish from the truck bed.” That was my response to fear.
Over the years, I’ve had to retrain my brain because I love the outdoors and didn’t want fear to limit me. Now, when I see or hear a snake, I’ve learned to slow things down. Instead of panicking, I assess the situation: “The snake is over there, so I’ll calmly walk this way.”
Identifying Core Fears in Therapy
Mark: It’s the same with our students. ERP isn’t just about exposures; there are steps we take beforehand. One of the first steps is identifying the core fear driving the anxiety.
Take someone with contamination OCD, for example. Their core fear might be death, throwing up, or getting a mysterious, incurable illness. For some, the fear is about being sick in public or feeling stuck with a debilitating condition. With ERP, we dig deep to understand what’s fueling the fear so we can address it effectively.
Tiffany: What’s the belief system behind ERP?
Mark: Right, it’s about understanding the belief system and what’s going on beneath the surface. To get there, you have to keep asking, “Then what?”
I tell my students, “We’re going to play the ‘Then What’ game,” and they usually roll their eyes like, “Not this again.” But here’s how it works. Let’s say someone has a fear of contamination. I’ll ask, “Okay, you touch the trash can. Then what?”
They might say, “Well, my hand gets sticky.”
“Then what?”
“Maybe I can’t get the stickiness off.”
“Then what?”
“Well, I might shake hands with someone I like, and they won’t want to be around me.”
“Then what?”
“Then I die alone.”
At that point, it’s no longer about touching trash cans. It’s about their deeper fear—dying alone or feeling unworthy of connection. So, when we do ERP, we’re not just working on touching trash cans; we’re addressing the core fear.
If you skip that step, you’re just playing a game of whack-a-mole. Maybe they can touch trash cans now, but then they develop a fear of eating lollipops, or something else replaces it. You need to target the root issue to make real progress.
When we start ERP, we build a hierarchy—a list of about 10 tasks ranging from things they can do with some discomfort to things they feel they absolutely can’t do.
Tiffany: Got it.
Mark: This is where systematic desensitization comes in. You work through the list gradually and repeatedly. It’s not, “Great, you touched the trash can. Next!” You want them to keep practicing until their anxiety around that task drops by about 50%.
We measure this using a scale called Subjective Units of Distress (SUDs), which runs from 0 to 10. A 0 means they’re calm, and a 10 means their anxiety is so high they can’t function. If they start touching the trash can at an 8, we aim for a 4 before moving on.
Even then, if they reach a 4 quickly, I’d have them repeat the task. The next time, they might start at a 7 instead of an 8, but if you skip ahead too soon, their anxiety could spike back to a 10.
One major misconception about ERP is that you force people to do things they don’t want to do. If you’re a clinician doing that, please stop. That’s not what ERP is about.
Tiffany: Why shouldn’t you make them do things they don’t want to do?
Mark: Because it can cause trauma. Forcing them into something they’re not ready for can break their trust in you, in therapy, and in the process itself. They might start thinking therapy is just about causing pain. Instead, you find that “Goldilocks” zone—the point where they think, “I don’t want to do this, but I’m willing to because I know it will help me move forward.”
That’s where you begin. You gradually work toward what they currently can’t do. And here’s the cool part: if they’re not ready to tackle it right now, that’s okay. It opens the door to some great conversations. You can have sessions focused on identifying the mental barriers—“What thoughts are holding you back from doing this exposure?”—and use tools like talk therapy or CBT to help them work through those barriers. Then you ask, “Are you ready now?” When they are, that’s when they feel that sense of accomplishment.
Early exposures in ERP can feel slow, especially with response prevention. But once they experience success—however success is defined in ERP—they often start to build confidence. I’ve seen it happen many times.
Success Stories in ERP
Mark: For example, I worked with a student near the end of his treatment. He’d been with us for almost a year and had significant social anxiety. One of his exposures was writing on a large poster board something like, “I have anxiety. Ask me about it,” or “I have crippling anxiety. This is hard for me.” Then he stood holding the sign in a student union building at a local university.
Tiffany: That’s amazing.
Mark: It was! At first, he was nervous and hesitant, but over time, his anxiety level—his SUDs—dropped from an 8 to a 4. Toward the end of the exercise, something incredible happened. A grandmother and her grandson approached him.
Now, I try to give students space during ERP exercises so it doesn’t feel like, “That guy’s making me do this.” So I was sitting about 20 yards away, working on my computer. I noticed them talking to him but didn’t think much of it at first. Then I looked up again a few minutes later, and they were still there. I figured I should check it out.
When I walked over, the grandmother looked at me and asked, “Are you the one making this young man do this?” I thought, “Uh oh, this isn’t going to go well.” But then she said, “I am so impressed with him for doing this and good for you for helping him.”
She pointed to her grandson and added, “He has crippling anxiety, and seeing your student doing this has inspired him.”
Tiffany: Oh, I love that.
Mark: Yeah, it was amazing. She told me, “He doesn’t know if he’ll ever be able to do something like this, but he wants to try someday.” It was so cool to witness.
Tiffany: That is cool.
Mark: The reason I bring this up is because, for that student, it was a huge success—a resounding success. I remember driving back with him afterward, and he said, “That was hard, but it was also really cool.”
Fast forward to the next Monday. In our program, we take the students skiing every weekend during the winter. Afterward, we usually check in during sessions, and I’ll start by asking, “What do you want to talk about today?”
This time, he says, “Can I tell you what I did over the weekend?” I said, “Sure, what’s up?” And he says, “I went up to Powder Mountain—the ski hill we go to—and I brought the signs with me. I held them there for about 20 minutes.”
I was floored. I said, “Really? I didn’t tell you to do that.” And he goes, “Yeah, I just thought it’d be a good idea.”
We ended up talking about it, and I pointed out, “Do you see the benefit of this?” That’s the next thing I want to highlight: the importance of doing exposures. It’s not always about a therapist assigning it. It’s about taking ownership and using exposure work to manage OCD as part of your life.
Because OCD is insidious. If you don’t stay on top of it, it will creep back in and can destroy your progress. But if you continue doing exposure work and response prevention on your own, it becomes a very manageable condition.
Tiffany: Isn’t that the magical moment in therapy—when a client takes what you’ve talked about in session and applies it on their own? There’s so much research on that.
The Role of Therapy Outside the Office
Tiffany: I can’t remember the exact statistic, but I know a lot of change happens outside the office. We don’t want clients to keep coming back to us forever. We want them to take what they’ve learned, create real change, and move forward.
Mark: Absolutely. The way I describe it—because I love using analogies and stories to explain things—is that therapy is like a NASCAR race.
Think about it: how long are the drivers in the pit? Just a second or two. But how crucial is that moment? They change the tires, wash the windshield, get some water, and pick up a bit of data about the track. Those seconds are critical. But the race itself? That’s 99% outside of the pits.
It’s the same with therapy.
Tiffany: I love that analogy.
Mark: Thanks. If someone comes into therapy thinking their one or two hours a week will completely fix things, I’d have to say, “I’ve got some lakeside property in Texas to sell you.” It doesn’t work that way.
Therapy is about learning skills, gaining new perspectives, and picking up tools. The real work happens outside the therapy office when you apply those things. That’s especially true with OCD treatment and exposure response prevention (ERP).
If you can keep up with ERP on your own—coming up with exposure ideas and doing them—you’ve got OCD’s number.
Tiffany: Yeah.
Mark: Sure, OCD might creep back in here and there, but you’ll be able to manage it well.
Tiffany: Wouldn’t you say that at that point, clients are helping rewire their brains? They’re forming new neural pathways, creating new patterns of behavior, and building better habits.
Mark: Well, yeah. Let’s talk about why ERP is so effective.
Tiffany: Yeah. Why is it?
Mark: When we talk about ERP, anyone who knows about OCD will tell you, "ERP is the gold standard treatment." And there’s a reason for that—it helps you learn and retrain your brain.
In our last episode, we talked about how anxiety is tied to how you appraise and interpret threats. ERP works by retraining your brain to appraise threats differently.
Let me give you an example. Anytime someone mentions appraisal, I think of Antiques Roadshow on PBS—or Pawn Stars for the younger crowd. Someone brings in an old item, like an iPhone 1, and says, "I think this is worth $15,000." The appraiser looks it over and says, "Well, there’s a scratch here, and it’s outdated tech, so it’s probably only worth about $500."
That’s what ERP is doing for your brain. It’s retraining it to assess fears and threats more realistically.
Take a fear like "I’m not good enough" or "God thinks I’m a sinner, and I’m going to hell." ERP helps you shift that thinking to something more balanced, like "Yeah, I make mistakes. I am a sinner. But that doesn’t mean I’m worthless or that I’m doomed."
Tiffany: Right.
Mark: Let’s look at another example. Imagine you’re constantly worried you have body odor. That fear drives compulsive behaviors—checking, rechecking, and repeatedly asking others for reassurance.
Real-Life ERP Examples and Techniques
Mark: The exposure, in this case, would be not putting on deodorant. And one thing I’ll say about exposure therapy is that we, as therapists, sometimes ask people to do things that make them think, "What in the world are you talking about?"
For example, I gave a presentation to one of our sister companies last week, and I shared an exposure we did with a student who had a fear of their toothbrush becoming contaminated in the bathroom. They were afraid that flushing the toilet would release particles into the air that might land on their toothbrush.
Tiffany: That’s a pretty specific fear!
Mark: Yeah, so we started small. First, we had them leave the toothbrush in the bathroom—something most people do. Then we had them hold it about a foot above the toilet while flushing. Later, they held it six inches above the toilet, and eventually, we had them put the toothbrush in their mouth after flushing.
Tiffany: Wow. Was the next step dipping it in the toilet?
Mark: That’s exactly where some therapists go, especially those involved with the International OCD Foundation. It’s part of a process called overcorrection. The idea is to help the person realize, "I dipped my toothbrush in the toilet. That was gross, but I didn’t die."
Tiffany: It’s a way to retrain their brain.
Mark: Exactly. After doing these exposures, having the toothbrush in the bathroom or on the counter doesn’t seem threatening anymore.
Tiffany: Makes sense.
Mark: This is one of the first things we explain to parents and patients: "We’re going to ask you to do things that make you very uncomfortable, but the goal is to retrain your brain to see that this discomfort isn’t a real threat."
Tiffany: It’s about breaking that perception of catastrophic harm.
Mark: Exactly. Dipping a toothbrush in the toilet might seem extreme, but the person realizes, "Okay, maybe I got sick, but it’s not the end of the world." That reframes their threat appraisal and helps them move past the fear.
Tiffany: That’s such an important shift.
Mark: You could argue that dipping the toothbrush in the toilet might make you sick—maybe even get diarrhea. But imagine someone terrified of having their toothbrush in the bathroom dipping it in the toilet and then experiencing that. It helps them to process their fear. Afterward, you ask, "When’s the next time you’re going to dip your toothbrush in the toilet?"
Tiffany: Probably never.
Mark: Exactly. Then you ask, "So you got diarrhea, but what would happen if it’s just on the countertop in the bathroom?" It helps them realize that fear is overblown and not likely to lead to anything bad.
Tiffany: I can see how that would help shift their perspective.
Mark: Right, but there’s an important piece here: you don’t want to reassure them. Reassurance is tempting because it’s human nature to want to comfort someone, but exposure therapy reinforces the idea that the situation is dangerous when it's not.
Tiffany: So it’s like an instinct to try and make them feel better?
Mark: Yes, exactly. I’ve had moments where I wanted to reassure a student—like when I saw someone at a university holding up a sign in an anxiety-provoking situation. I could see them getting tense and upset, and it took everything in me not to say, "It’s okay, they’re just jerks." But I had to resist.
Tiffany: Is this about calming the nervous system so it’s not on high alert?
Mark: Yes, that’s exactly it. Exposure therapy is about retraining the nervous system. You’re teaching it to lower its alert level. So, instead of the heightened reaction to a seemingly small threat, you help the person recognize that it’s not as dangerous as their brain thinks it is.
Tiffany: It’s about reprogramming the body’s response.
Mark: Right. And that’s where response prevention comes in—not just avoiding the compulsion but teaching the person how to respond differently. Dr. Pollard, a well-known ERP therapist, once said, "It’s not just about what not to do. It’s about what you can do." Instead of avoiding the toothbrush, you keep it in your mouth, but you practice coping skills, like diaphragmatic breathing or guided meditation, to help lower that anxiety by 50%.
Tiffany: That’s interesting. Would you use ERP with someone who has anxiety and PTSD (post-traumatic stress disorder)?
Mark: That’s where it gets tricky.
Tiffany: Yeah.
Mark: If exposure therapy is likely to re-trigger their PTSD, it’s better to address the PTSD first, possibly with EMDR or brain spotting.
Tiffany: Right, those methods also help rewire the brain.
Mark: Exactly. And this is where it gets complicated—sometimes treating PTSD helps with OCD, and sometimes treating OCD can improve PTSD. It’s not always clear-cut. But when you’re dealing with comorbid disorders, especially PTSD, you have to be cautious because improper exposure to work could potentially cause more trauma.
Tiffany: That makes sense.
Mark: That’s why I always recommend that anyone doing ERP get proper training first. Without the right training, you could unintentionally cause more harm than good. It’s not to scare people away from ERP, but it’s crucial to know what you’re doing.
Tiffany: Yeah, it’s the same with any therapeutic modality—we need to ensure we have the client’s best interests at heart. That’s why therapists go through rigorous training for years before being licensed, and then continue their education to stay on top of best practices, making sure we’re not causing harm.
The Role of Supervision and Support in Therapy
Mark: Yeah, you raise a good point about having people around you for support when you're just starting as a therapist. I attended the ICOF conference a couple of weeks ago, and one of the things that came up in almost every breakout session was the importance of being part of a consultation team. OCD is such an insidious mental health condition, and I've found myself in situations where I just think, “What the heck do I do now?”
Tiffany: Yeah, it can be overwhelming.
Mark: It is. It’s debilitating a lot of the time. So having a team of five other clinicians where you can tap out and say, “Help me out here,” is invaluable.
Tiffany: I’ve had those moments as a therapist too, where I feel like this is bigger than I can handle on my own. I need that support.
Mark: Exactly, and it helps you challenge yourself and think outside the box. At Waypoint, many of the students struggle with OCD around scrupulosity.
Tiffany: Remind our listeners, what is scrupulosity?
Mark: Sure. Scrupulosity is the fear of judgment—whether from others or God. It’s the “Am I good enough?” anxiety. I’ve developed my go-to exposures over time, but having a team to bounce ideas off of is so helpful. I might think I’m ready to do something with a student, and then my colleagues ask, “But Mark, should you do it that way?” It makes me think, and sometimes they come up with alternatives I hadn’t even considered.
Tiffany: That’s a great point—having others to challenge your approach is beneficial.
Mark: It is. And that same principle applies to parents. When I’m working with parents before a student goes on a home visit, for example, and I suggest an exposure, their eyes often go wide, and they’re like, “You want me to do what?” But then I remind them, “Yeah, I asked you to do this six months ago. It was tough, but it worked.” It’s encouraging for them to hear that from someone who’s been through it.
Tiffany: Absolutely, having a supportive network makes all the difference.
Mark: Exactly. And I’ve had parents tell me, “I found a Facebook group, or a Discord server about this issue,” and just seeing the difference it makes when they’re able to connect with people who’ve been there. It’s so powerful to have others say, “I’ve been through this—let’s keep going.”
Tiffany: I have a group of friends, and we’re always talking about the things our kids are dealing with. It’s so important to have that support, and we’ll talk more about that in the next episode.
Mark: Absolutely. Now, let’s talk about how effective ERP is.
Tiffany: How effective is it?
Mark: It’s extremely effective. OCD is such an insidious disorder, but when treated properly, it’s also incredibly treatable.
Tiffany: That’s interesting!
Mark: Yeah, because OCD can take over your whole life if it’s left untreated. You end up stuck in cycles like constant hand washing, checking things over and over, or worrying that you’ve left the stove on. But the good news is, it’s very treatable. When you look at the research on ERP, it’s through the roof in terms of effectiveness compared to other treatments.
Tiffany: Wow, that’s impressive.
Mark: It is. The key with ERP is that it’s action-based—it’s not just talking about it. Talk therapy is great, don’t get me wrong, I use CBT myself, but ERP is different. For example, I’ll take a kid, load them into a van, drive them to town, and say, “Okay, here’s what you’re going to do now.”
Tiffany: That’s what we need more of in therapy, right? More action, less just talking.
Mark: Exactly. Therapy needs more of that active practice. ERP is a very in-your-face way of practicing real-life situations. And in my experience, if someone’s struggling with OCD and ERP isn’t showing immediate results, that doesn’t mean the therapy isn’t working. It could just mean that they need to take a different path.
Tiffany: That makes sense. So what does the process look like?
Mark: In my practice, once kids start doing ERP and get through a couple of exposures—maybe three, four, or five—they start to build confidence. That’s when the neural pathways begin to shift. Instead of thinking, “I can’t do this,” they start to believe, “I can,” and they feel empowered in their lives.
Tiffany: I can just imagine those new neural pathways forming as they gain that confidence like they’re building up the ego strength they were lacking before.
Mark: Exactly. It’s all about rewiring those pathways and empowering them to take control of their lives.
Barriers to the Adoption of ERP
Tiffany: So, if ERP is so effective, why aren’t more people using it?
Mark: That’s a great question. I have a few ideas. The training I did was through something called BTTI—I always forget what it stands for, but I think it’s the Behavioral Teaching Technical Institute or something like that. It’s run by the International OCD Foundation (IOCDF), and right now there’s a two-year waitlist to get into their program. I just hired a couple of new therapists, and the first thing I had them do was sign up for it because it’s that important. I’ve been to a lot of trainings, but that was the one where I left with more questions than answers, thinking, “How am I going to apply all this?”
Tiffany: Wow, that sounds intense.
Mark: It is, but in a good way. It’s one of the best trainings I’ve been to. But I also think the fear factor plays a role in why more therapists don’t use ERP. I mean, in grad school, we’re taught to decrease the client’s anxiety, right? ERP is the exact opposite of that—it’s about increasing anxiety to help them face it.
Tiffany: That’s uncomfortable.
Mark: Exactly. It goes completely against everything we’re taught in school about managing comfort for the client. So, I think some therapists shy away from it because it feels counterintuitive. Instead, they might stick with CBT, focusing on cognitive distortions and teaching clients better-coping strategies.
Tiffany: I was just thinking that. It’s probably a big part of the reason people don’t know enough about ERP in the first place.
Mark: Exactly. Before I started working at Waypoint, I had no real exposure to ERP or OCD treatment either. It's just something a lot of clinicians aren't familiar with, and so they don't use it.
I remember talking to someone about my journey before coming to Waypoint. There was one student I worked with—without getting too graphic, he had a behavior that was pretty far outside the norm. I had no idea what was going on. I was probably about three years into my practice, so I didn’t have much to go off of. At the time, I was working with kids on the spectrum, and I thought it might be a sensory issue. So, I referred him to an occupational therapist and had him try different things.
Looking back now, with my ERP training, I can see that behavior was a compulsion. It was rooted in a fear of contamination and being dirty. And I think, "If I could just rewind..." I could’ve said, “Okay, here's what we’re going to do.” But honestly, they don’t teach you this stuff in grad school.
Mark: They don’t have enough time to teach you about it.
Tiffany: Yeah, and honestly, I don’t think most clinicians are trained or even aware of it. I remember just a couple of years ago, a friend came to me and said, “I’m struggling with OCD. Can you recommend a therapist who does ERP?” And I had to admit, I didn’t even know what ERP was. I felt a little embarrassed, but I told her I’d do some research. It highlighted how important it is for us as clinicians to be more exposed to this treatment, and to understand that ERP is such an effective technique.
Mark: Exactly. And I’ll say this—if you're a therapist or even a parent—I'll tell you one thing about the OCD community: it’s unique. I went to the OCD Foundation's conference a few weeks ago, and unlike many conferences where it's just clinicians walking around with name tags like "LCSW, LMFT," the OCD conference is for everyone. They’ve got breakouts for families, for individuals with OCD, and even for kids.
I remember the first time I went to this conference in Austin back in 2018. I didn’t quite grasp what it was all about until I saw this kid in the elevator, holding the same tote bag I had. He says, “Mom, I’m going to the trichotillomania breakout.” And I thought, “Oh no, please tell me you’re not spending your summer vacation at a conference for OCD.” But that’s the kind of community it is—because they understand how all-encompassing OCD can be.
Understanding Family Dynamics in OCD Treatment
Mark: The idea is that we need to make sure the parents, family members, and even siblings understand what’s going on. There are times when I do joint sessions with siblings, and they’ll say things like, “My brother’s just a pain in the butt.” And I’ll ask, “Can we talk about what’s going on inside his head? He’s not just being difficult—he’s trying to survive.” The sibling’s response is often, “Oh my gosh, I didn’t know that. That’s crazy.”
So, if you’re a clinician or a parent, there are great resources available. The International OCD Foundation (IOCDF) has a directory where you can find clinicians who specialize in ERP. If you’re a clinician, you can use the directory to find trained professionals in your area who can offer this specific support for clients with OCD.
For me, the biggest difference with ERP is that it’s not just office-based therapy.
Tiffany: Okay.
Mark: Right. In ERP, we don’t stay in the office. We go out into the field. For example, at Waypoint, we’re located in Northern Utah, so we take the students to places like Ogden, the mall, restaurants, and even waste management plants. ERP is something you do in real-world situations, not just in an office.
One thing I didn’t mention when talking about exposure work is script therapy. This is something I love to do with parents, especially. It’s considered best practice to have parents engage in exposure work alongside their kids. Here’s how it works: I have parents write down their feared outcomes and create a "Hollywood-style" script that includes everything they’re afraid of. They then record the script on their phone and listen to it two or three times a day. This is especially helpful because parents often engage in accommodation behaviors due to their fears.
Tiffany: Oh, that’s right.
Mark: Exactly. Parents can inadvertently accommodate their child’s OCD out of fear, so this script therapy helps them confront those fears and break the cycle.
Addressing Parental Fears in ERP
Tiffany: Yeah.
Mark: A lot of times, the fear parents have is that their child will leave them—either run away or stop talking to them. When I talk to these parents, they often say, "I know that’s not true. I know my child loves me." But when we do exposure work, they start to realize their child will stick around. So, I have the parents write a script where their child gets angry at them because they’re doing exposure work, and they imagine their child cutting them off forever. When we talk about ERP, it’s about facing these fears. In ERP, we help the client and their family understand that yes, the possibility of something happening—like touching a trash can and getting contaminated—is real. But so is the fear of setting a boundary with their child and them rejecting them. The idea is to face these possibilities head-on so they can become more accustomed to them. They start to realize that even if something does happen, they still have to hold that boundary with their child.
Tiffany: It may seem like the risk or the possibility is low, right?
Mark: Exactly. And that’s something I bring up when I’m working with parents. Sometimes, people might think I’m being too harsh, but I’m going to be honest with them. For example, when a child goes on a leave of absence or a home visit, I’ll give the parents a heads-up a couple of weeks in advance. I’ll let them know, “I’m going to have your kid do something you won’t like, but you need to set a boundary.” Before the visit, I’ll talk to the kid and ask, “What can we do to make your parents’ life difficult?” The kids often say things like, “I’ll sleep in until noon. That’d be awesome.” So, I’ll say, “Okay, sleep in until noon on Tuesday. When your parents come in, just keep lying in bed and see what happens.”
Eventually, the parents will need to give some kind of consequence, like saying, "You can’t go to your friend's house because you didn’t wake up on time. You need to do schoolwork." Then, I tell the kids, “I want you to argue with them, like, ‘That’s so unfair! I had to wake up early at Waypoint. Can’t I just sleep in this one time?’” And we’ll see if the parents stick to the boundary. After an hour or so, the kid can text me to say, “Hey, I slept in. Is that okay?” And I’ll reply, “Yeah, it’s fine. I gave you the heads-up. Let’s have a family session later to process what happened.”
Tiffany: That’s awesome.
Mark: The cool part is that after this exposure, I’ll get messages from the kids saying, “Mom, Dad, thank you so much for sticking to that boundary.” It’s powerful to see how well the parents can handle that challenge, and it helps both the kids and parents grow.
The Importance of Structure for Anxious Teens
Mark: The kids are often amazed when they realize that holding boundaries helps them. They’ll say, “I need this to be successful when I get home.” Parents are often shocked. They’re like, “Wait, you want me to wake up and follow through with this?”
Tiffany: Those moments are my favorite too—when the kid says, “Please, Mom and Dad, hold that boundary. I need it.”
Mark: It’s surprising how often that happens, right?
Tiffany: Yes.
Mark: We tend to think the kid wants us to back off, not hold boundaries, or just give them everything they want.
Tiffany: Yeah, they do want everything, but there’s a part of them that also craves structure.
Mark: Exactly. They want to know what to expect. It’s a need for safety.
Tiffany: And it feels safe when they have structure and boundaries.
Mark: For kids dealing with anxiety, that’s exactly what they’re searching for. If you can provide boundaries and clear expectations, it helps them feel safer. It can also support the ERP work and other therapeutic work we’re doing.
Tiffany: That makes a lot of sense. Finally, how can parents know if their teen needs ERP?
Mark: That’s a great question. While ERP is often used for OCD, it’s also very effective for treating anxiety.
Tiffany: So, any kind of anxiety?
Mark: Yes, exactly. ERP helps reprogram the way teens perceive and handle anxiety. If you have a teen struggling with anxiety, especially after hearing about the different types in our last episode, finding an ERP therapist in your area could be a great next step. ERP therapists are also trained in Cognitive Behavioral Therapy (CBT), so they can address anxiety from multiple angles.
Integrating ERP with Other Therapeutic Approaches
Mark: This helps them decide whether they need more exposure response prevention (ERP) or if they should focus more on talk therapy and teaching coping skills.
Tiffany: Thank you for explaining ERP and when parents should consider it.
Mark: My pleasure!
Tiffany: In our next podcast, we'll dive into treatment and care—what it looks like, how to find ERP therapy, and how to know when it's time for more intensive treatment. We’ll also share success stories. Stay tuned!
Mark: Looking forward to it!
Tiffany: Thank you.