Is ERP Scary? What to Expect in Your First Few ERP Therapy Sessions
Starting ERP therapy can feel intimidating, especially if you have spent a long time trying to avoid the thoughts, situations, or feelings that make you anxious. You might be wondering what your therapist will ask you to do, whether you will be pushed into your worst fears right away, or how you are supposed to handle the anxiety that comes with exposure.
ERP stands for Exposure and Response Prevention. It is an evidence-based treatment for obsessive-compulsive disorder (OCD) that involves gradually approaching situations, thoughts, feelings, or uncertainties that trigger anxiety while learning to resist compulsions and other behaviours you use to feel certain or safe. ERP can also be adapted for other anxiety-related difficulties when exposure is an appropriate part of treatment.
If you are considering ERP, understanding what happens in the first few sessions can make getting started feel a little less overwhelming.
Your First ERP Session: Understanding Your OCD and Anxiety
Your first session is generally focused on getting to know you and understanding what has been bringing you to therapy. Your therapist will ask about the thoughts, fears, or situations that cause distress, how you respond to them, and how anxiety or OCD is affecting your daily life.
If you are seeking treatment for OCD, this may involve discussing intrusive thoughts, images, urges, or doubts, along with the compulsions you perform in response. Compulsions are not always visible behaviours. They can also include mentally reviewing conversations, checking how you feel, trying to prove a thought wrong, repeating phrases in your head, or asking other people for reassurance.
You do not need to have everything figured out before your first appointment. You may not know whether something you do is a compulsion, or you may have difficulty explaining exactly what makes you anxious. That is part of what therapy is for.
Your therapist will also want to understand what you have been avoiding, what you have tried in the past, and what you would like to be able to do differently. Perhaps OCD is taking up hours of your day, anxiety is keeping you from social situations, or you are exhausted from constantly trying to make sure nothing goes wrong.
The goal is to understand the patterns keeping you stuck and begin identifying what you want treatment to help you change.
Your Second Session: Understanding the Anxiety Cycle
Once you and your therapist have a clearer picture of what you are experiencing, you will begin looking at how your anxiety or OCD works.
A common pattern involves experiencing a distressing thought, feeling, sensation, or uncertainty, interpreting it as something that needs to be resolved, and then doing something to reduce the discomfort.
For example, someone might have an unwanted intrusive thought, become anxious about what it means, and repeatedly analyse why it appeared. The mental reviewing might provide temporary relief, but the next intrusive thought brings the same doubt back.
Someone else might worry about making a mistake and repeatedly check their work until it feels right. Although checking can reduce anxiety in the moment, it can reinforce the belief that checking is necessary to prevent something bad from happening.
Your therapist will help you identify these patterns, including the less obvious ways you might be responding to anxiety. You will also discuss what response prevention could look like in your everyday life.
This does not mean you are doing something wrong by trying to feel better. These behaviours often develop because they seem to help. The difficulty is that relying on them can make it harder to learn that you can experience uncertainty or discomfort without needing to resolve it.
When Do Exposures Start?
You may begin discussing or practising exposures within the first few sessions, depending on your needs and treatment goals. You and your therapist will work together to identify situations, thoughts, or feelings that trigger anxiety and the responses you want to change.
An exposure involves intentionally approaching something that triggers anxiety or uncertainty rather than automatically avoiding it. Response prevention means resisting the compulsions or anxiety-driven behaviours you would normally use to feel better or gain certainty.
For example, someone with OCD might practise sending an email without repeatedly rereading it, while someone experiencing social anxiety might start a conversation without rehearsing every sentence beforehand.
Building an Exposure Hierarchy: How Do You Know Where to Start?
Initially, you and your therapist will explore your anxiety patterns and identify areas where you would like to make changes. From there, you will typically work toward building an exposure hierarchy: a structured list of exercises organized by how challenging they are likely to feel. You might rate each situation on a scale from 0 to 10 or 0 to 100 to help determine where to begin.
For example, someone who repeatedly checks their work might start by sending a low-stakes email after checking it once, then gradually work toward situations that make resisting the urge to check more challenging. Someone with social anxiety might begin by asking a simple question before working toward more difficult social situations.
Your hierarchy provides a roadmap for treatment, helping you and your therapist choose exercises that align with your goals. However, it is a guide rather than a rigid set of steps. You will not necessarily work through every exposure in order, and you do not always need to start with the easiest one.
ERP is not about being thrown into your worst fear without preparation. It is about gradually practising a different response to anxiety and uncertainty, with support from your therapist. The goal is not to wait until you feel completely ready, but to build your ability to approach difficult situations without relying on the behaviours that keep anxiety going.
Will My Anxiety Get Worse During ERP?
It is normal to feel nervous about deliberately approaching something that makes you anxious. You might worry that the anxiety will be unbearable, that you will lose control, or that you will not be able to resist a compulsion.
During exposure, anxiety may increase. You may feel uncomfortable, uncertain, or tempted to return to the behaviours that usually help you feel better. Sometimes the discomfort is less intense than expected; other times, it can be challenging.
The goal of ERP is not to guarantee that your anxiety disappears during every exercise. It is to help you learn that you can make room for discomfort and uncertainty without relying on compulsions or avoidance.
You are not expected to do everything perfectly. Your therapist will help you reflect on what happened, identify what you learned, and adjust future exercises as needed.
What Happens Between ERP Sessions?
ERP does not only happen in the therapy room. Practising between sessions is often an important part of treatment.
Your therapist may help you develop exercises to practise during the week. These are designed around your treatment goals and the patterns you are working to change.
For example, you might practise leaving a small uncertainty unresolved, resisting the urge to check something repeatedly, or allowing an uncomfortable thought to pass without trying to analyse it.
You will discuss what you noticed, what felt difficult, and what you learned when you meet again. If an exercise was particularly challenging, you and your therapist can work together to understand why and decide how to approach it next time.
The aim is not to complete every exercise perfectly. It is to build opportunities to respond differently to anxiety in your everyday life.
How Long Does ERP Take to Work?
There is no single timeline for ERP. Treatment length depends on your symptoms, the impact OCD or anxiety has on your life, your treatment goals, and how frequently you are able to practise between sessions.
Some people begin noticing changes in how they respond to anxiety relatively early in treatment. For others, progress takes longer, particularly when symptoms are complex or there are several patterns to address.
Progress does not always mean experiencing less anxiety. You might notice that you spend less time analysing intrusive thoughts, that you can leave a question unanswered, or that you are doing things you previously avoided even when anxiety is present.
Over time, these changes can create more room for the parts of life that matter to you.
Starting ERP Therapy at Ascend Anxiety Clinic
If you are considering ERP for OCD or anxiety, you do not need to know exactly what treatment should look like before you begin.
At Ascend Anxiety Clinic, we provide specialized anxiety and OCD therapy in Burlington, Ontario, and virtually across Ontario. Treatment is tailored to your individual experiences and goals, with an emphasis on helping you change the patterns that keep anxiety going.
We offer free consultations so you can ask questions, learn more about our approach, and decide whether working together feels like a good fit.
You can learn more about our services or book a free consultation through Ascend Anxiety Clinic.