Cognitive Behavioral Therapy: Prolonged Exposure and ERP

Any major prolonged exposure work is best done with a therapist. However, there are elements of exposure therapy that can be used on your own for less serious challenges related to anxiety- provoking stimuli. 

Prolonged exposure is a very effective, evidence-based therapeutic intervention that aims to promote emotional processing by activating the brain’s fear centre (the amygdala) while simultaneously integrating new information that’s inconsistent with the fear. Exposure can be imaginal (mentally imagining an anxiety-provoking situation) or in vivo (actually going into the situation). 

What’s key with prolonged exposure is continuing it until the initial physiological fight-or-flight response naturally starts to ebb. This is usually around 45 minutes. Leaving the situation before your body starts to calm itself down may just perpetuate the anxiety. 

Before beginning exposure work, you’ll develop a hierarchy of anxiety-provoking stimuli, rating them from lowest to highest intensity of associated anxiety/distress. You’ll also need to identify any safety behaviours you would normally use in these situations, and then you’d have to avoid using those during the exposure. 

Exposure begins with the least anxiety-provoking situation from the hierarchy, and then you gradually work your way up. Self-help exposure work might be manageable for issues where even the highest item on the fear hierarchy isn’t intensely distressing. However, exposure for more severe problems should definitely be done with the support of a therapist. 

There’s more on exposure in this section of a group therapy manual from the University of Michigan: Desensitization.pdf 

Exposure and Response Prevention 

A variation on prolonged exposure that’s used in OCD is exposure and response prevention (ERP). This involves exposure to a triggering stimulus without performing the compulsive behaviour, and it’s a good idea to have the support of a therapist with this. 

OCD involves a vicious cycle of obsessive thoughts => anxiety => compulsion => temporary relief => reinforces that obsessive thought is actually harmful 

ERP disrupts this cycle by breaking the feedback loop of compulsions reinforcing obsessions. This also teaches the brain that the feared stimuli aren’t actually as dangerous as they’re perceived to be. 

Workbooks are available from: 

• CRUfAD: 

• NHS inform: health-self-help-guides/obsessive-compulsive-disorder-ocd-self-help-guide


Pritam Chakraborty

As I was moving through life, I occasionally saw brief glimpses of beauty.

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