ERP is the first step for OCD, and medication facilitates it rather than replacing it. It works by tolerating uncertainty and distress, not by calming down, reframing or distracting, which can quietly become new compulsions. Build a ranked trigger list, prolong the gap before each compulsion, and tell patients the goal is to stop treating thoughts as threats, not to make the thoughts go away.
When we reach for it
ERP is the first step in the OCD algorithm. Medications come in when symptoms are severe or the patient is unwilling to do therapy.
“the first step of my algorithm is always that exposure response prevention is first step and med equations should be used if the symptoms are severe or the patient is unwilling to do therapy”
12:00Practical OCD Psychopharmacology: Evidence‑Based (& Non Evidence-Based) Medication ApproachAug 2025 Also said in 1 more episode
“ERP is first line and ERP is exposure response prevention. And the mechanism, as you were saying earlier, is tolerating uncertainty. And ERP is one of those things that gets thrown out a lot”
36:56What Is OCD? How to Understand It, Recognize It, and Treat ItJul 2025 Do not mistake the medication for the treatment. Medication reduces symptoms and facilitates treatment; the primary treatment for OCD is psychological and behavioral.
“Don't mistake the medication for the treatment. The medication facilitates the treatment. It reduces the symptoms. The primary treatment is psychological behavioral for OCD as far as we know it”
11:30Practical OCD Psychopharmacology: Evidence‑Based (& Non Evidence-Based) Medication ApproachAug 2025
How it works
The mechanism is tolerating uncertainty. OCD is not a thinking problem: the issue is not what the person thinks but how the brain responds to the thoughts, which is why ERP differs from CBT.
“ERP differs from CBT because OCD is not a thinking problem because the issue isn't what the person's thinking. The issue is how the brain is responding to the thoughts”
40:26What Is OCD? How to Understand It, Recognize It, and Treat ItJul 2025 List the triggers and rank them from least to most distressing, rating each 0 to 100 on subjective units of distress (SUDS).
“you get all the different triggers and you rank them from least to the most anxiety provoking. There's something called the SUDS, which is acronym for subjective unit of distress. So for each trigger, you go from zero to 100 to how distressing that trigger is”
44:32What Is OCD? How to Understand It, Recognize It, and Treat ItJul 2025 Target what matters most now: ask what they spend the most time on or what causes the most problems, whether hand washing, checking that family is not dead, or thoughts of jumping in front of a train.
“I say, what do you think you spend the most time on? Or what's causing the most problems right now in your life? Is it hand washing? Is it the checking in on your family not being dead? Is it your thoughts of jumping in front of a train”
47:19What Is OCD? How to Understand It, Recognize It, and Treat ItJul 2025 Patients should not enjoy ERP. It is slow, deliberate exposure to distress, and breathing techniques and calming skills do not treat the OCD.
“Patients should not enjoy ERP because it involves slow and deliberate exposure to the distress and tolerating and accepting discomfort. And what we're saying is... coping or calming skills don't treat the OCD like breathing techniques”
38:45What Is OCD? How to Understand It, Recognize It, and Treat ItJul 2025 During exposures, coach them to be curious about the anxiety and watch it. ERP is distress tolerance, not distraction and not calming yourself.
“try to be curious about the anxiety, try to watch the anxiety. And again, reinforcing that ERP is distress tolerance and it's not distraction. It's not calming yourself. It's tolerating the distress”
46:21What Is OCD? How to Understand It, Recognize It, and Treat ItJul 2025 For a highly motivated subset without access to formal ERP, explain ERP in the medication visit and give them workbooks.
“workbooks do work for highly motivated and particular subset of OCD patients. And I also think... For that subset of patients that I identify, I do walk through and explain ERP and then give them the workbooks”
43:10What Is OCD? How to Understand It, Recognize It, and Treat ItJul 2025
Talking to patients
ERP does not remove the thoughts or feelings. Teach patients not to do it hoping to be cured or to stop having the thoughts.
“the motivation is not to stop or remove the intrusive thoughts or the feelings. ERP doesn't remove the thoughts or the feelings. So I teach patients they shouldn't be doing it with the hope that they'll be cured or that they'll stop having the thoughts”
49:07What Is OCD? How to Understand It, Recognize It, and Treat ItJul 2025
Pitfalls
Patients can develop different compulsions than before and you might not notice at all. That can be a reason they are not getting better, because they are only suppressing the initial compulsion with a new one.
“they will just develop different compulsions than what they were doing before. And you might not notice it at all. And that can be a reason why they're not getting better because all they're doing is suppressing the initial compulsions with a new compulsion”
37:39What Is OCD? How to Understand It, Recognize It, and Treat ItJul 2025 A large share of OCD patients are very self-critical with depressive tendencies. Being too harsh with themselves can get in the way of doing ERP properly.
“there's just a subset of people of ocd maybe they're even a plurality or even the majority they're very self uh effacing and they have a lot of depressive tendencies they're really mean to themselves basically And that can be an impediment to doing the ERP properly because they're too self-critical, too harsh”
41:21What Is OCD? How to Understand It, Recognize It, and Treat ItJul 2025
It also comes up on
- Borderline personality disorderA subset looks like OCD but does not respond well to ERP and SSRIs, because the underlying problem is self and other relating. Suicidality better formulated through borderline is now being recast as ego-dystonic OCD obsessions.
- Exposure therapyExposure and response prevention is pointless until the patient can accept themselves and accept that what they learned in the past is not working and they need to learn something new.
- Talking to patientsOCD is chronic, not cured. Even after successful ERP, setbacks are expected in stressful periods such as a death or a job loss.
- OCDWe are convinced OCD proper is much more a neurobiological problem than a psychological one, not just obsessionality that grew into bad habits. The more severe cases cannot be knocked out with a run through an ERP workbook.
- OCDA subset of borderline personality disorder looks like OCD but does not respond well to ERP and SSRIs, because the underlying problem is self and other relating.
- Personality disordersIgnoring a problem you need to treat does harm too. It is as if stigma against OCD kept us from recommending exposure and response prevention.
- SSRIsMedication is not the primary treatment for OCD. It is a symptom reducer, often very important, and sometimes needed just to get people into ERP. Expect a 30 to 40 percent reduction, not a cure.
- StigmaIgnoring a problem you need to treat does its own harm. It is as if stigma against OCD kept us from recommending exposure and response prevention.
From these episodes
- Practical OCD Psychopharmacology: Evidence‑Based (& Non Evidence-Based) Medication ApproachAug 2025 · 2 points
- What Is OCD? How to Understand It, Recognize It, and Treat ItJul 2025 · 10 points
Every point above is something said on the Psychofarm podcast, with the words as spoken and a link to the moment in the episode. It is education, not medical advice, and an episode reflects what we thought when we recorded it.