What is the approach to implementing Exposure and Response Prevention (ERP) therapy for a patient with Obsessive-Compulsive Disorder (OCD) as a Psychiatric Nurse Practitioner (Psych NP)?

Implementing ERP for OCD as a Psychiatric Nurse Practitioner

As a Psych NP, you should refer patients with OCD to a therapist specifically trained in ERP while managing pharmacotherapy, as ERP is a specialized psychotherapy technique that requires dedicated training in exposure-based interventions and is outside the typical scope of NP practice. 1, 2

Understanding Your Role vs. Therapist Role

What ERP Actually Entails

• ERP involves gradual exposure to fear-provoking stimuli combined with instructions to abstain from compulsive behaviors, requiring specialized training in exposure hierarchy development and response prevention techniques 2
• The therapy demands intensive between-session homework assignments, which are the strongest predictor of good outcomes and require therapist expertise to design and monitor 1, 2
• ERP typically requires 10-20 hours of direct therapist contact over 9-12 weeks, with twice-weekly sessions initially being most effective 3, 4

Your Primary Responsibilities as a Psych NP

Provide comprehensive psychoeducation at the initial visit:

• Explain that OCD is a common, well-understood disorder with effective treatments that can achieve at least partial symptom reduction and improved quality of life 1
• Address stigma and shame that often delays treatment seeking 1, 5
• Educate about the biological and psychological underpinnings of OCD 1

Initiate or optimize pharmacotherapy:

• Start an SSRI as first-line medication, using higher doses than typically used for depression (e.g., fluoxetine 60-80mg, sertraline 200mg, escitalopram 20-30mg) 1, 2
• Allow 8-12 weeks at adequate doses before determining treatment response 2
• For severe OCD or comorbid major depression, combine SSRI with referral for CBT/ERP rather than using either alone 1, 2

Coordinate care with the ERP therapist:

• Refer to therapists specifically trained in ERP (not just general CBT practitioners) 1, 2
• Monitor medication adherence and side effects while the therapist conducts ERP 1
• Address family accommodation behaviors that may undermine ERP effectiveness 1

When You Might Provide Limited ERP-Adjacent Support

Psychoeducation About ERP Principles

• Explain that ERP works by helping patients face feared situations without performing compulsions, allowing anxiety to naturally decrease 2
• Normalize that anxiety will initially increase during exposures before improving 6
• Emphasize the critical importance of homework adherence between therapy sessions 1, 7

Supporting Ongoing ERP Treatment

• Encourage patients to complete between-session exposures prescribed by their therapist 7
• Reinforce progress and identify "innovative moments" where patients successfully resisted compulsions 6
• Avoid providing reassurance about obsessional content, as this functions as a compulsion 5

Treatment Algorithm for Your Practice

Step 1: Initial Assessment and Treatment Planning

• Assess OCD severity using Y-BOCS (Yale-Brown Obsessive-Compulsive Scale) 1
• Evaluate for comorbid depression, which affects treatment sequencing 2
• Determine if symptoms are mild-moderate (ERP referral alone) or severe (combined SSRI + ERP) 1, 2

Step 2: First-Line Interventions

• Mild-moderate OCD: Refer for ERP therapy as monotherapy 2
• Severe OCD or comorbid depression: Start SSRI AND refer for ERP simultaneously 1, 2
• Provide psychoeducation and address family accommodation at this visit 1

Step 3: Monitoring and Optimization (8-12 weeks)

• If inadequate response to SSRI monotherapy, add ERP referral if not already done 2
• If inadequate response to ERP alone, add SSRI 2
• Optimize SSRI dose to higher end of range before switching agents 2

Step 4: Treatment-Resistant OCD

• Switch to different SSRI or clomipramine 2
• Consider augmentation with aripiprazole 5-15mg, brexpiprazole, or memantine 2
• Refer for intensive ERP (multiple sessions per week or day-treatment programs) 1, 4
• Consider glutamatergic agents like N-acetylcysteine as augmentation 2

Alternative Delivery Methods You Can Recommend

When in-person ERP is inaccessible:

• Video teletherapy ERP achieves similar outcomes to in-person treatment with large effect sizes (g=1.0) and 62.9% response rates 3
• Computer-assisted self-help programs with ERP components lasting more than 4 weeks show efficacy, though with higher dropout rates 8, 1
• These digital interventions work best when they include psychoeducation, cognitive elements, and structured ERP exercises 8

Critical Pitfalls to Avoid

Do not attempt to conduct formal ERP yourself without specialized training in exposure therapy techniques, as improper implementation can worsen symptoms or cause treatment dropout 4

Avoid providing reassurance about obsessional content during medication management visits, as this reinforces the OCD cycle and undermines concurrent ERP 5

Do not use standard depression/anxiety doses of SSRIs for OCD—higher doses are required and underdosing is a common cause of treatment failure 1, 2

Do not discontinue treatment prematurely—OCD is typically chronic and requires long-term management with booster sessions every 3-6 months after initial improvement 1

Address family accommodation explicitly, as family members often unknowingly maintain OCD symptoms by participating in rituals or providing excessive reassurance 1, 5