What the Research Really Says About ERP
The "gold standard" label is worth a closer look. Here's what the studies actually show, and why newer approaches are changing the conversation.
This is Part 3 of a series on finding effective OCD treatment. Part 1 sets the stage, and Part 2 breaks down the CBT umbrella problem.
ERP has earned its place in OCD treatment. Decades of research support it, and it is the approach most OCD specialists are trained in first. But "gold standard" is a label worth examining before you accept it at face value.
Here is what that label actually means, and what it leaves out.
How "Gold Standard" Gets Assigned
In clinical research, gold standard status is built through accumulating randomized controlled trials over time. ERP had a significant head start. Not because it was the first approach that ever helped people with OCD, but because it was the first to play by the rules of academic research.
A general practitioner from Australia, Dr. Claire Weekes, was successfully guiding patients through obsessive anxiety for nearly 20 years before ERP was even named, publishing Hope and Help for Your Nerves in 1962. This was four years before Victor Meyer introduced ERP in 1966.
Dr. Weekes' acceptance-based method predated both ERP and ACT. The Anxiety and Depression Association of America now calls her "The Grandmother of Cognitive Behavioral Treatment for Anxiety." She was nominated for the Nobel Peace Prize in the 1980s, her books had reached hundreds of thousands of people across 14 languages, and she was appointed an MBE in 1978.
But because her evidence was clinical and experiential rather than built on randomized controlled trials, it didn't count in the eyes of the research establishment. ERP, meanwhile, had decades to accumulate studies before any competitor entered the arena on those terms.
What the Studies Actually Show
When you examine the ERP research more carefully, the picture gets more nuanced. Meta-analyses show that when ERP is compared head-to-head against other active psychological therapies, the difference in effectiveness is essentially zero.
Perhaps most striking, a recent analysis found that three-quarters of ERP studies were conducted by researchers with a vested interest in ERP's success, and those studies reported dramatically inflated results compared to studies without that bias.
Meanwhile, 40 to 50 percent of people who complete ERP do not reach full remission, and up to 25 percent show no meaningful improvement at all.
None of this means ERP doesn't work. It remains an important tool in the management of OCD.
But a tool is not a toolbox.
What Newer Approaches Are Showing
Newer approaches like Inference-Based CBT (I-CBT) are demonstrating comparable outcomes in clinical trials with significantly higher tolerability. This means clients find the process less distressing and are more likely to stay engaged and not drop out of therapy.
This matters more than it might sound. A treatment that works beautifully in theory but drives people out of the room is not a complete solution.
I-CBT works at the very beginning of the OCD cycle: the obsessional doubt, the "what if." Rather than focusing on resisting compulsions, it targets the faulty reasoning that gives the obsession its credibility in the first place.
ACT, meanwhile, focuses on changing your relationship with your thoughts rather than trying to change or eliminate the thoughts themselves. It centers on learning to accept uncertainty and take committed action aligned with your values. In ACT-focused work, we design exposures that are personally meaningful and directly support the life you want to lead.
Mindfulness practices add another layer. Practicing mindfulness strengthens your ability to observe intrusive thoughts with detachment, shifting from reactive fear toward what I'd describe as a mindset of acceptance. This does not mean accepting the thoughts as true or agreeing with them. It means learning to accept the mind's production of these noisy thoughts and choosing not to judge, engage with, or act upon them.
Why This Matters for You
In my experience, clients who have been in therapy with clinicians who rely on ERP as the one and only answer, rather than one component of a comprehensive and individualized approach, often blamed themselves when ERP wasn't enough. They dropped out of therapy for a while and tried to manage OCD alone.
You are not the problem. The approach was incomplete.
In the next post, we'll look at why one-size-fits-all treatment so often fails high-functioning adults, and what a truly individualized approach looks like.
In the meantime, I have put together a free guide with a set of questions worth asking a potential OCD therapist, including what to listen for in their answers, the difference between an informed and an uninformed response, and the signs worth noticing along the way.
Download the Free Guide: Questions to Ask Your OCD Therapist →
References
Weekes, C. (1962). Self Help for Your Nerves (published as Hope and Help for Your Nerves in the US). Angus & Robertson. See also: Anxiety and Depression Association of America. Claire Weekes, MD, DSc: The Grandmother of Cognitive Behavioral Treatment for Anxiety. https://adaa.org/learn-from-us/from-the-experts/blog-posts/consumer/claire-weekes-grandmother-of-cognitive-behavioral-therapy
Reid, J.E., Laws, K.R., Drummond, L., et al. (2021). Cognitive behavioural therapy with exposure and response prevention in the treatment of obsessive-compulsive disorder: A systematic review and meta-analysis of randomised controlled trials. Comprehensive Psychiatry, 106, 152223. https://pubmed.ncbi.nlm.nih.gov/33618297/
Hezel, D.M. & Simpson, H.B. (2019). Exposure and response prevention for obsessive-compulsive disorder: A review and new directions. Indian Journal of Psychiatry, 61(Suppl 1), S85-S92. https://pmc.ncbi.nlm.nih.gov/articles/PMC6343408/
Wolf, N., van Oppen, P., Hoogendoorn, A.W., et al. (2024). Inference-Based Cognitive Behavioral Therapy versus Cognitive Behavioral Therapy for Obsessive-Compulsive Disorder: A Multisite Randomized Controlled Non-Inferiority Trial. Psychotherapy and Psychosomatics, 93(6), 397-411. https://pubmed.ncbi.nlm.nih.gov/39427635/
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