OCD Series – Post 2: Tolerating Distress in ERP
Introduction
If you’ve started Exposure and Response Prevention (ERP) therapy for Obsessive–Compulsive Disorder (OCD), you already know the process isn’t about feeling comfortable. It’s about retraining your brain by allowing anxiety to rise, staying with the discomfort, and resisting rituals.
The question many people ask at this stage is:
“How do I actually sit with this much distress without giving in?”
This post—the second in our OCD Series—is designed to accompany your second therapy session. It explores how ERP uses discomfort as a teaching tool, why anxiety during exposures is expected, and what strategies you can use to tolerate distress without rituals.
Why Anxiety Rises in ERP
During ERP, you deliberately trigger the thoughts, images, or situations your OCD fears most. Naturally, anxiety and uncertainty spike. This isn’t a sign of failure—it’s the therapeutic goal.
When you don’t do the compulsion:
Your brain learns that anxiety isn’t dangerous.
You discover that you can handle uncertainty.
Over time, the feared situation loses its power.
Anxiety in ERP is like a workout for your nervous system. You’re strengthening your tolerance muscle, one exposure at a time.
Habituation vs. Inhibitory Learning
Two main scientific models explain why ERP works:
Habituation: If you stay with a fear long enough, anxiety naturally rises, peaks, and falls. Over repeated exposures, the anxiety decreases faster and less intensely.
Inhibitory Learning: ERP doesn’t erase old fear pathways—it builds new ones. You learn “I can have this thought and nothing bad happens,” which overrides OCD’s alarm system.
Either way, the process requires tolerating distress long enough for your brain to rewire.
The Role of Uncertainty
OCD thrives on the demand for 100% certainty:
“What if I left the door unlocked?”
“What if I ran someone over and didn’t notice?”
“What if I acted on a violent thought?”
ERP doesn’t promise certainty. Instead, it helps you live with normal uncertainty—the same uncertainty everyone faces but OCD exaggerates.
When you learn to say, “I can’t be 100% sure, but I can live with that uncertainty,” OCD loses its grip.
Skills for Tolerating Distress
Here are practical techniques that help you ride out the storm of anxiety without rituals.
1. Mindful Observation
Notice the thought or feeling like an observer:
“Here is anxiety.”
“My brain is telling me a story.”
“This is OCD, not a fact.”
Mindfulness shifts you from reacting to noticing.
2. Grounding
Bring yourself into the present moment using your senses:
Name 5 things you can see.
4 things you can touch.
3 things you can hear.
2 things you can smell.
1 thing you can taste.
Grounding helps anchor you while anxiety runs its course.
3. Urge Surfing
Imagine the urge to ritualise as a wave: it rises, peaks, and falls. Your job is not to fight or avoid it, but to “surf” until it passes.
Remind yourself: “If I don’t act on this compulsion, it will eventually fade.”
4. Breathing for Tolerance
Instead of using breath to “calm down,” use it to create space for discomfort:
Inhale: “Here comes anxiety.”
Exhale: “I can let it be.”
This shifts the focus from escape to willingness.
5. Acceptance Statements
Try phrases such as:
“I am willing to feel this anxiety if it means living by my values.”
“Discomfort is temporary. Freedom is forever.”
“I don’t have to like this, I just have to allow it.”
6. Values Anchoring
Connect exposures to what matters most. Example:
“I’m resisting handwashing because I want to spend more time with my kids.”
“I’m facing this intrusive thought because my values are stronger than OCD.”
Client Exercise: Create a Distress Tolerance Toolbox
Write down 5 strategies you’ll use when anxiety spikes during ERP. Examples:
Grounding (5–4–3–2–1).
Urge surfing visualisation.
A values reminder statement.
10 slow breaths with acceptance.
Calling a supportive friend (without reassurance-seeking).
Keep this list handy—on your phone, in your pocket, or taped to your mirror.
Reflection After Exposures
After each exposure, ask yourself:
How high did my anxiety go (0–100)?
Did it eventually come down, even a little?
What did I learn about my ability to tolerate discomfort?
What would OCD have me do, and what did I choose instead?
This reinforces progress and helps track patterns.
Common Pitfalls and How to Handle Them
Compulsion Creep
You may find yourself performing rituals subtly (e.g., mentally reviewing, subtle avoidance).
Solution: Be honest with yourself and your therapist—small compulsions count.
White-Knuckling
Trying to “tough it out” with gritted teeth.
Solution: Shift to a willingness mindset—let anxiety come and go rather than bracing against it.
Avoiding Exposures
Fear of distress can lead to procrastination.
Solution: Break exposures into smaller steps and remind yourself why you’re doing them.
Case Example
Sarah has contamination OCD. She avoids touching public surfaces and washes her hands dozens of times a day. In ERP, she begins with touching her own doorknob without washing. Anxiety rises to 80/100. Using urge surfing, she notices her body’s discomfort rise and fall. After 15 minutes, anxiety drops to 40. She realises: “I didn’t wash, and nothing catastrophic happened.”
Over weeks, Sarah moves up her hierarchy—touching shopping trolleys, pressing lift buttons, eventually using a public toilet. Her anxiety still rises, but she now knows she can ride it out without compulsions.
Encouragement: Anxiety as a Teacher
It’s easy to see distress as the enemy. In ERP, distress is the teacher. It shows you where OCD is strongest, and each time you tolerate it, you weaken OCD’s hold.
Think of distress as a signal of progress. The more willing you are to feel it, the freer you become.
Reflection Prompt
Take 10 minutes and journal:
What was my most difficult exposure this week?
How did I respond to the urge to ritualise?
Which distress tolerance strategy worked best for me?
What value am I moving toward by doing ERP?
Conclusion
ERP therapy is not about comfort—it’s about freedom. Distress during exposures is not a sign that you’re failing, but proof that you’re retraining your brain. With tools like mindfulness, grounding, urge surfing, and values anchoring, you can tolerate discomfort and take back your life from OCD.
This is a courageous journey. By practicing these skills, you’re building resilience, confidence, and a new relationship with uncertainty.
In Post 3 of the OCD Series, we’ll explore how to live by your values instead of fears, integrating Acceptance & Commitment Therapy (ACT) principles into ERP.
