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Exposure and Response Prevention Via Telehealth During the COVID-19 Pandemic

By August 18, 2020April 6th, 2021Andrew Cohen, M.S., Blogs

Exposure and Response Prevention (ERP) is the gold standard treatment for OCD and Anxiety disorders and is typically conducted via in-person sessions.  During ERP, patients are gradually exposed to their anxiety triggers while refraining from engaging in any safety behaviors, or compulsions.  Doing so helps rewire patients’ fight or flight response and obtain long-term relief from anxiety.  During these unprecedented times of COVID-19, and thus the surge in usage of telehealth, it is essential to learn how to adapt traditional in-person ERP to the online platform.  This article will outline helpful ways to ensure that our patients are getting the most out of their ERP treatment via telehealth.

  1. Mindfulness, Mindfulness, and more Mindfulness:

ERP treatment is not going to be as successful without effective mindfulness training. This is even more true when conducting treatment via telehealth.  For example, in telehealth sessions, it is very easy for both therapists and patients to become distracted by text messages, emails, or other notifications that pop up on our computers.  Mindfulness skills are a great way to help us notice a distraction that pops up and then bring our attention back to the session.  Additionally, before patients engage in exposure exercises in their telehealth sessions, it can be beneficial to have them participate in a guided meditation, mindfulness walk, or a five senses grounding exercise to bring them “into the room.”  This exercise will help the patient be fully present in his or her discomfort during the exposure.  Lastly, teaching your patient to notice when he or she is becoming distracted during exposures, and to redirect attention back to the exercise, is essential to give the patient the full benefit of the exercise.

  1. Keep the patient engaged during exposures:

It is common for a patient’s mind to wander and distract from discomfort during exposures in both in-person and telehealth sessions.  Thus, it is helpful to use different strategies to keep patients in the moment, such as by checking in with the patient frequently to monitor his or her distress level, having the patient record a hot phrase and listen to it on loop, and having the patient engage in in-vivo exposures, when possible.  In-vivo exposures refer to engaging in the exposure in real life, rather than listening to a narrative of it happening.  In-vivo exposures can be useful in telehealth when the patient has triggers that are in his or her home setting, as this provides an opportunity to practice exposures in the patient’s real-life setting. For example, if the patient’s bedroom is a triggering place, have him or her remain in the bedroom for the duration of the session.

  1. Engage in the exposures with the patient:

Engaging in in-person exposures with our patients can be a great way to motivate them to push themselves. This is also true via telehealth. An example of translating this skill to telehealth would be having a patient with a fear of touching contaminated objects or surfaces in his or her home, such as a phone, bring the phone to the telehealth session to show you he or she is engaging in the exposure.  At the same time, the clinician would bring his or her own phone to engage in the exposure.  Another way of doing this can be by utilizing the screen share function on most video chat platforms to stare at a triggering picture or watch a triggering video with your patient.

  1. Have your patient take you with them:

One of the great things about telehealth is that it is so accessible and mobile.  Video chatting software is available on cell phones and this makes it so you can engage in sessions outside of the home.  For exposures surrounding the fear of driving, for example, you can conduct the session over Bluetooth, so that your patient can engage in driving exposures, with his or her clinician, while also staying safe.

  1. Assigning and Reviewing Homework:

Another benefit of engaging in ERP via telehealth is that we can observe how our patients are doing their exposure homework in the home setting, which is not possible when seeing patients in the office. This way, you can make necessary adjustments, offer suggestions to enhance their exposures, and ideally increase the benefits they experience from treatment. Often, patients are engaging in small safety behaviors, such as seeking reassurance, without even knowing it. Thus, being able to course correct in the moment is going to increase the effectiveness of the exposure exercise.

While engaging in in-person ERP may feel more productive and beneficial, there are ways to make sure we are providing our patients with effective treatment during this rapidly evolving COVID-19 pandemic.  Incorporating these skills with our patients may help increase the benefit they experience from treatment. If you have any questions, comments, or concerns, do not hesitate to reach out to me at