ERP Therapy for OCD: What to Expect in Your First Session

‍You've finally decided to start  ERP therapy for your OCD. You've heard it works. You've done your research and you've found a qualified therapist who feels like a good fit. 

But now you're sitting in your car outside the office (or staring at the Zoom link), and your brain is spinning:

What if they make me do something I'm not ready for?
What if I can't handle it?
What if talking about my intrusive thoughts makes them worse?
What if they think I'm crazy?

Let's take the mystery out of your first ERP session by showing you exactly what to expect.

What Is ERP Therapy? (Quick Overview)

Before we dive into the details of your first session, let's define ERP. .

Exposure and Response Prevention (ERP) is the gold-standard treatment for OCD. It’s made up of two main parts:

1. Exposure: Gradually facing situations, thoughts, or objects that purposefully trigger your anxiety
2. Response Prevention: Learning to resist the compulsions or rituals you normally rely on to reduce your anxiety and feel better. 

The goal of ERP isn't to eliminate anxiety. Rather, ERP teaches your brain that you can tolerate uncertainty and discomfort without using compulsions. ERP is gradual, collaborative, and designed at a pace that feels right for you. 

Before Your First Session: What to Prepare

What to Bring (or Have Ready)

For In-Person Sessions:

• Insurance card (if using insurance)
• Completed intake paperwork 
• A list of current medications 
• A journal or notes about your OCD symptoms (optional but helpful)

For Virtual Sessions:

• A quiet, private space where you can talk openly about your experiences with OCD
• A reliable and stable internet connection 
• Headphones (optional, for privacy)
• Tissues (it's okay if you get emotional)

What to Think About Beforehand

Your therapist will ask questions to better understand your symptoms, but it helps to reflect on:

• What compulsions take up the most time in your day.
• What situations, people, or places do you avoid because of OCD.
• How OCD is impacting your life, work, academics, or relationships.
• What you’d like to be able to do if OCD weren't controlling you?

Don't worry if you can't articulate everything perfectly. Your therapist will help guide the conversation and help you share what’s most important

What Actually Happens in Your First ERP Session

Starting ERP can feel intimidating and overwhelming but knowing what to expect can help reduce a lot of that uncertainty. Here is a step-by-step breakdown of a typical first session:

Part 1: Building Rapport and Establishing Trust (15-20 minutes)

Your therapist will start by getting to know you as a person, not just your OCD. They might ask about:

• What brought you to therapy now
• How you're feeling about starting ERP
• Any previous therapy experiences
• Your goals and hopes for treatment

What this feels like: This part of the session should feel more like a conversation not a Q&A. A good OCD therapist creates a safe, judgment-free space where you can be vulnerable and share about your experiences with OCD  honestly. You should leave the first session feeling heard and validated, not judged or uncomfortable. 

Part 2: Understanding Your OCD (20-30 minutes)

Next, your therapist will do a thorough assessment of your OCD symptoms.

They'll ask detailed questions about:

Obsessions (Intrusive Thoughts)

• Types of  intrusive thoughts you experience.
• How often they occur.
• Themes (harm, contamination, relationships, etc.)
• How distressing they feel on a scale of 1-100?

Compulsions (Rituals and Behaviors)

• What you do in response to those thoughts. 
• Mental rituals (counting, analyzing, reviewing)
• Physical compulsions (checking, washing, arranging)
• Avoidance behaviors
• Reassurance-seeking 

Impact on Your Life

• Activities you avoid. 
• How much time OCD consume each day. How it’s affecting work, academics, relationships, or daily functioning. 

What this feels like: It might feel vulnerable or uncomfortable to talk about your intrusive thoughts out loud, especially if this is the first time. Your therapist understands these thoughts are inconsistent with your beliefs and values and recognizes these as symptoms of OCD.  

Part 3: Psychoeducation About OCD and ERP (15-20 minutes)

Your therapist will explain the cycle of  OCD and why ERP is so effective. You'll learn:

How OCD Maintains Itself

• The OCD cycle: Intrusive thought → Anxiety → Compulsion → Temporary relief → Repeat
• Why compulsions actually strengthen OCD over time
• How avoidance feeds the disorder

How ERP Breaks the Cycle

• Exposures teach you to tolerate uncertainty or anxiety without needing to do compulsions, even if the feared outcome may happen
• Response prevention shows that anxiety can naturally decrease without compulsions and help build new, non-threatening associations 
• Why facing fears gradually is different from just "trying harder" to resist or ignore them
• Anxiety is manageable and compulsions aren’t needed, creating long-lasting relief rather than temporary comfort

What Treatment Will Look Like

• Building an exposure hierarchy (a list  of fears from easiest to hardest)
• Starting with manageable exposures and gradually progressing to harder exposures 
• Between-session exposure practice to help your brain learn new patterns 
• Expected timeline and what success looks like

What this feels like: Relief. Many people say this psychoeducation alone provides validation and a greater  understanding of why your  brain does what it does.

Part 4: Setting Treatment Goals (10-15 minutes)

Together, you'll identify specific, measurable goals for treatment.

Examples of Good ERP Goals:

• "I want to be able to leave the house without checking the locks more than once"
• "I want to touch doorknobs without washing my hands afterward"
• "I want to have intrusive thoughts without spending hours analyzing them"
• "I want to go to social events without constantly seeking reassurance"
• "I want to drive without turning around to check if I hit someone"

What this feels like: Hopeful. You're painting a picture of what life could look like without OCD running the show.

Part 5: Creating Your Initial Exposure Hierarchy (15-20 minutes)

This is where the real work begins. But, don't worry! You're not starting g exposures during your first session.

Your therapist will work with you to:

1. List all your OCD triggers:  Everything that makes you anxious and/or avoid
2. Rate each one:  Usually on a scale of 0-100 for how much anxiety it causes
3. Organize them from least to most difficult:  Creating a "ladder" to climb

Example Contamination OCD Hierarchy:

• 20/100 — Touching a clean doorknob in my home
• 35/100 — Touching a doorknob in a public building
• 50/100 — Sitting on a park bench
• 65/100 — Using a public restroom
• 80/100 — Touching a trash can
• 95/100 — Touching the floor of a public bathroom

What this feels like: A mix of anxiety and relief. Anxiety because about to start confronting your fears; relief because you and your therapist will work at a pace that feels manageable for you. 

Important: You won't begin with the hardest exposure on your list. You'll begin exposures with the things that make you anxious but feel manageable.

Part 6: Discussing Next Steps and Homework (10 minutes)

Your therapist will explain what happens next and might assign between-session homework.

Typical first-session homework:

• Keep a log of your compulsions for the next week (just tracking, not changing anything)
• Notice when you're seeking reassurance
• Continue reflecting on your goals
• Sometimes, a very simple exposure practice (like resisting one specific compulsion once)

What this feels like: Encouraging. Your therapist wants you to be successful and gradually increase your confidence to face your fears. 

What Your First Session Will NOT Include

Let's clear up some misconceptions:

❌ You Won't Be Forced Into Scary Exposures

Reality: Your first session is almost entirely education, discussion and planning. You're building trust and understanding, not confronting your biggest fears yet.

❌ Your Therapist Won't Judge Your Intrusive Thoughts

Reality: OCD therapists hear all different types of thoughts ranging from contamination to harm thoughts and everything in between. They understand these are symptoms, not reflections of who you are.

❌ You Won't Be Thrown Into the Deep End

Reality: ERP is a gradual, collaborative process. You're in control of the pace. Your therapist will gently challenge and encourage you, but will never force you to do anything.  ❌ Talking About Your Fears Won't Make Them Worse

Reality: Many people worry that discussing intrusive thoughts will amplify them. Surprisingly, the opposite is true.Exposure to the thoughts themselves is often the first step in treatment.

How You Might Feel After Your First Session

It's normal to experience a mix of emotions:

Relief
"Finally, someone understands what I'm going through."

Hope
"There's actually a path forward. This might really work."

Nervousness
"What if I can't do the exposures? What if I fail?"

Exhaustion
"That was emotionally draining. I need a nap."

Validation
"My thoughts don't make me a terrible person. They're just OCD."

All of these feelings are completely normal.

Common Questions About Your First ERP Session

"What if I cry during my first session?"

That's completely okay. OCD is exhausting, isolating, and overwhelming and it’s common and normal to feel emotional during your first session. Many people cry during their first session due to feelings of relief, fear, or just talking to someone who finally gets it. Your therapist will have tissues and compassion ready.

"What if I can't fully explain my intrusive thoughts?"

Your therapist will help. They're skilled at asking the right questions to understand your symptoms, even if you struggle to articulate them. You don't need to have everything perfectly organized.

"Do I have to tell my therapist every single intrusive thought?"

You don’t have to share everything right away. . For ERP to work, it’s important to eventually open up,about your obsessions. But you can start with the "easier" ones and work up to sharing the more uncomfortable or upsetting ones as trust with your therapist grows. "What if the therapist says I don't have OCD?"

When working with a qualified therapist  they'll help you understand what's going on. Sometimes people come in thinking they have OCD when it's actually generalized anxiety or another condition. . A thorough  assessment will clarify your diagnosis and recommend the right treatment path for you..

"Will I start exposures in the first session?"

Most of the time, no.  Most first sessions focus on assessment and psychoeducation about OCD and ERP. . However, some therapists might do a very gentle exposure (like sitting with uncertainty for a few minutes) to demonstrate how it works. You'll never be surprised or forced.

"How do I know if this therapist is the right fit?"

Trust your gut, but give it a couple sessions. You should feel:

• Heard and validated
• Confident in their expertise
• Challenged but supported
• Hopeful about the treatment plan

If something feels off, it's okay to seek a second opinion.

What to Do If You're Anxious About Your First Session

It's completely normal to feel nervous. Here's how to manage pre-session anxiety:

Before the Appointment:

✓ Remind yourself why you're doing this:  Write down what OCD has stolen from you and what you want back
✓ Practice self-compassion:  It takes courage to start therapy and every step matters
✓ Don't do extra compulsions:  Resist the urge to "prepare" by doing more rituals
✓ Eat and stay hydrated:  Basic self-care helps you stay present and focused during session
✓ Give yourself extra time:  Don't rush to get there; arrive with a few minutes to spare

During the Appointment:

✓ Share our nervousness:  Tell your therapist how you’re feeling! They'll help you feel more comfortable
✓ Ask questions — If something is unclear, ask your therapist to clarify. Your understanding of OCD and the treatment process matters.  ✓ Take breaks if needed:  It's okay to pause and breathe
✓ Remember: this is about you:  The session is designed to help and support you, not to judge you

After the Appointment:

✓ Resist the urge to analyze every detail:  Don't replay the session obsessively. It’s normal to have thought and process your experience, but give yourself a limited time
✓ Do something kind for yourself:  You did a hard thing; acknowledge that
✓ Reach out to support:  Tell a friend or loved one how it went

The Bottom Line

Your first ERP session is about building a foundation, not diving into deep exposure work.

You'll spend the time:

• Getting to know your therapist
• Having your symptoms properly understood
• Learning why ERP works
• Creating a roadmap for treatment
• Setting goals that matter to you

You're not expected to be "ready" or "brave" yet. You're expected to show upand you're already doing that by reading this.

Ready to Take the First Step?

If you're in Houston or anywhere in the US and ready to start ERP therapy, our team at Houston Anxiety and Wellness Center specializes in evidence-based OCD treatment.

What makes us different:

• Extensive training in ERP therapy
• Experience with all OCD subtypes
• Compassionate, judgment-free approach
• In-person (Houston/Montrose) or online sessions (42 states)
• Clear treatment plans from day one

Schedule your first session and start building the life OCD has been keeping from you!

Your first session might feel scary—but it's also the beginning of getting your life back. You've got this.