How to Handle Extreme Anxiety During ERP (Without Avoiding the Exposure)

Exposure and Response Prevention (ERP) is a highly effective model of therapy, but most people fear undertaking the exposures if their anxiety gets too high, after all, they have created elaborate compulsions to manage this anxiety and suddenly being told to expose themselves to the things they fear can be a bit daunting. In my recent articles I have been trying to bring more of my experiences from my therapy practice into my writing as I have found that it is the pitfalls and difficulties that I see in session that can help you, the reader, the most, especially if you are trying to help yourself. Feeling a little anxiety is necessary, as in order to do ERP, there needs to be enough anxiety that you can cut by half, during the exposure, this is explained in more details in this NHS leaflet.

You will be taught how to manage the anxiety, but if it is overwhelming there are other things you can do, or perhaps you need to go further down your hierarchy for a less anxiety provoking experiment. If this is the first time you have come across ‘hierarchy’ I recommend you read my complete Guide to ERP that explains what this is, and when you’ve done that, I have an article telling you how to construct your hierarchy.

Understanding Extreme Anxiety in ERP

1. Why It Happens
   When you face your triggers during ERP, you’re sending your brain the message: “I’m stepping into danger.” Even though the real-life threat might be minimal or nonexistent, your fight-or-flight response still fires up. This is perfectly normal. I recommend you read my article on how to break down fears in ERP so that they are more manageable.
2. Why Avoidance Feels Tempting
   When anxiety spikes, a natural response is to escape—physically or mentally. However, in ERP, avoidance undoes the progress you’ve worked so hard to achieve. Every time you confront the feared situation and remain with the discomfort, you’re teaching your brain that you can handle anxiety without resorting to compulsions or escape.

1. Grounding Techniques to Anchor Yourself

When anxiety hits at full force, grounding exercises can help root you in the present moment.

• 5-4-3-2-1 Method: Name five things you can see, four things you can touch, three things you can hear, two things you can smell, and one thing you can taste.
• Progressive Muscle Relaxation: Tense and then release different muscle groups—start from your toes, move up to your calves, thighs, all the way to your face. This focus can keep you from spiraling into panic.

In my practice, I often encourage clients to start with grounding as soon as they notice the first signs of escalating anxiety—like shallow breathing or racing thoughts. It’s easier to manage anxiety when it’s at a simmer rather than a full boil.

2. Breathing Exercises to Regain Control

Even though breathing is automatic, using it consciously can short-circuit overwhelming anxiety.

• Box Breathing: Inhale for a count of four, hold for four, exhale for four, and hold again for four.
• Pursed-Lip Breathing: Inhale slowly through your nose, then exhale gently through pursed lips as if you’re blowing on hot soup.

I’ve had clients report that they initially found these techniques “too simple” to be effective. Yet, once they committed to practicing them regularly—even outside anxiety spikes—they noticed a significant difference in how quickly they could dial down intense panic.

3. Self-Talk and Reframing

Our thoughts can either intensify anxiety or help us cope. ERP tends to trigger catastrophic thinking (“I can’t handle this; I’m going to lose it”), which only fuels the anxiety fire. You can read more on how your thoughts affect your mental health in this article.

• Mantra Examples:
  • “I can tolerate this discomfort.”
  • “I’m doing ERP; this anxiety is part of the process.”
  • “This feeling is temporary.”
• Reality Checks: Remind yourself of times when you successfully handled anxiety before. You can say to yourself, “I felt like this last week, and I got through it. I can do it again.”

The reality check is something I apply in my personal life, if I am finding something difficult or stressful. What happens to me is that each time something makes me anxious, it’s almost as if it is a novel experience, that I have never felt anxiety before, or at least that is how my body and mind reacts, so I remind myself I have felt anxiety before, and managed perfectly fine and can do it again.

4. Mindful Observation (Defusion from Thoughts)

A core challenge in ERP is getting hooked by anxious thoughts—making them feel absolutely real. Mindful observation helps you notice thoughts without buying into them. I have an article on how cognitive diffusion helps with OCD; but in a nutshell, it is the ability to distance yourself from the thoughts.

• Labeling Thoughts: If you have a thought like “I can’t do this,” mentally label it as “I am having the thought that I can’t do this.”
• Visual Metaphor: Imagine your thoughts are clouds passing through the sky. You don’t have to chase them or push them away—just let them drift.

5. Use Micro-Exposures and Breaks Wisely (But Don’t Avoid)

Extreme anxiety can feel unmanageable if you bite off more than you can chew. While we want to avoid outright avoidance, you can still structure your exposures in a way that gradually increases your tolerance.

• Chunk Down the Exposure: Instead of jumping into a high-level exposure for an hour, start with a shorter timeframe (e.g., 5 or 10 minutes), then build up.
• Planned Breaks: Schedule brief, mindful breaks if the anxiety becomes too intense. Use a coping tool like grounding or a quick breathing exercise. The key is to return to the exposure, not to abandon it.

ERP like all models has some leeway. When I worked in the NHS in UK, I used a form of micro exposures with a client whose rituals around washing were so interfering and time consuming she could hardly leave the house. This is where professional leeway comes into play, you can still have some compulsions, but start to perform them differently. With this lady, she was still allowed to perform some washing compulsions, but, for example, only wash to her elbow instead of scrubbing right up her arm.

6. Enlist Support (But Avoid Reassurance-Seeking)

Having a trusted friend or family member aware of your ERP journey can be invaluable. However, it’s important to avoid excessive reassurance. If you constantly rely on someone else saying “Everything will be okay,” you might undermine the self-trust and tolerance-building that ERP fosters.

• Accountability Partner: Ask someone to check in on your progress, rather than provide reassurance.
• Therapeutic Support: Don’t hesitate to bring up severe anxiety spikes with your therapist. Together, you can tweak your ERP plan to make it both challenging and manageable.

7. Celebrate Small Wins and Reflect on Progress

Acknowledgment goes a long way in maintaining motivation and confidence:

• Micro-Celebrations: Give yourself credit after every exposure session—no matter how big or small.
• Track Your Progress: Keep a log of your daily or weekly exposures. Note the intensity of anxiety at the start and end. Seeing the numbers improve over time is incredibly motivating.

A client once told me that even though her anxiety was still high, tracking her daily exposure scores showed a downward trend in overall distress. That reminder became a powerful antidote to hopelessness.

The Importance of Professional Guidance

While these strategies are effective, nothing replaces professional support. If you’re feeling overwhelmed or suspect you need a more personalized approach, consider reaching out to a qualified therapist. In therapy, you’ll get a tailored ERP plan and ongoing feedback—both of which are crucial for long-term success.

Final Thoughts

ERP is about learning to live with uncertainty, embracing discomfort, and discovering your own resilience. Extreme anxiety is part of the journey, but it doesn’t have to derail your progress. By using grounding, mindful observation, structured exposures, and the right support system, you can work through those intense spikes without avoiding the very experiences that lead to healing.

Remember: every time you choose to face anxiety instead of running from it, you’re rewiring your brain, step by step. You have the strength to see this through, and your future self will thank you for it.