Therapeutic Approaches

ERP Therapy & Rumination Focused Exposure and Response Prevention (RF-ERP) for OCD, Pure O, and Rumination


Exposure and Response Prevention therapy (ERP), and Rumination Focused Exposure and Response Prevention (RF-ERP) are targeted treatments for Obsessive Compulsive Disorder (OCD). I have found RF-ERP works incredibly well for OCD, and other rumination related anxiety problems including Pure O (unofficial term for OCD without physical compulsions, where people think, think, think [ruminate] about specific themes and feel like they can’t stop). Please note that RF-ERP is cutting edge, and as such has not been empirically validated yet in clinical trials. However, I have found it helps many clients who have found little success trying to reduce their rumination over many years of seeking therapy.

Central to the Rumination Focused ERP approach is the revelation that rumination is something you are doing, not something that is happening to you (although it usually feels like the latter!) Given this, rumination is controllable.

RF-ERP understands that rumination is an unconscious behaviour that we can become conscious of, and then learn to control. Once we know how to stop ruminating, we can enjoy a restored sense of agency over our minds, where we can choose to think and problem solve something if we want to, or choose to just drop it. Often people with rumination problems will have complex mixed feelings, or uncomfortable aspects of their reality, or old unresolved traumas underneath their rumination, which they can choose to confront once they can stop ruminating, if they want to enjoy life without even having the urge to ruminate any more.

How do I know if Rumination Focused Exposure and Response Prevention (RF-ERP) is for me? If you feel like you can’t stop thinking, obsessing, ruminating, worrying about specific themes or fears or concerns, then RF-ERP can very likely help you. Examples of themes or concerns include: fear of harming others, fear of sexual deviance, fear of having made some mistake, fear of being mentally stuck on something for ever (including on physical sensations or pain), fear’s of dating the wrong person or obsessive jealous thoughts. RF-ERP could help you learn to stop worrying about these issues, and restore a sense of control over your own mind, so that it becomes a friendly place again.  

Rumination Focused Exposure and Response Prevention (RF-ERP) was developed by Dr Michael J Greenberg in the USA after 20 years of suffering with OCD despite seeing multiple therapists, devouring vast amounts of clinical psychological literature on OCD, and even becoming accredited in teaching people many of the standard OCD treatment approaches to other therapists. I am currently the only therapist in Australia trained in RF-ERP, and I am in talks with Michael about facilitating an Australian based training for therapists (if you are a therapist, reach out!).

The theory behind the technique holds that all OCD has rumination at its core, and that it is actually a behaviour that feels automatic but that people can learn to control, and that there are often mixed feelings and urges underneath that need to be addressed. I believe the popular understanding of OCD before RF-ERP was missing a few crucial pieces of information: rumination is a defence mechanism which feels unconscious but can actually be controlled, most intrusive thoughts occur as a result of rumination rather than just being fired off by the brain or unconscious, there usually IS some kind of emotional trauma/mixed feelings/urges underneath it all that the person is trying to manage by thinking – but it only makes things worse. 


Exposure and response prevention (ERP) is aimed to help people with Obsessive Compulsive Disorder (OCD) and compulsive behaviour or thinking.

ERP provides a structure and psychoeducation that allows clients to choose to challenge their fears in a stepwise fashion to gain a sense of competence and confidence. To do things they are afraid of that normally prompt compulsions but to instead refrain from those compulsions.

In Rumination Focussed Exposure and Response Prevention…

you are taught to stop rumination so you can regain a sense of agency over your mind. Only then do you consider doing exposures, and you do them while inhibiting rumination and any normal compulsive actions (eg., reassurance seeking, hand-washing).

Exposures will simply be to do the things you want to do but normally avoid due to fear of bad thoughts/rumination (eg. if you avoid going to cemeteries or cooking, you might choose to visit a cemetery or cook a meal respectively, but without ruminating etc.).

You will know how to stop ruminating (and how to not even start!), before you begin exposures.

Because all anxiety in OCD comes from rumination (according to this model) exposure becomes a very low anxiety inducing experience once rumination is controllable.


Learn about RF-ERP by listening to
Dr. Michael J Greenberg

The best place to learn about Rumination Focused Exposure and Response Prevention is by listening to Dr Michael J Greenberg explain it in two podcast episodes, and by reading his bite sized articles on it at

Podcast: The OCD Stories

Dr Michael J Greenberg is the young and brilliant psychologist from New York City who created the Rumination Focused Exposure and Response Prevention approach, and I believe I’m the first psychologist in Australia to have completed his new training program with him. You can find these two podcast episodes:

Dr Michael Greenberg: Rumination Is a Compulsion

Dr Michael Greenberg: Putting Rumination and
Agency at the Center of ERP

‘What is the problem you are seeking help with?’ Is the first question I will ask you. Good on you for seeking help.