RF-ERP Order of Operations *

* Published December 2022

Please note that Rumination-Focused ERP is a new and evolving approach to ERP. It has not yet been researched, and therefore to the extent that it differs from classical ERP, it is not evidence-based.

RF-ERP Order of Operations


  • Gather information about symptoms, family of origin, and current relational dynamics
  • Potential HW: Make a list of all forms of triggers/compulsions and avoidance

Core Fear

Psychodynamic Case Formulation

  • Educate about healthy aggression and attachment
  • Identify individual’s conflict between healthy aggression and attachment
  • Connect current symptoms with family of origin and current relational dynamics
  • Keep in mind:
    • This is a barebones formulation based on the information you have. It would be impossible to have more than that within one or two sessions.
    • This is a working hypothesis.  It is subject to revision and refinement.
    • There can be more than one form of healthy aggression in the formulation, even though there is only one Core Fear.

Rumination-Focused Case Formulation and Treatment Plan

  • Explain how rumination factors into the person’s symptoms
  • Explain your treatment plan, providing a rationale for starting with response-prevention of rumination

How to Stop Ruminating (and How to Stop Paying Attention)

  • Down to 0 anxiety and 0 effort

Do not proceed with ERP until the patient can reach 0/0 in session.

  • This does not preclude psychodynamic work
  • This does not preclude exposures the patient can do without ruminating (e.g., they realize they’re ready to let go of a symptom and it doesn’t make them anxious to do so)

Complete Initial Exercises

  • Use the smallest possible exposures to show a person:
    • That they can control rumination even when triggered
    • Why the proposed treatment plan makes sense
    • How you will approach exposure
    • Note: The last exercise (ongoing trigger) may not be relevant to all cases

If a person primarily ruminates in the context of a trigger skip to “Identify targets for exposure” and begin exposure.

If a person ruminates all the time, even absent a trigger (e.g., pure O, sensorimotor):

  • Assign no rumination, research, or reassurance-seeking
  • Assign monitoring any times they get stuck (context and content)
  • Prepare the patient for common challenges:
  • Major triggers
  • Sticky days

Address stuck points:

Proceed to exposure (1) when a person is able to control rumination outside of session.  They don’t have to be perfect about rumination, they just have to have enough control that they can do an exposure while refraining from rumination.

Identify targets for exposure:

  • Triggers/compulsions
  • Avoidance


  • Complete exposures with the goal of eliminating all forms of compulsion and avoidance
  • Guiding principles:
    • Do what makes sense, keeping in mind why you are doing what you’re doing
    • Think about the overarching goal of restoring agency
    • Set people up for mastery experiences 
    • It doesn’t matter how much ERP happens in session vs out of session, as long as compulsion and avoidance are being eliminated.  Here are reasons to do exposures in session:
      • To show someone how they’re OCD works 
      • To show them how to do an exposure in the context of not ruminating
      • To show them that they are able to do something
      • To practice


Continue to address rumination

Continue to address emotional and relational dynamics


1. There is already some element of exposure even before we formally start exposure, because there are always naturally occurring triggers in a person’s life, and also because we do exposure as part of the initial exercises.  We are just asking the person to practice response-prevention in the context of naturally occurring triggers, before we assign anything more challenging.

Please note that this article is for your information only and does not constitute clinical advice or establish a patient-psychologist relationship.