A Shifting Target: When OCD Keeps Moving the Goalposts in ERP

Written By Ian O Brien

About this Series

This article is part of an ongoing series based on my MSc research into why people struggle to engage with ERP (Exposure and Response Prevention) — the gold-standard therapy for OCD. The research analysed over 100 interviews from The OCD Stories podcast to explore the real challenges people face in starting, sticking with, or completing ERP.

Each post focuses on a different theme that emerged from the study — bringing together lived experience, research insight, and practical ideas for what might help.

For some people, ERP doesn’t feel like steady progress — it feels like chasing a moving target. Just as one fear begins to fade, another takes its place. New obsessions appear, compulsions shift, triggers multiply.

Many people in my research described OCD as “sneaky” or “creative,” constantly finding new ways to stay in control. This unpredictability made recovery feel uncertain and, at times, discouraging.

Even when exposures were going well, mental compulsions often slipped in unnoticed, undermining progress. For others, OCD turned its focus onto the therapy itself — insisting that ERP be done “perfectly” or turning self-monitoring into another form of checking.

When this happens, ERP can begin to feel less like freedom and more like another demand, overshadowed by the sense that OCD keeps changing the rules.

Why This Happens

One of the most challenging aspects of OCD is its tendency to shift themes. Research shows that when one obsession quiets down, another often emerges — usually within the same “dimension” of OCD (Pinciotti et al., 2021). For example, someone who once experienced moral scrupulosity may later develop existential fears, both driven by the same intolerance of uncertainty. If ERP only targets the surface fear, progress can feel temporary, as new obsessions take its place.

Mental compulsions add further complexity. They’re often mistaken for “just thoughts” and can be missed in treatment (Gillihan et al., 2012). Research by Wairauch et al. (2024) shows they are active, effortful behaviours. People performing mental rituals are typically concentrating intently to “get them right.” These rituals provide immediate relief (negative reinforcement) and sometimes even a sense of control (positive reinforcement), making them highly persistent. This explains why being told to “just stop ruminating” rarely works — the compulsion serves a powerful purpose.

Wairauch and colleagues also found that compulsions evolve over time, adding new rules or steps to preserve their anxiety-reducing effect. This can make ERP feel like it’s always trying to catch up. Unless therapy addresses the underlying process — the need for certainty or the pursuit of a “just right” feeling — OCD can keep re-emerging in new forms.

Therapists may unintentionally reinforce this cycle when they focus only on visible rituals or the current obsessional theme. Pinciotti et al. (2021) recommend designing exposures that target the broader process of uncertainty tolerance, rather than just today’s content. This allows learning to generalise so that when OCD shifts, the skills still apply.

What Can Help

When OCD keeps “shifting the target,” the aim isn’t to chase each new theme — it’s to build skills that apply across them, so progress doesn’t reset each time symptoms change.

Here are some things that might help in therapy:

1. Aim at the Process, Not Just the Content

Exposures work best when they go beyond the specific fear of the moment and target OCD’s underlying driver — the need for certainty or a “just right” feeling. Research shows that when exposures are built around uncertainty itself, rather than a single trigger, the learning generalises even as OCD shifts themes (Pinciotti et al., 2021; Knowles & Olatunji, 2023).

2. Get Creative with Exposures

When fears are abstract — moral, existential, or philosophical — it can help to move beyond standard in-vivo tasks. Imaginal exposures, writing exercises, or values-based activities can all make the work more relevant (Ramsey et al., 2024). For some, technology such as virtual or online ERP helps bring exposures into real-life contexts with therapist support (Ferreri et al., 2019; Voderholzer et al., 2024).

3. Do More In-Session Exposures

Doing exposures together in therapy allows the therapist to model how to stay with fear and resist rituals in real time. This guided practice can build confidence and motivation, and ensure the learning sticks (Jordan et al., 2017).

Key Takeaway

OCD often shifts form, but the underlying process remains the same. By focusing on uncertainty tolerance rather than every new obsession, using flexible exposure methods, and practising these skills repeatedly, ERP can stay effective even as symptoms evolve. The goal isn’t to respond to each new theme — it’s to strengthen the ability to face uncertainty in whatever form OCD takes.

References

  • Ferreri, F., Bourla, A., Peretti, C. S., Segawa, T., Jaafari, N., & Mouchabac, S. (2019). How New Technologies Can Improve Prediction, Assessment, and Intervention in Obsessive-Compulsive Disorder (e-OCD): Review. JMIR mental health, 6(12), e11643. https://doi.org/10.2196/11643

  • Gillihan, S. J., Williams, M. T., Malcoun, E., Yadin, E., & Foa, E. B. (2012). Common Pitfalls in Exposure and Response Prevention (EX/RP) for OCD. Journal of obsessive-compulsive and related disorders, 1(4), 251–257. https://doi.org/10.1016/j.jocrd.2012.05.002

  • Jordan, C., Reid, A. M., Guzick, A. G., Simmons, J., & Sulkowski, M. L. (2017). When exposures go right: Effective exposure-based treatment for obsessive–compulsive disorder. Journal of Contemporary Psychotherapy: On the Cutting Edge of Modern Developments in Psychotherapy, 47(1), 31–39. https://doi.org/10.1007/s10879-016-9339-2

  • Knowles, K. A., & Olatunji, B. O. (2023). Intolerance of uncertainty as a cognitive vulnerability for obsessive-compulsive disorder: A qualitative review. Clinical Psychology: Science and Practice, 30(3), 317–330. https://doi.org/10.1037/cps0000150

  • Pinciotti, C. M., Riemann, B. C., & Abramowitz, J. S. (2021). Intolerance of uncertainty and obsessive-compulsive disorder dimensions. Journal of anxiety disorders, 81, 102417. https://doi.org/10.1016/j.janxdis.2021.102417

  • Ramsey, K. A., Browning, L. E., Chang, A. H., & McGuire, J. F. (2024). Clinician-reported challenges associated with delivery of exposure with response prevention for patients with obsessive-compulsive disorder. Journal of Obsessive-Compulsive and Related Disorders, 42, 100895. https://doi.org/10.1016/j.jocrd.2024.100895

  • Voderholzer, U., Meule, A., Koch, S., Pfeuffer, S., Netter, A. L., Lehr, D., & Zisler, E. M. (2024). Effectiveness of One Videoconference-Based Exposure and Response Prevention Session at Home in Adjunction to Inpatient Treatment in Persons With Obsessive-Compulsive Disorder: Nonrandomized Study. JMIR mental health, 11, e52790. https://doi.org/10.2196/52790

  • Wairauch, Y., Siev, J., Hasdai, U., & Dar, R. (2024). Compulsive rituals in Obsessive-Compulsive Disorder - A qualitative exploration of thoughts, feelings and behavioral patterns. Journal of behavior therapy and experimental psychiatry, 84, 101960. https://doi.org/10.1016/j.jbtep.2024.101960

Ian O Brien
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Past and Present Burdens: Why Co-Occurring Struggles Can Complicate ERP