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 could make recovery feel like a game of whack-a-mole — exhausting, confusing, and at times demoralising.

Even when exposures were going well, mental compulsions often slipped in unnoticed, undoing hard-won gains. For others, OCD turned its attention to the therapy itself — demanding that ERP be done “perfectly” or turning self-monitoring into another ritual.

When this happens, ERP can start to feel less like freedom and more like another trap — progress overshadowed by the sense that OCD is always one step ahead.

Why This Happens

One of the trickiest things about OCD is its ability to keep moving the goalposts. Research shows that when one obsession quiets down, another often pops up — usually within the same “dimension” of OCD (Pinciotti et al., 2021). For example, someone who grew up with moral scrupulosity may later develop existential fears, both fuelled by the same intolerance of uncertainty. If ERP only targets the surface fear, it can feel like playing whack-a-mole: you beat one obsession, and another quickly takes its place.

Mental compulsions make this even more complicated. They’re often mistaken for “just thoughts” and missed in treatment (Gillihan et al., 2012). But research by Wairauch et al. (2024) shows they are far from passive. People performing mental compulsions are usually highly focused, concentrating intently to “get them right.” These rituals deliver immediate relief (negative reinforcement) and sometimes even a sense of control (positive reinforcement), which makes them incredibly sticky. It also explains why being told to “just stop ruminating” rarely works — the compulsion is serving a powerful function.

Wairauch and colleagues also found that compulsions evolve over time, adding new rules or steps to keep their anxiety-reducing power. This means ERP can sometimes feel like it’s chasing after a moving target. Unless treatment is aimed at the underlying process — the need for certainty, or for things to feel “just right” — OCD can keep reinventing itself in new ways.

Therapists can unintentionally reinforce this cycle if they focus only on the most visible rituals or the current obsessional theme. Pinciotti et al. (2021) recommend designing exposures that aim at the bigger picture — helping you learn to tolerate uncertainty itself, not just today’s fear. That way, when OCD shifts, the learning still applies, and you’re not left feeling like you have to start all over again.

What Can Help

When OCD keeps “shifting the target,” the goal isn’t to chase each new theme forever — it’s to build skills that work across themes, so you’re not starting from scratch every time.

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 will always try to change the rules — but therapy can get ahead of it. By targeting the process (intolerance of uncertainty) rather than every new obsession, using creative exposures, and practicing flexibility, you build skills that work across themes. The goal isn’t to win every single whack-a-mole battle — it’s to stop playing the game on OCD’s terms.

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