Exposed by Exposure: When ERP Means Facing Shame as Well as Fear
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.
ERP is designed to help you face fear — but for many, the hardest part isn’t the exposure itself. It’s exposing your inner world.
A strong pattern from my research was that people often struggled to share their most private or taboo obsessions — around harm, sexuality, or morality. Some said they couldn’t tell anyone, even their therapist, what was really happening in their mind. Staying silent only made things worse, giving intrusive thoughts more power and deepening isolation.
Shame threaded through many of these stories. People described feeling deeply self-conscious about their thoughts, terrified of being judged, or convinced that their reactions — like unwanted arousal — proved something awful about them. For some, ERP wasn’t just about facing fear; it also meant revealing parts of themselves they’d spent years hiding.
This theme explores how shame can make ERP feel impossible to begin — and what helps create enough safety and understanding to start sharing what’s really going on.
Why This Happens
Shame can feel like a lock on the door to therapy — and ERP can feel like being asked to throw that door wide open. Laving et al. (2023) found a significant, moderate link between OCD severity and shame overall. Shame was particularly associated with dimensions involving taboo or ego-dystonic thoughts, such as harm and unacceptable thoughts. These fears can feel like they say something terrible about who you are, which makes sharing them feel risky.
Public misunderstanding only makes this harder. In one study, most people recognised contamination OCD as OCD, but only about a third recognized harm or taboo obsessions — and those were the ones they found most frightening and unacceptable (McCarty et al., 2017). If the wider world sees these thoughts as dangerous or “wrong,” it’s no wonder many people keep them secret — sometimes for years.
But staying silent has a cost. Several people in my research said their intrusive thoughts only grew louder and more consuming when they didn’t talk about them. For ERP to work, the feared thoughts have to be named and brought into the open so they can be faced safely in therapy.
This is why the therapeutic relationship matters so much. Studies show that feeling respected, validated, and unjudged is what gives people the courage to share their most private fears and stick with ERP (Lee & Rees, 2011; Marsden et al., 2018). For some, online therapy can even make this step easier, offering a sense of distance and privacy that makes disclosure feel safer (Knopp-Hoffer et al., 2016).
Put simply: shame keeps OCD in the dark. Therapy has to offer enough light — through safety, trust, and validation — so that you can bring even the most feared thoughts into the open.
What Can Help
Feeling exposed by ERP can be one of the hardest parts of therapy — but you don’t have to face it all at once.
Here are some things that might help in therapy:
1. Build safety first
What often makes ERP possible isn’t just the techniques — it’s the sense that your therapist truly sees you, respects you, and won’t judge you. Research shows that this feeling of safety and trust is often what unlocks real progress in ERP (Lee & Rees, 2011; Baird, 2020). Slowing down to build that foundation can make it far easier to face difficult material later.
2. Normalise the thoughts
Almost everyone experiences unwanted, intrusive thoughts from time to time (Radomsky et al., 2014). What makes them distressing in OCD is how out of sync they feel with your values. Understanding this — that the thoughts themselves aren’t dangerous or revealing, just misinterpreted — can reduce shame and make it easier to talk about them openly.
3. Use language that softens shame
How we talk about OCD matters. Using accurate, compassionate language — like “harm-themed OCD” rather than “violent thoughts” — helps separate the person from the problem. It signals that the thoughts are symptoms, not reflections of character, and can make sharing them less daunting.
4. Ease into disclosure
If saying taboo thoughts aloud feels impossible, start smaller. Writing them down, using worksheets, or even discussing them in broader terms first can help build comfort and trust over time. Gradual disclosure is still progress.
5. Strengthen shame resilience
Approaches that focus on self-compassion and emotional regulation — such as ACT, CFT, or mindfulness-based work — can help you stay grounded when shame flares up (Dearing & Tangney, 2011). These tools make it easier to face exposures without being derailed by self-criticism or guilt.
Key Takeaway
Shame can make ERP feel impossible — but it isn’t a dead end. With safety, normalisation, supportive language, and structured steps, you can bring even your most private fears into the open and finally target what matters most.
References
Baird, N. E. V. (2020). “Desperately banging on the door”: High-intensity therapist’s experience of delivering cognitive behavioural therapy to individuals with obsessive compulsive disorder: A thematic analysis (Unpublished doctoral thesis). [University of East London].
Dearing, R. L., & Tangney, J. P. (Eds.). (2011). Shame in the therapy hour. American Psychological Association. https://doi.org/10.1037/12326-000
Knopp-Hoffer, J., Knowles, S., Bower, P., Lovell, K., & Bee, P. E. (2016). 'One man's medicine is another man's poison': a qualitative study of user perspectives on low intensity interventions for Obsessive-Compulsive Disorder (OCD). BMC health services research, 16, 188. https://doi.org/10.1186/s12913-016-1433-3
Laving, M., Foroni, F., Ferrari, M., Turner, C., & Yap, K. (2023). The association between OCD and Shame: A systematic review and meta-analysis. The British journal of clinical psychology, 62(1), 28–52. https://doi.org/10.1111/bjc.12392
Lee, Y. H., & Rees, C. S. (2011). Is exposure and response prevention treatment for obsessive–compulsive disorder as aversive as we think? Clinical Psychologist, 15(1), 17–21. https://doi.org/10.1111/j.1742-9552.2011.00001.x
Marsden, Z., Teahan, A., Lovell, K., Blore, D., & Delgadillo, J. (2018). Patients' experiences of cognitive behavioural therapy and eye movement desensitisation and reprocessing as treatments for obsessive‐compulsive disorder. Counselling & Psychotherapy Research, 18(3), 251–261. https://doi.org/10.1002/capr.12159
McCarty, R. J., Guzick, A. G., Swan, L. K., & McNamara, J. P. H. (2017). Stigma and recognition of different types of symptoms in OCD. Journal of Obsessive-Compulsive and Related Disorders, 12, 64–70. https://doi.org/10.1016/j.jocrd.2016.12.006
Radomsky, A. S., Alcolado, G. M., Abramowitz, J. S., Alonso, P., Belloch, A., Bouvard, M., Clark, D. A., Coles, M. E., Doron, G., Fernández-Álvarez, H., Garcia-Soriano, G., Ghisi, M., Gomez, B., Inozu, M., Moulding, R., Shams, G., Sica, C., Simos, G., & Wong, W. (2014). Part 1—You can run but you can't hide: Intrusive thoughts on six continents. Journal of Obsessive-Compulsive and Related Disorders, 3(3), 269–279. https://doi.org/10.1016/j.jocrd.2013.09.002
