Harmful ‘ERP’: When Poorly Delivered Therapy Makes OCD Worse
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 one of the most effective treatments for OCD — but only when it’s delivered well.
Many people in my research described experiences where ERP went wrong: exposures were rushed, response prevention wasn’t explained, or the approach was rigid and impersonal. Instead of building confidence, these missteps left people more anxious, confused, or even traumatised.
Some felt pushed into extreme exercises without understanding why. Others were encouraged to distract themselves or perform exposures without guidance — practices that turned ERP into something punishing rather than therapeutic. For many, it wasn’t ERP that failed, but the way it was taught and supported.
This theme looks at what happens when ERP loses its balance — when therapy becomes something done to a person rather than with them — and why skill, safety, and collaboration are essential for the process to work.
Why This Happens
ERP is one of the most effective treatments for OCD — but only when it’s delivered well. Many of the problems people described weren’t about ERP itself, but about how it was implemented. When therapists lack training, supervision, or experience with OCD, key pieces of ERP can be skipped or done incorrectly, leaving clients vulnerable to feeling worse.
Several people in my research study shared that response prevention — the “RP” in ERP — was never explained, leaving them doing exposures while still performing mental rituals. Others were encouraged to distract themselves during exposures, which research shows interferes with learning by preventing you from fully experiencing the anxiety and its natural decline (Gillihan et al., 2012).
Gillihan et al. (2012) highlight common therapist pitfalls, including:
Stopping short of full exposure — leaving “safe areas” untreated, which increases relapse risk.
Choosing the wrong exposure type — using imaginal when in vivo would be more effective (or vice versa).
Encouraging distraction or reassurance — which sends the message that anxiety is intolerable.
Missing mental compulsions — allowing rituals to continue covertly and undermine progress.
Failing to address the core fear — leading to slow progress and symptom-shifting.
Not working with family members — which can allow reassurance and accommodation to persist at home.
These gaps can make ERP feel like punishment rather than therapy — and may leave clients concluding it “doesn’t work” when they never actually experienced it as intended.
The problem isn’t just missing steps; it’s also about rigidity. When ERP is delivered as a one-size-fits-all protocol, without accounting for symptom subtype, co-occurring conditions, or life circumstances, it can feel mechanical and invalidating. The solution isn’t to abandon ERP, but to work with clinicians who can deliver it with fidelity and flexibility — explaining the process clearly, tailoring it to the individual, and building a sense of safety and collaboration.
What Can Help
When ERP is delivered poorly, it’s not just unhelpful — it can actually make symptoms worse. The goal isn’t to abandon ERP, but to work toward the right kind of ERP: skilled, collaborative, and tailored to you.
Here are some things that might help in therapy:
1. Work with a Skilled ERP Therapist
Not every clinician who offers ERP has specialist training in OCD. Look for someone with dedicated ERP education or supervision (e.g., IOCDF’s BTTI or specialist mentorship). A well-trained therapist will explain both exposure and response prevention clearly, and help you understand how rituals are identified and resisted throughout the process.
2. Notice What’s Missing
ERP is not about simply “pushing through.” It depends on staying with anxiety while preventing both overt and mental rituals, so the fear can rise and fall naturally. When this isn’t explained or supported, progress can stall or symptoms can worsen (Gillihan et al., 2012).
3. Shape ERP Around Your Core Fears
Effective ERP focuses on the heart of the fear, not just the surface triggers. Building and revisiting a hierarchy together — and adjusting it as OCD shifts — ensures exposures are challenging but doable, and targeted where they’ll make the biggest difference.
4. Plan for Support Along the Way
ERP can be intense, especially early on. Agreeing in advance on pacing, debriefing, and how to handle overwhelm can make the process more sustainable. Regular check-ins or booster sessions help maintain progress and prevent burnout.
Key Takeaway
Bad ERP isn’t proof that ERP doesn’t work — it’s proof that you deserve better care. When ERP is delivered with proper training, attention to your unique needs, and support for resisting rituals, it can be life-changing. The goal isn’t just to do exposures — it’s to do them safely, collaboratively, and in a way that helps you reclaim your life.
References
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
