Let Down: When ERP Isn’t Enough or OCD Comes Back

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.

ERP can be life-changing — but for some, it doesn’t feel like enough.

Many people in my research described feeling under-supported by the limits of standard therapy. Weekly sessions couldn’t always match the intensity of their OCD, leaving them to face powerful symptoms with little day-to-day structure or guidance. Others spoke about the discouragement of relapse — when symptoms returned after a period of real progress.

For some, the disappointment came from believing they were “done” with OCD, only to find it resurfacing months later. That return often brought confusion and doubt about what recovery really means.

These experiences highlight an important reality of ERP: progress can fluctuate, and ongoing support beyond the therapy room is often key to maintaining change.

Why This Happens

When ERP feels like it “wasn’t enough,” it may not mean the therapy failed — but that the intensity didn’t match the severity of the OCD. Weekly outpatient sessions are often effective for mild to moderate symptoms, but more severe or entrenched OCD sometimes needs a stronger dose of treatment. In these cases, intensive formats such as residential or inpatient programs can offer significant benefits. A meta-analysis by Veale et al. (2016) found large improvements in OCD symptoms for people admitted to specialist programs, suggesting that for some, a higher level of care can make ERP more effective.

Relapse can also contribute to feeling “let down.” OCD naturally waxes and wanes (Sharma & Math, 2019), so flare-ups are common — sometimes years later — yet many people aren’t given a relapse-prevention plan. Without clear guidance, a return of symptoms can feel like therapy “didn’t work,” rather than a normal part of long-term management.

Finally, certain factors can increase the likelihood of needing more intensive support. Research shows that severe depression, being without a partner, and lower quality of life can predict the need for higher-intensity treatment (du Mortier et al., 2021). This means that effective treatment often needs to address broader wellbeing — including mood, relationships, and functioning — alongside ERP to sustain progress.

What Can Help

When ERP feels like “not enough,” the solution isn’t to give up — it’s to adjust the level of support and plan for long-term progress.

Here are some things that might help in therapy:

1. Talk About Treatment Intensity

Weekly ERP sessions are often effective for mild to moderate OCD, but more severe or long-standing symptoms may need a higher level of care. Intensive outpatient programs (IOP), day treatment, or residential ERP can provide the momentum and structure required for deeper progress, especially when symptoms feel unmanageable in weekly therapy.

2. Explore Flexible Formats

If full-time treatment isn’t feasible, there are still ways to increase intensity — such as adding a second weekly session, extending session length, or incorporating therapist-supported telehealth ERP (Machado-Sousa et al., 2023). These options can maintain continuity and reduce the “reset” feeling between sessions.

3. Plan for Early Warning Signs

Relapse prevention starts with awareness. Mapping out early indicators that OCD is creeping back — such as spending more time on compulsions, avoiding exposures, or noticing new themes — allows for timely adjustments before symptoms escalate (Külz et al., 2020).

4. Prepare for OCD’s Changing Course

OCD naturally fluctuates, with periods of remission and relapse (Sharma & Math, 2019). Symptoms may also shift in focus, which can feel discouraging if unexpected. Normalising this pattern and planning ahead helps prevent future flare-ups from feeling like failure.

5. Create a Written Relapse Plan

A clear, step-by-step plan for responding to setbacks — including when to restart self-directed ERP, when to schedule a booster session, and which supports to draw on — can make future episodes less overwhelming and more manageable.

Key Takeaway

Feeling like ERP “wasn’t enough” doesn’t mean the therapy failed — it means a different level or format of support may be needed. Effective OCD care adapts over time, balancing structure, intensity, and relapse planning so that progress can continue even when symptoms fluctuate. The goal isn’t to complete ERP once, but to have the right tools and plan to keep moving forward.

References

  • du Mortier, J. A. M., Remmerswaal, K. C. P., Batelaan, N. M., Visser, H. A. D., Twisk, J. W. R., van Oppen, P., & van Balkom, A. J. L. M. (2021). Predictors of Intensive Treatment in Patients With Obsessive-Compulsive Disorder. Frontiers in psychiatry, 12, 659401. https://doi.org/10.3389/fpsyt.2021.659401

  • Külz, A. K., Landmann, S., Schmidt-Ott, M., Zurowski, B., Wahl-Kordon, A., & Voderholzer, U. (2020). Long-Term Follow-up of Cognitive-Behavioral Therapy for Obsessive-Compulsive Disorder: Symptom Severity and the Role of Exposure 8-10 Years After Inpatient Treatment. Journal of cognitive psychotherapy, 34(3), 261–271. https://doi.org/10.1891/JCPSY-D-20-00002

  • Machado-Sousa, M., Moreira, P. S., Costa, A. D., Soriano-Mas, C., & Morgado, P. (2023). Efficacy of internet-based cognitive-behavioral therapy for obsessive-compulsive disorder: A systematic review and meta-analysis. Clinical Psychology: Science and Practice, 30(2), 150–162. https://doi.org/10.1037/cps0000133

  • Sharma, E., & Math, S. B. (2019). Course and outcome of obsessive-compulsive disorder. Indian journal of psychiatry, 61(Suppl 1), S43–S50. https://doi.org/10.4103/psychiatry.IndianJPsychiatry_521_18 

  • Veale, D., Naismith, I., Miles, S., Gledhill, L. J., Stewart, G., & Hodsoll, J. (2016). Outcomes for residential or inpatient intensive treatment of obsessive–compulsive disorder: A systematic review and meta-analysis. Journal of Obsessive-Compulsive and Related Disorders, 8, 38–49. https://doi.org/10.1016/j.jocrd.2015.11.005

Ian O Brien
Previous

Harmful ‘ERP’: When Poorly Delivered Therapy Makes OCD Worse
Next

Out of Reach: When OCD Fears Feel Hard to Capture in ERP