Out of Reach: When OCD Fears Feel Hard to Capture 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.

Not all fears are easy to recreate in therapy. Some obsessions are abstract, situational, or deeply tied to specific life contexts — which can make ERP difficult to plan or sustain.

Many people in my research described their fears as “slippery,” hard to bring into the room or to reproduce on demand. Imaginal exposures often felt artificial, while real-life triggers appeared too unpredictably to practise with consistency. For others, ERP depended on circumstances that didn’t always arise, making regular practice difficult to maintain.

This left many feeling stuck between understanding what ERP required and not knowing how to make it happen. The anxiety was real — but the pathway to evoke it safely and intentionally often felt out of reach.

Why This Happens

When obsessions are abstract, situational, or primarily mental, ERP can feel difficult to anchor. People in research studies often said their fears didn’t seem to “fit the system” (Leeuwerik et al., 2023), and repeated trial-and-error attempts to trigger anxiety felt frustrating or unproductive.

Clinicians encounter similar challenges. Baird (2020) described therapists feeling “lost in the complexity” when working with taboo content or co-occurring conditions, which sometimes led them to rely on rigid protocols — symptom checklists and hierarchies — that left clients feeling boxed in. Ramsey et al. (2024) similarly found that sexual, harm, and religious obsessions were among the hardest to design exposures for. These themes often required imaginal exercises (over 80% of the time for sexual and harm, 53% for religious), which many clinicians viewed as less effective than in-vivo work.

This matters because, as Leeuwerik et al. (2023) noted, when exposures feel irrelevant or artificial, motivation tends to drop and engagement becomes harder to sustain.

When OCD themes are less accessible, ERP needs creativity and collaboration. The goal isn’t to push harder, but to build a bridge between lived experience and exposure work — through imaginal exercises that feel emotionally connected, values-based experiments, or learning to stay present long enough for new learning to take hold.

What Can Help

When your obsessions don’t seem to fit into a typical ERP plan, the answer isn’t to push through exposures that feel irrelevant or impossible — it’s to adapt ERP so it feels meaningful and doable.

Here are some things that might help in therapy:

1. Make Exposures More Real and Engaging

If imaginal exposures feel too abstract, they can be strengthened by using your own words, adding sensory details, or recording them for replay between sessions (Gillihan et al., 2012). Therapist-led exposures can also make a difference — seeing how to stay with anxiety long enough for learning to occur helps build confidence and skill (Jordan et al., 2017).

2. Get Creative With Hard-to-Reach Fears

When fears can’t easily be recreated — such as harm coming to others, moral failures, or existential worries — exposures can still target the underlying uncertainty. Approaches like imaginal exercises, values-based exposures, or even virtual-reality–assisted ERP can make difficult themes more accessible (Ramsey et al., 2024; Ferreri et al., 2019). For some, it helps to take exposures beyond the therapy room — practising them in real-world settings, over video or phone, or even with the therapist accompanying them into daily environments where triggers naturally occur.

3. Expect Trial-and-Error

When obsessions don’t fit neatly into standard ERP, it often takes experimenting to find what works. Testing and adjusting exposures is not a sign of failure but part of the process (Leeuwerik et al., 2023). Ongoing collaboration and refinement help keep exposures relevant, challenging, and effective.

Key Takeaway

When OCD fears feel too abstract, complex, or situational to access, it doesn’t mean ERP can’t help — it means the plan needs to adapt. Working collaboratively to design exposures that feel relevant, achievable, and grounded in your values can turn “out of reach” fears into opportunities for meaningful progress.

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].

  • 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

  • Leeuwerik, T., Caradonna, G., Cavanagh, K., Forrester, E., Jones, A.‐M., Lea, L., Rosten, C., & Strauss, C. (2023). A thematic analysis of barriers and facilitators to participant engagement in group exposure and response prevention therapy for obsessive–compulsive disorder. Psychology and Psychotherapy: Theory, Research and Practice, 96(1), 129–147. https://doi.org/10.1111/papt.12430

  • 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

Ian O Brien
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