Past and Present Burdens: Why Co-Occurring Struggles Can Complicate 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.

One clear pattern from my research was how much people were already carrying before ERP even began.

For some, the challenge wasn’t just facing fear — it was doing so while living with depression, burnout, or the lingering effects of past trauma. Others described how constant self-criticism or emotional numbness made it hard to stay present during exposures, leaving them unable to benefit from the process.

These added struggles often made ERP feel like fighting two battles at once: one against OCD, and another against yourself. The motivation, energy, or emotional availability needed for ERP simply wasn’t there — or came and went in waves.

This theme explores how co-occurring difficulties like trauma, mood disorders, or dissociation can make ERP feel out of reach, and why effective support sometimes needs to begin by lightening those burdens before meaningful exposure work can start.

Why This Happens

For many, ERP isn’t just about facing fears — it’s about doing so while already carrying a heavy psychological load. Depression, anxiety, trauma, ADHD, and other co-occurring conditions are not side issues but part of daily life for most people with OCD.

Sharma et al.’s (2023) meta-analysis of over 15,000 individuals found that 69% of people with OCD have at least one psychiatric comorbidity. Mood disorders were the most common (48%), followed by anxiety disorders (32%), ADHD (16%), tic disorders (14%), and obsessive–compulsive–related disorders (14%). Personality disorders were present in over a third of adults (35%), with OCPD the most frequent (17%).

These numbers matter because comorbidity isn’t just a statistic — it shapes what ERP feels like. People with depression often describe struggling to “summon the strength” to do exposures, let alone complete homework between sessions (Leeuwerik et al., 2023). Low motivation, fatigue, and harsh self-criticism can make ERP feel like an impossible demand. Similarly, trauma histories can complicate exposure work: for some, exposures inadvertently trigger flashbacks or dissociation, making it difficult to stay present or feel safe.

The key takeaway: ERP doesn’t happen in a vacuum. Untreated depression, trauma, or other conditions can drain the energy and focus needed for exposure work, increase dropout risk, and make ERP feel overwhelming.

What Can Help

When depression, trauma, or other burdens make ERP feel unmanageable, the solution isn’t to simply “push harder.” Instead, it’s about creating the right foundation — enough stability, energy, and safety — so ERP becomes something you can engage with.

Here are some things that might help in therapy:

1. Assess ERP readiness and set the right pace

Before starting exposures, it helps to check whether this is the right time — and at what intensity. Gordon et al. (2023) note that issues such as suicidality, self-injury, substance use, or medically unstable eating behaviours can make ERP unsafe or ineffective until they’re stabilised. Depression and trauma can also slow progress if not supported alongside OCD work. This doesn’t mean ERP is off the table — it means pacing and sequencing matter. Sometimes that involves starting with shorter sessions, weaving in skills or psychoeducation first, or tackling avoidance in smaller steps before moving to the hardest fears.

2. Integrate trauma- and depression-informed approaches

When trauma or dissociation is part of the picture, ERP may need to be paired with grounding or trauma-sensitive methods — such as trauma-informed ERP, prolonged exposure, or mindfulness-based interventions — to prevent retraumatisation (Gorbis et al., 2024). If depression is present, behavioural activation and structured problem-solving can help restore energy and motivation, making ERP more sustainable over time.

3. Ask for extra support between sessions

Low mood or energy can make it hard to stay consistent. Leeuwerik et al. (2023) found that participants with co-occurring depression often benefited from added contact between sessions — such as brief check-ins, reminders, or structured accountability — to maintain engagement. Extra scaffolding helps keep progress steady even when motivation dips.

4. Normalise the emotional weight of the work

Knowing that nearly 70% of people with OCD also live with another mental health condition (Sharma et al., 2023) can help reduce shame about struggling. Framing ERP as something that can be tailored to your current capacity — not a test of willpower — helps shift the focus from “doing it right” to “doing it sustainably.”

5. Build a bigger support system

Sometimes ERP works best when it’s part of a broader plan. Involving family, peer support, medication management, or adjunct therapies can create a stronger base of stability. When the work is shared, ERP stops feeling like something carried alone and starts feeling more supported and achievable.

Key Takeaway

When you’re carrying depression, trauma, or other burdens, ERP can feel impossible — but that doesn’t mean you can’t recover. With the right pacing, extra support, and a plan that takes your whole life into account, ERP can become something you can do — one step at a time.

References

  • Gorbis, E., Gorbis, A., & Jajoo, A. (2024). Clinical insights into PTSD and OCD comorbidity. International Journal of Biomedical Research & Practice, 4(3), 1-9.

  • Gordon, C., Gasbarro, A., Wendell, V., Fischer, S., Hardin, R., & Marino, J. (2023). Assessing exposure and response prevention readiness for clients with obsessive compulsive disorder and co-occurring conditions: A decision-making model and case example. Professional Psychology: Research and Practice, 54(4), 305–313. https://doi.org/10.1037/pro0000516

  • 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

  • Sharma, E., Sharma, L. P., Balachander, S., Lin, B., Manohar, H., Khanna, P., Lu, C., Garg, K., Thomas, T. L., Au, A. C. L., Selles, R. R., Højgaard, D. R. M. A., Skarphedinsson, G., & Stewart, S. E. (2021). Comorbidities in Obsessive-Compulsive Disorder Across the Lifespan: A Systematic Review and Meta-Analysis. Frontiers in Psychiatry, 12, 703701. https://doi.org/10.3389/fpsyt.2021.703701 

Ian O Brien
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Exposed by Exposure: When ERP Means Facing Shame as Well as Fear