Past and Present Burdens: Why Co-Occurring Struggles Can Complicate ERP
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 many, the challenge wasn’t just facing fear — it was doing so while managing depression, burnout, or the lingering effects of trauma. Others described how constant self-criticism or emotional numbness made it difficult to stay present during exposures, limiting the benefits of therapy.
These additional struggles often made ERP feel like a double demand: confronting OCD while also contending with depleted energy or emotional exhaustion. Motivation and focus fluctuated, leaving people unsure how to keep the work going.
This theme explores how co-occurring difficulties such as trauma, mood disorders, or dissociation can complicate ERP — and why effective support sometimes needs to begin by reducing these burdens before meaningful exposure work can take hold.
Why This Happens
For many people, ERP isn’t just about confronting fear — it’s about doing so while already managing other psychological challenges. Depression, anxiety, trauma, ADHD, and related conditions are not side issues but part of daily life for most people with OCD.
A meta-analysis by Sharma et al. (2023) involving over 15,000 individuals found that 69% of people with OCD have at least one psychiatric comorbidity. Mood disorders were 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 figures highlight how comorbidity shapes the experience of ERP. 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 self-criticism can make the process feel daunting. Trauma histories can add further complexity: exposures may inadvertently trigger flashbacks or dissociation, making it difficult to stay present or feel safe enough for learning to occur.
In short, ERP doesn’t happen in isolation. When depression, trauma, or other conditions remain unaddressed, they 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 challenges make ERP hard to sustain, the goal isn’t to “push through.” It’s to create the stability, energy, and safety needed for the work to be effective.
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
Living with depression, trauma, or other conditions can make ERP harder to begin and maintain — but with the right pacing, preparation, and support, progress is still possible. Building stability first allows exposure work to take root. The aim isn’t to tackle everything at once, but to create the conditions where ERP becomes doable and effective, 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
