Clinical Psychologist Dr Emily O’Leary from the OCD Clinic Brisbane explores what makes Exposure and Response Prevention so effective, so challenging, and so deeply human.
A quote you might hear from me often is: “The thing about OCD recovery is that it asks you to be brave before you feel ready. But readiness comes in the doing, not the waiting,” by Dr. Steven Phillipson, Clinical Psychologist.
And this is so true in what I see in my day-to-day practice. I believe there is real bravery in those who face their fears on purpose. In therapy, it doesn’t always look dramatic. Sometimes it’s as simple as choosing to not google your symptom this time, or walking away from the stove without checking that the gas is off, or letting a thought go without seeking reassurance from your partner.
These brave moments – gentle, ordinary, yet profound – sits at the heart of Exposure and Response Prevention (ERP), the gold-standard treatment for obsessive–compulsive disorder (OCD).
At the OCD Clinic Brisbane, ERP forms the backbone of how we help people reclaim their lives. It’s grounded in science and decades of clinical research. But behind those impressive results is another truth: ERP is also incredibly hard. For some, it feels almost impossible.
What the Numbers Tell Us
While ERP is widely recognised as an effective treatment for OCD, the statistics tell a more complex story. Around half of all people who begin ERP do not experience significant improvement. Another quarter drop out before completing therapy, and about the same number never begin at all.
That’s not a small minority – that’s nearly half of everyone who considers ERP.
It’s a sobering statistic that raises an important question:
If ERP works so well, why do so many people find it difficult to begin or stay the course?
A Universal Struggle: Why Fear Feels So Personal
At its heart, ERP isn’t just about OCD. It’s about something profoundly human – the tension between safety and growth.
As humans, we all crave comfort, even when it keeps us stuck. ERP shines a light and pushes against that instinct, and asks people to sit with discomfort long enough to realise they can survive it.
It’s a process that mirrors courage in everyday life – the same courage it takes to have a hard conversation, to face uncertainty, or to let go of control.
This is why ERP feels so deeply personal. It doesn’t just treat fear; it teaches freedom.
What Makes ERP So Challenging
Researchers have spent years exploring why ERP can be so confronting – and their findings reveal both personal and systemic factors that shape how people experience treatment. There are six key points, as a clinician, I want everyone to know:
- ERP Is Intentionally Confronting
That’s right, you heard me. Although it sounds mean, ERP asks people to face their fears deliberately, and to resist the urge to make things feel “safe.” It’s the reason it works, but also the reason it can feel so intense.
Without enough preparation or emotional support, the discomfort that makes ERP effective can quickly become overwhelming. Instead of being a bridge to recovery, it can feel like a wall that’s too high to climb.
“ERP isn’t about being fearless – it’s about learning that fear doesn’t have the final say.” - The Rationale Doesn’t Always Land
One of the strongest predictors of success in ERP isn’t courage – it’s understanding.
When clients truly grasp why they’re doing ERP – that it’s not punishment but a process of retraining the brain – they’re far more likely to stay engaged. When the “why” is unclear, therapy can feel confusing or even cruel.
“Understanding the ‘why’ isn’t just educational – it’s emotional safety.” - ERP Can Feel Too Rigid or Impersonal
Some clients describe ERP as overly structured or mechanical. Others say their treatment didn’t fully reflect the complexity of their OCD – especially when their compulsions were mental rather than visible.
If therapy feels generic or disconnected from lived experience, engagement becomes difficult. ERP works best when it’s flexible, creative, and deeply personal.
Therapist Factors Matter – A Lot
Not all ERP is created equal. The way therapy is delivered matters. When therapists rush exposures, offer reassurance, or focus only on surface symptoms, clients can feel unseen and unsupported.
ERP is as much about relationship as it is about repetition. People stay in therapy when they feel understood, safe, and guided by someone who truly knows OCD. So they stand firm and confident in the plan when they are struggling.
Mental Compulsions Are Often Missed
ERP is often shown using visible rituals like checking or cleaning. But many people perform mental compulsions – silent reassurance-seeking, repeating phrases, or mentally reviewing events.
If these are overlooked, progress can stall. Recognising and addressing the invisible side of OCD is essential for real change.
Life Outside Therapy Gets in the Way
Even with motivation, real life can make ERP hard to maintain. Depression, trauma, family pressures, or financial stress can all disrupt the process. We often hear in the clinic, “I couldn’t do my ERP homework this week because XYZ,” and we get it.
No one practices ERP in isolation. Therapy happens in the context of life – and sometimes, life itself is the biggest barrier. Finding ways to overcome these barriers is key to success in treatment.
What This Means for Therapy
None of this means ERP isn’t effective. It absolutely is. But the way it’s delivered matters deeply.
Research consistently shows that ERP works best when it’s:
- Clearly explained and collaboratively planned
- Personalised to each person’s fears, values, and context
- Delivered by therapists with specialist training in OCD
- Supported by a strong, trusting therapeutic relationship
At OCD Clinic Brisbane, this is our focus. We slow down the process. We spend time helping people understand the why before they face the what. We adapt exposures thoughtfully and build compassion into every step.
“Courage isn’t built by force – it’s built by safety.”
Final Thoughts: You’re Not Failing – The Model Might Be
If you’ve found ERP difficult, overwhelming, or disappointing, it doesn’t mean you’re beyond help. And it certainly doesn’t mean you didn’t try hard enough.
It may simply mean that the therapy wasn’t yet shaped around you – your life, your needs, your form of OCD.
The next step in the evolution of ERP isn’t about making people tougher; it’s about making therapy wiser – combining the science that works with the compassion that heals.
Because ERP isn’t about erasing fear.
It’s about rediscovering freedom, one brave moment at a time.
References
Abramowitz, J. S., Blakey, S. M., Reuman, L., & Buchholz, J. L. (2018). New Directions in the Cognitive-Behavioral Treatment of OCD: Theory, Research, and Practice. Behavior Therapy, 49(3), 311–322.
Bevan, A., Oldfield, V. B., & Salkovskis, P. M. (2010). A qualitative study of the acceptability of an intensive format for the delivery of cognitive-behavioural therapy for obsessive-compulsive disorder. The British Journal of Clinical Psychology, 49(Pt 2), 173–191.
Farris, S. G., McLean, C. P., Van Meter, P. E., Simpson, H. B., & Foa, E. B. (2013). Treatment response, symptom remission, and wellness in obsessive-compulsive disorder. The Journal of Clinical Psychiatry, 74(7), 685–690.
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.
Lee, Y. H., & Rees, C. S. (2011). Is exposure and response prevention treatment for obsessive–compulsive disorder as aversive as we think? Clinical Psychologist, 15(1), 17–21.
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.
Marsden, Z., Teahan, A., Lovell, K., Blore, D., & Delgadillo, J. (2018). Patients’ experiences of cognitive behavioural therapy and eye movement desensitisation and reprocessing as treatments for obsessive‐compulsive disorder. Counselling & Psychotherapy Research, 18(3), 251–261.
Millar, J. F. A., Halligan, S. L., Gregory, J., & Salkovskis, P. M. (2020). When cognitive behavioural therapy for obsessive-compulsive disorder fails: Service user perspectives. [Unpublished doctoral thesis]. University of Bath.
Öst, L. G., Havnen, A., Hansen, B., & Kvale, G. (2015). Cognitive behavioral treatments of obsessive-compulsive disorder: A systematic review and meta-analysis of studies published 1993–2014. Clinical Psychology Review, 40, 156–169.
Wheaton, M. G., & Chen, S. R. (2021). Homework completion in treating obsessive–compulsive disorder with exposure and ritual prevention: A review of the empirical literature. Cognitive Therapy and Research, 45(2), 236–249.
