SaraBrungardt, PhD., LPC

Owner& Director of CalmOCD

Scottsdale,AZ~Tucson,AZ ~ Sandy, UT

Virtualin 15 states

Let me be honest with you about something.

Every week, we sit acrossfrom people with OCD who have already tried to get better. They found atherapist, did the work, and walked away more confused  or more hopeless than when they started. Andalmost every time, the therapy they received had the same name: Exposure andResponse Prevention.

ERP is often called the“gold standard” for treating OCD. In the right hands, it genuinely is. QualityERP, though, is genuinely hard to find and that gap is exactly what this article is about.

This is our attempt toexplain why.

OCD is already misunderstood. Itstreatment isn’t far behind.

The World HealthOrganization ranks OCD among the top ten most debilitating mental healthconditions on the planet. Not top fifty. Top ten. And yet it remains one of themost trivialized, most misrepresented conditions in popular culture, reduced tojokes about hand-washing and “being a little OCD” about organization.

That misunderstandingdoesn’t stop at the general public. It reaches into treatment rooms.

Because OCD is so widelymisunderstood, treating it well requires something most therapists simplyhaven’t been trained to do. And here’s the uncomfortable part: in our field,anyone can call themselves an OCD specialist. Any therapist, psychologist, counselor,social worker, marriage and family therapist, etc., can add the word“specialist” or “coach” to their bio and start booking OCD clients the sameday. No governing body will stop them. No certification is required.

We’re not saying this totear anyone down. We’re saying it because people with OCD deserve to know whatthey’re looking for  and what they shouldrun from.

So what is ERP, really?

Exposure and ResponsePrevention has two parts, and the second one is the part that actually mattersmost.

The Exposure piece meansdeliberately facing the thoughts, images, situations, and triggers that set offyour anxiety and obsessions  instead ofavoiding them. The Response Prevention piece means choosing, in that moment ofdiscomfort, not to do the thing your brain is screaming at you to do.

That thing you feelcompelled to do to make the fear go away is called a compulsion. And compulsions aren’t just physical. Checkingthe lock is a compulsion. So is silently reassuring yourself that you’re a goodperson, mentally replaying an event to make sure nothing bad happened, orGoogling your symptoms at 2 a.m. If you’re doing it to neutralize distress, itcounts.

The logic of ERP iselegant: every time you perform a compulsion, you teach your brain that thefear was real and the ritual kept you safe. Stop the ritual, tolerate thediscomfort, and the brain slowly  butgenuinely  learns otherwise.

When it’s done well, itworks. The problem is how often it isn’t.

Two things good ERP never does

Good ERP is not sudden whenyou walk into a therapist’s office before any psychoeducation is provided. Youdon’t walk into your first session and face your worst fear. A skilledtherapist builds a gradual, collaborative process, one where you’re challenged,yes, but never blindsided.

Good ERP is not extreme.Effective exposures don’t need to be reckless or cruel to be therapeutic. If atherapist is pushing you into things that feel harmful or absurd, that’s notcourage-building. That’s a red flag. Lastly, good ERP gives you results. Itdoesn’t mean you are barely improving.

It starts with education, realeducation

Here’s something thatsurprises a lot of people: the most important part of OCD treatment often isn’tthe exposures. It’s what comes before them. It’s when we build a strongfoundation and when we facilitate the learning process.

Good treatment begins withdeep, thorough psychoeducation  and thateducation should keep showing up throughout the entire therapeutic process, notjust in session one. It means your therapist isn’t just handing you a worksheetor a workbook. They’re helping you understand your brain. What makes your OCDsymptoms increase, what makes them decrease, and how you accomplish this.

That includes understandingyour specific OCD cycle not OCD in the abstract, but yours. Exactly how yourobsessions start, what emotions they stir up, what compulsions follow, and whythat moment of relief feels so convincing even though you know it’s makingthings worse.

It means understandingwhat’s happening neurologically when an intrusive thought hits. Why does thebrain treat certain thoughts like emergencies? Why it’s so hard to just “let itgo.”

It means getting realanswers to the questions you’re probably too afraid to ask out loud: Why do Ihave this? Will it ever actually get better? Could I pass this to my kids? WillI ever have a normal life? What if this isn’t OCD at all and I am just a horribleperson?

It means learning how torespond to intrusive thoughts  becausethat’s a skill, and it has to be taught. It means learning to process theemotions OCD generates: the anxiety, yes, but also the shame, the guilt, the bone-deepfear that something is fundamentally wrong with you.

And it means understandingyour own compulsions fully enough to start resisting them  including the ones that live entirely insideyour head.

The bigger picture

ERP is evidence-basedtreatment for OCD  but the best caredoesn't stop there. Skilled OCD specialists draw from multiple evidence-basedmodalities to support healing from every angle. Acceptance and Commitment Therapy(ACT) helps you stop fighting your thoughts and start living according to yourvalues anyway. Mindfulness teaches you to observe your mental experiencewithout being consumed by it. Metacognitive Therapy shifts your relationshipwith your thoughts at a deeper level, targeting the beliefs you hold about yourthinking itself. Dialectical Behavior Therapy (DBT) builds the emotionalregulation skills that make the hard work of recovery not just possible, butsustainable.Radically Open DBT (RO-DBT) addresses overcontrol, rigidperfectionism, emotional suppression, and social disconnection that can driveand maintain OCD symptoms by teaching openness, flexibility, and genuineconnection. Family-based approaches like Supportive Parenting for AnxiousChildhood Emotions (SPACE) help the people who love you stop accidentallymaking things worse. Inference-Based CBT (I-CBT) helps you identify and correctthe faulty reasoning processes that fuel obsessional doubt without requiringexposure exercises (and can be used as a stand alone treatment).

None of this replaces ERP.It’s what makes ERP stick.

What we actually want for ourclients

Our job isn’t to reduceyour anxiety score. Our job is to understand your brain so completely  every pattern, every trap, every way your OCDhas learned to hook you  so we can teachyou how to outmaneuver it.

But more than that, our jobis to make sure you stop feeling like a victim of your own mind. There areparts within the OCD experience that are out of your control; however, peopleare always surprised to learn that there are actually things that are in yourcontrol.

We want our clients to wakeup knowing  not hoping, knowing  they can handle whatever OCD throws at themeach day. That confidence doesn’t come from avoiding triggering things orperfectly managed anxiety levels. It comes from having done the hard thing andlearning something from it.

That’s what we celebrate.Not low anxiety- learning.

Are you holding your childfor the first time in months? Are you sitting with discomfort and not fallingapart? Are you noticing that the mental ritual you’ve been doing for yearsnever actually kept you safe? Are you engaging with friends again?

The brain is building newpathways and that is what healing looks like.

One last thing

If your OCD therapistspends your sessions asking how your exposures went and moving on — no deeperprocessing, no pattern recognition, no working through what happened and whythat’s not enough. ERP works, but it doesn’t work in a vacuum. The conversationmatters enormously.

Why this discussion matters: Therisk

The suicide risk in OCD iswidely considered to be underestimated. Since it takes on average at least adecade for someone to receive an accurate OCD diagnosis, and 95% of thosediagnosed with OCD do not receive the most effective treatment (Deusser et al.,2025).

In clinical samples, themean rate of lifetime suicide attempts is 14.2%, ranging across studies from 6%to 51.7% (Albert et al., 2019). One study shows suicide risk is 10 times morelikely in those suffering from OCD (Fernández de la Cruz et al., 2017).

This is why we’re speakingout. The stakes of getting this wrong are not abstract. They are not clinical.They are fatal.

PartTwo is coming: What do exposures actually look like in OCD treatment?

There’smore to say and it matters.

Albert U, De RonchiD, Maina G, Pompili M. Suicide Risk in Obsessive-Compulsive Disorder andExploration of Risk Factors: A Systematic Review. Curr Neuropharmacol.2019;17(8):681-696. doi: 10.2174/1570159X16666180620155941. PMID: 29929465;PMCID: PMC7059158.

Deusser, R., Saxena, S.,McCracken, A., Tentoni, N., Cogen, S., Crofut, R., Litvin, B., & Arfanakis,J. (2025). America's OCD care crisis: National findings on the failure ofeffective OCD treatment to reach patients. International OCD Foundation. https://iocdf.org/wp-content/uploads/2025/12/Full-Report-Americas-OCD-Care-Crisis-12-9-2025.pdf

Fernández de la Cruz, L., Rydell, M., Runeson, B.,D'Onofrio, B.M., Brander, G., Rück, C., Lichtenstein, P., Larsson, H., &Mataix-Cols, D. (2017). "Suicide in obsessive–compulsive disorder:a population-based study of 36,788 Swedish patients." MolecularPsychiatry. Published online July 19, 2016.