Practical Tips for Overcoming OCD Treatment Challenges

As clinicians treating obsessive-compulsive disorder (OCD), we've all been there: sitting across from a client who desperately wants to get better but seems to hit every possible roadblock when it comes to exposure and response prevention (ERP). You've crafted the perfect exposure hierarchy, explained the rationale with the enthusiasm of a TED talk speaker, and yet your client is still avoiding that doorknob like it's radioactive.

Sound familiar? In a recent comprehensive survey completed by Ramsey et al. (2024), 228 clinicians revealed what many of us already suspected: 92.8% of clinicians endorsed at least one challenge in the use of exposures when treating OCD clients. The good news? You're definitely not alone in this struggle. The even better news? There are evidence-based strategies to help us navigate these common pitfalls.

The Compliance Conundrum: When Homework Doesn’t Happen

The elephant in the clinical room is often compliance and motivation. Of the client-related challenges endorsed by clinicians, these issues topped the list. A client may nod enthusiastically, agreeing to touch three doorknobs between sessions, and then return the following week without having laid a hand on a single one.

The research backs up our clinical observations—greater levels of homework adherence are associated with better clinical improvements in the context of ERP, making this challenge particularly crucial to address.

So how do we encourage clients to put the work into homework?

• Start Small, Think Big: Rather than assigning three doorknobs, start with one. Better yet, start with a doorknob they already touch daily but with a twist—have them touch it without immediately washing their hands. The key is building momentum through successive approximations. If your client is struggling with the latter, work with them to touch your doorknob, sit back down, talk it out, and then offer them your sanitizer.
• Technology as Your Treatment Ally: Mobile health applications have shown promise in supporting between-session exposures. Usage of mHealth applications (e.g., NOCD or Liberate) outside of office can support clients' success in completing OCD exposures. Think of these tools as your digital co-counsel, providing gentle nudges and tracking capabilities when you're not there.
• The Buddy System: Consider implementing what some researchers call “community E/RP helpers”. These trained “coaches” or personnel at the Bachelors' level, work with clinicians to support clients' completion of exposures in the real world. If you do not have access to a formal case management program, encouraging clients to create their own by identifying a supportive family member or friend to help with exposures can be invaluable. Bringing that person to session and creating a plan will be vital.

The Access Problem: When Your Office is Just an Office

Here's a challenge that might make you chuckle (or cry): nearly 20% of clinicians endorsed lack of access to exposure stimuli as a challenge of delivering ERP for OCD. This is particularly problematic for certain symptom domains. The symptoms most frequently endorsed as being the hardest for utilizing exposures in-office were: hoarding or saving compulsions (37%); hoarding or saving obsessions (29.6%); sexual obsessions (23.1%); religious obsessions (20.8%); harm-related obsessions (18.1%); and religious compulsions (18.1%).

Unless your clinical office happens to be equipped with a fully stocked laboratory, a messy storage closet, public restrooms, and a convenient collection of “contaminated” objects, you're going to need some creative solutions.

Consider trying one of these:

• Virtual Reality: Immersive virtual reality (VR) presents one novel solution to address this challenge. While we're not quite at the point where every clinical office has a VR headset (though that day may be coming), the technology is becoming increasingly accessible. VR exposures can potentially simulate a vast array of OCD stimuli and scenarios—such as going to hell as an exposure for individuals with scrupulosity symptoms or striking pedestrians while driving a motor vehicle for individuals with harm avoidance obsessions. A well-known option is oVRcome, which allows the clinician to monitor and/or participate.
• Imaginal Exposures: When in vivo exposures aren't feasible, don't underestimate the power of well-crafted imaginal exposures. The use of imaginal exposures was most frequently endorsed as being required for: sexual obsessions (80.8%); harm-related obsessions (80.4%); religious obsessions (52.8%). The key is making them vivid, detailed, and emotionally engaging. Think less “imagine touching a doorknob” and more “feel the cold metal under your fingertips, notice the slight stickiness from the previous person's hand…” If you worry your creativity is not up for the task, this might be a great time to leverage AI.

The Engagement Challenge: Making ERP Less Terrifying

Let's be honest, asking someone to deliberately trigger their worst fears isn't exactly an easy sell. Clinicians may also struggle to get clients with OCD invested in completing challenging and distressing exposures, which may impede treatment progress and negatively impact clinical outcomes.

Here are a few tips to increase engagement:

• Values-Based Motivation: By working with clients to connect their goals/values to exposures, clinicians can enhance clients' engagement in ERP. Instead of “touch the doorknob because I said so”, try “touching the doorknob moves you closer to being the spontaneous friend who can grab coffee without a 20-minute bathroom ritual”.
• Gamification Strategies: Strategies to “gamify” therapeutic exposures for OCD may help improve clients' motivation in-session. This doesn't mean turning therapy into Pokémon GO (though that could be interesting), but rather incorporating elements of challenge, achievement, and progress tracking that tap into our natural competitive instincts. For example, create an “exposure challenge ladder” where clients earn points for completing different difficulty levels of exposures, with visual progress bars showing their advancement toward personal goals.
• The Technology Factor: The inclusion of technology in session may also boost client engagement in ERP, particularly for younger clients that value technology. Even something as simple as using a smartphone to record exposure videos that clients can review later can increase engagement and provide valuable feedback opportunities. Additionally, apps that connect clients with OCD support communities can be particularly powerful, as they allow clients to share progress with others facing similar challenges or provide peer encouragement during difficult exposures. These platforms tap into the fundamental need for connection and the realization that “we're not alone”, often providing encouragement from someone who truly “gets it” in ways that can be more motivating than clinical interventions alone.

Specific Symptom Challenges: The Usual Suspects

The research reveals some clear patterns in which OCD symptoms present the greatest treatment challenges. The OCD symptoms commonly endorsed as providing difficulties in the completion of out-of-session exposures included: sexual obsessions (36.9%); harm-related obsessions (34.1%); religious compulsions (27.6%); religious obsessions (27.1%). These symptom domains require special consideration and often carry significant shame and social stigma, making clients reluctant to engage in exposures.

For these challenging domains, consider:

• The Harm-Reduction Approach: Rather than allowing your client to expect perfect exposure compliance from the start, consider adopting a harm-reduction model that meets clients where they are. For a client with sexual obsessions who avoids all physical contact, begin with brief, appropriate social interactions rather than jumping to more triggering exposures. This approach acknowledges that partial progress is still meaningful progress. By celebrating incremental improvements, we help clients develop self-efficacy and build momentum for more comprehensive exposure work.
• Incorporating ACT Strategies: Clinicians can choose to supplement ERP delivery by incorporating ACT strategies to promote psychological flexibility and increase value-guided action. Teaching clients to observe their thoughts without judgment can be particularly helpful for shame-laden symptoms. ACT helps reduce the all-or-nothing thinking that can paralyze both clients and clinicians when traditional ERP feels overwhelming.

The Bottom Line

Treating OCD with ERP isn't easy. The challenges we face are real, documented, and shared by the vast majority of our colleagues. But with creativity, flexibility, and a willingness to embrace new technologies and approaches, we can help our clients navigate the exposure maze successfully.

You're not failing as a clinician when you encounter these challenges—you're joining a very large, very normal club of helpers who care enough about their clients to keep searching for solutions.

As the field continues to evolve, with new technologies and treatment approaches emerging regularly, stay curious and stay flexible. Remember that sometimes the best exposure for a clinician is to their own tolerance for uncertainty in treatment. After all, if we can model that for our clients, we're already halfway to successful ERP delivery.