ERP Didn't Work for Me: Different Approaches, Including Longer-Term Therapy
What to consider if ERP helped but not enough, or didn’t work at all.
A course of ERP is a challenging experience by its nature. You spend weeks deliberately triggering the thoughts, doubts and situations that set off OCD and anxiety, and then not doing what you’d normally do to feel better, whether that’s a physical compulsion or some form of checking, seeking reassurance or rumination.
So if ERP didn’t work for you, or helped but not as much as you’d hoped, it’s hard not to wonder what went wrong and whether anything else will help.
There are options, and which one makes sense depends on what happened, what’s still going on and what you want from treatment. These are the main ones:
Going back to ERP with a different approach
Cognitive therapy for OCD
Acceptance and Commitment Therapy (ACT)
Medication
Longer-term psychotherapy, alongside or after OCD-specific treatment
Going back to ERP
ERP has the strongest evidence behind it, so one attempt that didn’t help isn’t a good reason to write it off. It helps to work out why it didn’t help.
A lot of OCD is hidden from the outside world. Some people wash or check, and those compulsions are easier to spot, both for you and for a therapist. But some people spend hours in their heads, going back over a conversation, analysing a feeling or focusing on a physical sensation, checking whether they really love their partner, trying to work out what a thought says about them, or subtly asking for reassurance.
If those mental compulsions weren’t picked up, or stayed hidden, you could be doing an exposure and resisting a physical compulsion, which can look like success. But if you’re still engaging in a mental compulsion, the loop of trigger, anxiety, compulsion and relief is still being maintained, and the OCD is getting what it wants.
How the work was set up matters too. A clear plan built around your triggers and compulsions, including the mental ones, makes a difference, as do regular practice between sessions, enough sessions and a therapist who didn’t end up reassuring you or steering round the hardest exposures.
A partner or family member who reassures you or helps you avoid things, even with the best intentions, can keep the cycle going too. A different therapist, a more tailored plan or a more intensive course can help.
Cognitive therapy for OCD
Cognitive therapy for OCD looks at the beliefs that keep obsessions going. It’s part of the same CBT family as ERP, and it’s another option if you can’t or don’t want to do ERP. It’s offered by specialist OCD services, who can advise on whether it’s worth considering.
Acceptance and Commitment Therapy (ACT)
ACT is an option to try alongside ERP. It doesn’t try to get rid of the thoughts or prove them wrong, which can often just be another way of engaging with them and feeding the cycle. It aims to change how you relate to your thoughts.
One process that ACT focuses on is cognitive fusion, which is when a thought stops feeling like a thought and starts feeling like a fact, a warning or an instruction. “Maybe I don’t love her” or “what if I’ve done something terrible” arrives, and you respond as though it has to be dealt with immediately. You might also find you compulsively engage with thoughts, as if their presence means there is something you need to solve or work out straight away.
Defusion is the practice of stepping back far enough to see the thought as something your mind is producing, without needing to agree with it, argue with it or work out what it means.
Dropping anchor is one of the techniques used for this. When anxiety is at its height, it’s easy to get pulled further into your head. Dropping anchor means first acknowledging the thoughts and feelings you’re having without judgement or excessive engagement, and then turning your attention to what’s actually here: your feet on the floor, your breathing, the room around you.
ACT is about engaging in life rather than being controlled by OCD and anxiety, so the final step is getting on with whatever you were doing before you were triggered, with your full attention, which is why it combines so well with ERP practice. Dropping anchor isn’t a way of making the anxiety go away. If you use it to get rid of the feeling, it quickly becomes another compulsion, so it’s best learned with someone who can help you recognise that distinction.
ACT also keeps you focused on your values. OCD tends to shrink a life down to managing anxiety, doubt and uncertainty, and values work asks what you’d be doing if the doubt weren’t calling the shots. That might be the kind of partner, parent, friend or colleague you want to be, or the things you’ve stopped doing because the OCD took up the space. Values can give you some clarity while unpleasant that come with OCD are raging, and they can motivate you to drop anchor, resist mental compulsions and unhook from intrusive thoughts, whether during exposures or just in day-to-day life.
Used on its own, the evidence for ACT in OCD isn’t as strong as it is for CBT with ERP, which is why it’s most often used alongside it.
Medication
Medication is another option, and many people with OCD take it alongside therapy or on its own. SSRIs are the type most often prescribed. There are some things specific to OCD that are worth knowing about, including how medication is chosen, how it’s dosed and how long it’s given before judging whether it’s helped. So if you’ve tried medication already, or are thinking about it, it’s worth asking your GP or psychiatrist about the options. They can talk you through different medications and doses, and whether a referral to a specialist OCD service would be useful.
Longer-term psychotherapy
Longer-term psychotherapy, including humanistic and psychodynamic forms, doesn’t have the same evidence base as ERP, so it shouldn’t replace it. But that doesn’t mean someone with OCD can’t benefit from long-term psychotherapy in the same way as anyone else. There’s more on this in Can psychotherapy help with OCD?.
What it offers is something different: the chance to understand who you are underneath the OCD and how your life experiences might have shaped the way you see yourself. For a lot of people, that’s the part that’s been missing.
Some people with OCD have also had traumatic life experiences, difficult relationships or challenging upbringings. Plenty of people with OCD are very harsh with themselves, and many also live with shame, depression or other kinds of anxiety. ERP and ACT work on how you respond to the obsessions and compulsions, but they don't always reach deeper beliefs about yourself and your core fears.
Some people find that the OCD keeps turning up in new forms, like a game of whack-a-mole, while those underlying beliefs and the experiences that shaped them remain unexplored. Longer-term work gives you room to notice what you believe about yourself when the doubt is loudest, and how that shows up in your closest relationships. The point isn't to find the one cause, but to know yourself well enough that the thoughts have less hold.
There’s some caution around long-term psychotherapy for people with OCD, because the process can turn into another form of reassurance-seeking, or another attempt to be certain about why you are the way you are. So it helps to work with a therapist who can help you understand the story behind your self-doubt or negative self-view, without attaching unnecessary meaning to your intrusive thoughts and obsessions, while also calling out any excessive attempts to get certainty, seek reassurance or keep other OCD patterns going.
Finding a way forward
These options aren’t mutually exclusive. Some people go back to ERP with a better-tailored plan, some add medication, and some find they want a deeper understanding of themselves and how their mind works.
I'm an integrative psychotherapist, trained in Transactional Analysis psychotherapy, and I offer longer-term, relational and depth-oriented work, including Psychotherapy for OCD & Intrusive Thouhgts. I have additional training in working with OCD, including ERP and ACT.
This means I can bring an understanding of obsessive patterns and the ways they are maintained, while also making space to explore the wider emotional and relational experiences that shape your life. I don't see these as competing approaches: sometimes we need to work directly with the OCD, and sometimes there's more to understand about the person living with it. If you're looking for an approach that takes both seriously, you're welcome to get in touch.
