How ERP for OCD Can Feel Safer for Neurodivergent (and Neurotypical) People: Values, Affirmation, and Defusion

ERP for OCD is meant to be challenging. But “challenging” is not the same as “unsafe.” When ERP is collaborative, affirming, and paced to the person in front of you, it can feel steadier—even when the exposures are hard.

In this article, you’ll learn:

• What “safe ERP” actually means (and what it doesn’t)

• How to build an ERP hierarchy from values—not just fear ratings

• How LGBTQIA+ affirming, justice-based care can reduce shame (without minimizing real-world risks)

• How ACT-style cognitive defusion can support response prevention without arguing with thoughts

• Practical ERP adaptations for autism/ADHD, sensory needs, and demand avoidance

💡 Key takeaway: Safe ERP isn’t about avoiding discomfort—it’s about consent, collaboration, and a plan you can actually follow.

If you’re newer to ERP for OCD, you can also start with our overview of obsessive-compulsive disorder and treatment options.

What “safe ERP” actually means (and what it doesn’t)

ERP is supposed to be uncomfortable; “safe” = consent, pacing, collaboration

ERP (exposure and response prevention) is a first-line, evidence-based treatment for OCD.[1,2] It works by helping you face triggers (exposures) and practice not doing the behaviors or mental rituals (response prevention) that keep OCD strong.[1]

So yes: ERP will feel uncomfortable. But “safe ERP” has some clear features:

• Informed consent: you understand the rationale, the steps, and your options

• Collaborative pacing: you and the therapist co-create the hierarchy and decide what “hard enough” means today

• Precision (not punishment): exposures are designed to target compulsions and avoidance—not to “teach you a lesson”

• Respect for context: trauma history, sensory needs, identity, and discrimination stressors are part of the clinical picture

A common misconception is that ERP must feel like being “thrown in the deep end” to work. In reality, ERP is typically planned and graduated—done in a progressive way so you can build skills and confidence over time.[1]

✅ Key takeaway: You don’t need “maximum distress” for ERP to be effective—you need consistent, well-designed practice.[1,2]

Signs ERP is not being delivered safely (coercion, flooding, bias, invalidation)

ERP can be delivered poorly. Research and clinical guidance describe common pitfalls - like over-reassuring, under-doing response prevention, or mis-targeting exposures.[4]

“Unsafe” delivery often shows up as:

• Coercion: “If you don’t do this exposure, you’re not committed.”

• Flooding without consent: jumping to high-intensity tasks without preparation or a rationale

• Bias or invalidation: minimizing identity-related stress, misgendering, or pathologizing culture/faith

• Exposure to real harm: asking you to enter situations that are objectively unsafe, or ignoring safety planning

• Compulsion substitution: the exposure is “done,” but safety behaviors and mental rituals are still running the show

Ethical discussions about exposure-based treatment emphasize that informed consent, therapist competence, and careful risk/benefit decisions matter—especially when exposures intersect with real-world safety issues.[3]

🚦 Key takeaway: “No pain, no gain” is not a clinical standard. Good ERP is structured, ethical, and grounded in consent.[3,4]

Building exposure hierarchies from values—not just fear levels

Values vs. compulsions: “What does OCD steal from your life?”

A typical ERP hierarchy uses distress ratings (often SUDS: Subjective Units of Distress) to sort exposures from easier to harder. That can help.

But many people—especially neurodivergent clients or anyone with shame-heavy OCD themes—do better when we add a second axis:

• Fear/uncertainty: “How intense is the trigger?”

• Values impact: “What does OCD block you from doing?”

OCD often steals:

• Time (hours of checking, researching, or rumination)

• Connection (avoiding relationships, intimacy, parenting moments)

• Autonomy (needing certainty before you act)

• Integrity (compulsions that conflict with your values)

When your hierarchy is values-based, ERP becomes less about proving you can tolerate distress—and more about reclaiming your life.

🌿 Key takeaway: A values-based ERP hierarchy keeps the “why” in view, which can improve follow-through when things get hard.

Turning values into measurable exposure targets (connection, autonomy, justice, parenting)

Here’s a simple way to translate values into exposure targets.

Step 1: Name the value.

• Connection

• Autonomy

• Justice/fairness

• Parenting presence

Step 2: Name the OCD pattern that blocks it.

• Reassurance seeking

• Mental reviewing/rumination

• Avoidance of certain people/places/identity topics

• Checking (locks, emails, health symptoms)

Step 3: Build a ladder of “value moves.”

Practical example (Connection value + relationship OCD / reassurance seeking):

• Low: Send a text without rereading it more than once; do not ask a friend to “check if it sounds okay.”

• Medium: Share a genuine feeling with your partner and allow uncertainty about how it lands (no follow-up reassurance questions).

• High: Attend a social event and practice letting “What if they judge me?” thoughts be present without scanning for proof.

Practical example (Parenting presence + contamination OCD):

• Low: Sit on the floor to play for 5 minutes before washing.

• Medium: Help with a messy snack and delay washing by 10 minutes.

• High: Do a full bedtime routine after a “contaminating” task and wash only at your planned time.

📌 Key takeaway: The best hierarchy items are specific, repeatable, and clearly linked to a compulsion you’re training your brain to drop.

Justice-based, LGBTQIA+ affirming framing inside ERP

Separating OCD doubt from real-world safety/discrimination concerns

Many LGBTQIA+ people with OCD get stuck in a painful double-bind:

• OCD amplifies uncertainty ("What if I’m unsafe? What if I’m wrong? What if people hate me?")

• Real-world discrimination means some safety concerns are legitimate

Affirming ERP does not dismiss reality. Instead, it helps you separate:

• OCD-driven rituals (compulsions that promise certainty)

• Wise safety behaviors (actions based on realistic risk and personal boundaries)

A helpful test is: “Does this behavior expand my life, or shrink it?”

• Wise safety behavior: sharing your location with a trusted person when meeting someone new

• OCD compulsion: checking your location sharing 20 times and replaying every possible scenario for hours

🧭 Key takeaway: Affirming ERP targets the ritual—not your identity, not your values, and not your right to safety.

Reducing shame: pronouns, identity affirmation, minority stress as context

Shame is fuel for OCD. When therapy feels invalidating, OCD often gets louder.

Minority stress research describes how chronic stigma, expectations of rejection, concealment pressure, and internalized stigma can increase mental health burden for LGBTQ people.[7] In ERP, that context matters.

What affirming ERP can look like:

• Asking and using correct pronouns consistently

• Naming “minority stress” as a background load that can raise baseline anxiety

• Avoiding pathologizing identity exploration

• Addressing shame-driven compulsions (like overconfessing or “proving” you’re a good person)

✅ Key takeaway: When identity is affirmed, ERP can focus on the OCD process (uncertainty + ritual), not defending your humanity.

Response prevention without “arguing with” intrusive thoughts

Rumination vs. response prevention: dropping the mental ritual

For many people, the main compulsion is internal:

• Rumination (debating, analyzing, reviewing)

• Mental checking (“Do I feel sure yet?”)

• Reassurance scanning (searching memory for proof)

ERP for OCD includes response prevention for mental rituals—not just visible behaviors.[1,4]

A common misconception is that response prevention means “replace the thought with a better thought.” But for OCD, arguing can turn into another ritual.

Instead, response prevention often looks like:

• Not answering the question OCD asks

• Not doing “one more” mental review

• Returning attention to the task in front of you

🧠 Key takeaway: Response prevention isn’t winning an argument with OCD—it’s refusing to play the certainty game.[4]

Cognitive defusion (“I’m having the thought that…”) + allowing uncertainty

ACT (Acceptance and Commitment Therapy) is commonly used alongside ERP to help people relate differently to intrusive thoughts—especially when fusion and rumination are strong.[6]

Cognitive defusion is a skill that creates space between you and the thought.[5]

Practical example: a defusion script for response prevention

• OCD thought: “What if I accidentally harmed someone?”

• Defusion: “I’m having the thought that I might have harmed someone.”

• Next move: “I can carry this uncertainty and keep driving.”

ACT research in OCD suggests acceptance-based approaches can reduce OCD severity and improve functioning, and they’re often studied as alternatives or adjunct frameworks for OCD care.[6]

🌧️ Key takeaway: Defusion helps you practice uncertainty on purpose—so you can act in line with your values anyway.[5,6]

Neurodiversity-affirming ERP adaptations (autism/ADHD, sensory, demand avoidance)

Neurodivergent OCD is common—and it can change how ERP needs to be delivered.

Adaptations don’t mean “watering down” ERP. They mean reducing barriers so the core mechanisms (exposure + response prevention) can happen consistently.

Accessibility: predictable plans, scripts, visual supports, paced demands

Helpful adaptations may include:

• Predictable session structure and a written plan for the week

• Clear “if/then” scripts (what to do when the urge spikes)

• Visual supports (hierarchy cards, checklists, timers)

• Shorter, more frequent exposures for attention and energy limits

• Sensory-informed planning (exposures that are targeted but not unnecessarily sensory-overwhelming)

Research on adapted CBT approaches for OCD with co-occurring autism suggests tailored CBT can be effective in real-world settings.[8] And broader CBT literature for autistic youth with anxiety highlights the value of thoughtful adaptation, even as the evidence base continues to evolve.[9]

Note on language: “PDA-style demand avoidance” is a descriptive term some communities use, but it is controversial and not recognized as a standalone diagnosis in major diagnostic manuals. (Many clinicians focus on autonomy-supportive, low-shame approaches regardless of label.)[11]

🧩 Key takeaway: For neurodivergent clients, the goal is the same—drop rituals—while the route can be more structured, sensory-informed, and autonomy-supportive.[8,9,11]

Tracking progress by functioning/values—not just distress ratings

SUDS can be useful data, but it’s not always the best progress marker—especially for alexithymia, masking, sensory overload, or fluctuating attention.

Values-based, functional metrics can include:

• Minutes per day spent ruminating (and trends over weeks)

• Number of “value moves” completed (even with discomfort)

• Reduced avoidance (places, people, tasks)

• Reduced reassurance seeking and checking

• Increased participation (work, school, relationships, self-care)

✅ Key takeaway: The win isn’t “feeling calm.” The win is living your life while OCD is noisy—and letting the noise be there.

Finding an affirming ERP provider (telehealth/online in Tennessee)

ERP is specialized, and fit matters. If you’re looking for online ERP therapy in Tennessee, telehealth can meaningfully reduce access barriers and can be effective for OCD care when delivered competently.[10]

Consult questions that screen for competence + cultural humility

You can ask:

• “How do you build ERP hierarchies—do you incorporate values?”

• “How do you handle mental compulsions like rumination and reassurance seeking?”

• “What does informed consent look like in your ERP process?”

• “How do you avoid flooding or coercion?”

• “How do you approach identity-themed OCD (e.g., LGBTQIA+ themes) in an affirming way?”

• “What neurodiversity accommodations do you routinely offer (structure, sensory planning, scripts)?”

If you want to learn more about our approach, you can explore Specialized Therapy services and meet our team.

When ERP should be modified, paused, or coordinated with higher support

Sometimes the safest next step is adjusting the plan.

ERP may need modification, pausing, or additional support if:

• There’s acute risk (self-harm, severe suicidality) or active psychosis

• Substance use or medical instability is interfering with safety

• Trauma symptoms are destabilizing and need parallel support

• The hierarchy is consistently too steep (dropout risk increases when exposures feel unworkable)

• You need coordinated care (med management, higher level of care, family support)

A skilled ERP clinician can coordinate care, adjust pacing, and keep exposures values-aligned rather than “white-knuckled.”

🛟 Key takeaway: The goal is sustainable ERP—not heroic ERP. A plan you can keep doing beats a plan you avoid.

A next step that’s both compassionate and effective

If ERP for OCD has felt like “too much” in the past, it may not mean you’re “bad at ERP.” It may mean the delivery didn’t fit you.

Safer-feeling ERP is still ERP:

• clear consent

• collaborative pacing

• values-based targets

• affirming context

• response prevention supported by defusion

• accessible structure for neurodivergence

If you’re ready to explore your options, you can start with a mental health screening or reach out through our contact page to ask about next steps.

About the Author

ScienceWorks is led by Dr. Kiesa Kelly, PhD. She has more than 20 years of experience in psychological and neuropsychological assessment across outpatient, hospital, and community settings.

Her clinical work focuses on thoughtful, individualized evaluation and recommendations that consider learning, attention, executive functioning, and emotional/behavioral health.

References

1. Law C, Boisseau CL. Exposure and Response Prevention in the Treatment of Obsessive-Compulsive Disorder: Current Perspectives. Psychol Res Behav Manag. 2019;12:1167-1174. doi: 10.2147/PRBM.S211117 • PubMed

2. Reid JE, Laws KR, Drummond L, Vismara M, Grancini B, Mpavaenda D, Fineberg NA. Cognitive behavioural therapy with exposure and response prevention in the treatment of obsessive-compulsive disorder: A systematic review and meta-analysis of randomised controlled trials. Compr Psychiatry. 2021;106:152223. doi: 10.1016/j.comppsych.2021.152223 • PubMed

3. Olatunji BO, Deacon BJ, Abramowitz JS. The cruelest cure? Ethical issues in the implementation of exposure-based treatments. Cogn Behav Pract. 2009;16(2):172-180. doi: 10.1016/j.cbpra.2008.07.003

4. Gillihan SJ, Williams MT, Malcoun E, Yadin E, Foa EB. Common pitfalls in exposure and response prevention (EX/RP) for OCD. J Obsessive Compuls Relat Disord. 2012;1(4):251-257. doi: 10.1016/j.jocrd.2012.05.002 • PubMed

5. Association for Contextual Behavioral Science (ACBS). Cognitive Defusion (Deliteralization). (Web resource). https://contextualscience.org/cognitive_defusion_deliteralization

6. Twohig MP, Hayes SC, Plumb JC, Pruitt LD, Collins AB, Hazlett-Stevens H, Woidneck MR. A randomized clinical trial of acceptance and commitment therapy versus progressive relaxation training for obsessive-compulsive disorder. J Consult Clin Psychol. 2010;78(5):705-716. doi: 10.1037/a0020508 • PubMed

7. Meyer IH. Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: conceptual issues and research evidence. Psychol Bull. 2003;129(5):674-697. doi: 10.1037/0033-2909.129.5.674 • PubMed

8. Flygare O, Andersson E, Ringberg H, et al. Adapted cognitive behavior therapy for obsessive–compulsive disorder with co-occurring autism spectrum disorder: A clinical effectiveness study. Autism. 2020. doi: 10.1177/1362361319856974 • PubMed

9. Roberts K, Rankin PM, et al. A cognitive help or hindrance? A systematic review of cognitive behavioural therapy to treat anxiety in young people with autism spectrum disorder. Clin Child Psychol Psychiatry. 2025. doi: 10.1177/13591045251314906 • PubMed

10. Feusner JD, et al. Effectiveness of video teletherapy in treating obsessive-compulsive disorder in children and adolescents with exposure and response prevention: Retrospective longitudinal observational study. J Med Internet Res. 2025;27:e66715. doi: 10.2196/66715 • PubMed

11. National Autistic Society. Demand avoidance. (Webpage). https://www.autism.org.uk/advice-and-guidance/behaviour/demand-avoidance

Disclaimer

This article is for educational purposes only and is not a substitute for professional diagnosis, treatment, or medical advice. If you are in immediate danger or experiencing a crisis, call 988 (U.S.) or your local emergency number.

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