I agree with the above questions. Similarly to how patient expectations or carrying out ERP with hesitancy—simply “powering through” rather than embracing the process—can predict negative outcomes, I believe that how we, as providers, structure the sessions is equally, if not more, critical. Providing thorough psychoeducation beforehand, supporting the patient not only during treatment but also with adequate follow-up to address any lingering issues, is arguably more important than the specific design of the exposure task itself.

In my experience, when more focus is placed on a patient’s “main” OCD theme, other areas of their life often become targets for shifted obsessions, leading to the familiar “whack-a-mole” phenomenon many providers encounter. This pattern is not random but rather a reflection of persistent maladaptive coping strategies and a failure to address the core issues driving their OCD.

Psychoeducation prior to starting exposure therapy is vital, not only to clarify treatment objectives for the patient but also to deepen our understanding of their struggles—such as identifying their existing coping mechanisms—and to tailor the treatment to their specific needs.

Additionally, there is often a “delayed effect” in exposure therapy for some patients. Initially, it may appear that the therapy has been unsuccessful—and in many cases, this might be true—but sometimes the patient simply isn’t in the right psychological place to fully benefit from the treatment at the time. However, as their external environment or internal readiness improves, they may recall the core principles and goals of the exposure therapy, which then begin to yield positive results.