OCD treatment
The gold standard: ERP
Exposure and Response Prevention (ERP) is the most effective psychological treatment for OCD. It involves gradually exposing yourself to the thoughts, situations, or objects that trigger your obsessions, while resisting the urge to perform compulsions.
The principle is straightforward: by staying with the anxiety without performing the compulsion, you learn that the anxiety will naturally decrease on its own, and that the feared consequences do not occur. Over time, the obsession-compulsion cycle weakens.
ERP has response rates of up to 80% in the general population. It is recommended by NICE as the first-line psychological treatment for OCD.
ERP is not about suffering
Good ERP is collaborative, gradual, and paced to what you can manage. You work with your therapist to build an exposure hierarchy - a list of feared situations ranked from least to most anxiety-provoking - and you start at the bottom. You should never be forced into exposures you are not ready for.
Why standard ERP often falls short for neurodivergent people
Standard ERP was developed with neurotypical populations. When applied without adaptation to autistic or ADHD people, it can be less effective or even counterproductive.
Processing differences. Standard ERP assumes typical processing speed and communication. Autistic people may need longer to process exposure exercises, understand the rationale, and develop new associations. Rushing the process can increase distress without therapeutic benefit.
Sensory overwhelm. For autistic people, exposure exercises may trigger sensory distress alongside or instead of OCD-related anxiety. If the therapist does not understand this, they may push exposure to stimuli that are genuinely painful at a sensory level, which is harmful rather than therapeutic.
Alexithymia. Standard ERP relies on the person being able to rate their anxiety level (often on a 0-10 scale). For people with alexithymia - difficulty identifying and describing emotions - this is unreliable. They may know something feels wrong but not be able to quantify it as “anxiety at level 6.”
Executive function. ERP typically involves homework between sessions: practising exposures, resisting compulsions, and recording outcomes. For people with ADHD, the executive function demands of consistent between-session practice can be a significant barrier.
Demand sensitivity. Some autistic people experience demand avoidance, where externally imposed tasks trigger a strong avoidance response. If ERP is framed as something the person must do, this can create resistance that is about the demand itself rather than about the OCD.
Adapting ERP for neurodivergent people
Research and clinical experience have identified several key adaptations that make ERP more effective for autistic and ADHD people.1
Communication and language
Use literal, concrete language. Avoid metaphors and idioms that may be confusing. Explain the rationale for each step explicitly rather than assuming it is obvious. Use closed questions rather than open-ended ones when exploring thoughts and feelings.
Visual and structured tools
Use visual exposure hierarchies (with pictures or diagrams rather than just verbal descriptions). Anxiety thermometers using drawings or visual scales can be more accessible than number ratings. Written session summaries help with processing and recall.
Pacing
Allow more time for each step. Autistic people may need longer treatment timelines, and this should be planned for from the outset. Slower pacing is not failure - it is appropriate accommodation.
Sensory awareness
Distinguish between OCD-related anxiety and sensory distress during exposures. If an exposure triggers genuine sensory pain (such as being in a noisy environment for someone with hyperacusis), this is not therapeutic exposure - it is harm. Exposures should target OCD anxiety specifically, with sensory accommodations in place.
Special interests
Incorporating special interests into the treatment process can increase engagement and motivation. Examples include using special interest themes in psychoeducation materials, involving special interests in exposure exercises where relevant, and building reward systems around special interests.
Collaborative framing
The most effective approach positions the therapist as the OCD expert and the person as the autism (or ADHD) expert. This collaborative model respects the person’s self-knowledge and gives them genuine authority over how their neurodivergent needs are accommodated within treatment.
Adaptation makes a difference
Autism-adapted CBT for anxiety and OCD has shown a 51% treatment response rate in autistic young people - a meaningful improvement over non-adapted approaches. Key modifications included increased session structure, visual aids, substantial parent involvement, and flexibility in session length and number.2
CBT for OCD
CBT for OCD combines ERP with cognitive techniques that address the beliefs and thinking patterns that maintain OCD. For example, a person with harm OCD might hold the belief that having a violent thought means they are capable of violence. CBT helps examine and challenge this belief.
Adaptations for neurodivergent people
The adaptations needed for CBT in OCD are similar to those needed for CBT more broadly (covered in detail on our CBT page).
Key considerations include using concrete language and visual aids, breaking down cognitive restructuring into explicit, structured steps, being cautious with abstract cognitive concepts (some autistic people find the metacognitive demands of CBT difficult), and differentiating between OCD-driven thoughts and autistic thinking patterns.
CBT should not aim to change autistic thinking patterns - only OCD-related thinking patterns. A therapist who understands both conditions can help the person distinguish between the two.
Medication
SSRIs
Selective serotonin reuptake inhibitors (SSRIs) are the first-line medication treatment for OCD. They are effective in reducing OCD symptoms in both neurotypical and neurodivergent people.
Sertraline is often preferred for autistic people due to its milder side effect profile. Other SSRIs used for OCD include fluoxetine, fluvoxamine, and paroxetine. OCD typically requires higher SSRI doses than depression, and it can take 8-12 weeks for the full effect to be seen.
An important distinction: SSRIs reduce OCD symptoms but do not affect autistic repetitive behaviours. If an autistic person’s repetitive behaviours improve on SSRIs, this suggests those behaviours were OCD-driven rather than autistic.
Augmentation for treatment-resistant OCD
Around one in three people with OCD do not respond adequately to SSRIs alone. In these cases, augmentation with a low-dose atypical antipsychotic (most commonly risperidone or aripiprazole) may be helpful. Both of these medications are also approved for use in autistic people for managing irritability, making them particularly relevant for autistic people with treatment-resistant OCD.3
Augmentation should be time-limited (typically a maximum of three months), and the medication should be discontinued if there is no response.
ADHD medication and OCD
For people with both ADHD and OCD, the interaction between medications needs careful management. Stimulant medication for ADHD does not typically worsen OCD, and in some cases it can help by improving the executive function needed to engage with ERP. However, this should be monitored.
Accessing OCD treatment in the UK
NHS
OCD treatment is available through NHS Talking Therapies (self-referral) and through secondary mental health services (GP referral). However, access to neurodivergent-adapted OCD treatment varies significantly by area.
When referring, mention your neurodivergence so the service can match you with a therapist who has relevant experience. If the service does not have experience adapting OCD treatment for neurodivergent people, ask about specialist referral options.
Specialist organisations
- OCD Action - specialist OCD support, self-help resources, and community: ocdaction.org.uk
- OCD-UK - information, peer support groups, and treatment guidance: ocduk.org
- International OCD Foundation - evidence-based resources including guidance on neurodivergent-adapted treatment: iocdf.org
Treatment works, even when it needs adapting
If you have tried standard OCD treatment and it did not work, this does not mean OCD treatment cannot help you. It may mean the treatment was not adapted for how your brain works. Neurodivergent-adapted ERP and CBT can be effective - the key is finding a therapist who understands both OCD and neurodivergence.
Further reading on neurobetter
neurobetter services
- Local services directory - find OCD specialists near you
- Ask a Counsellor - get a confidential response from a registered counsellor
If you are in crisis
If you are struggling right now, please visit our Get Help Now page for immediate support options, including Samaritans (116 123), Crisis Text Line (text SHOUT to 85258), and NHS 111.
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Kilduff, A. (2023). Treating OCD in the neurodiverse client: ERP adaptations for autism. International OCD Foundation. https://iocdf.org/wp-content/uploads/2023/07/BLOG_-ASD_OCD-How-To-Adapt-ERP.pdf ↩
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Development and pilot testing of internet-delivered, family-based cognitive behavioral therapy for anxiety and obsessive-compulsive disorders in autistic youth. (2023). Journal of Autism and Developmental Disorders. https://doi.org/10.1007/s10803-023-05958-1 ↩
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Dold, M. et al. (2015). Antipsychotic augmentation of serotonin reuptake inhibitors in treatment-resistant obsessive-compulsive disorder: an update meta-analysis of double-blind, randomized, placebo-controlled trials. International Journal of Neuropsychopharmacology, 18(9). https://doi.org/10.1093/ijnp/pyv047 ↩
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