3 Crucial Reasons Why Exposure Therapy Fails In OCD That Isn’t Treatment Resistant

The brain’s basal ganglia are known to be responsible for the sticky thoughts in OCD. Another part of the brain associated with the basal ganglia is the nucleus accumbens (NA). In familiar terms, people refer to the NA as the pleasure centre. However, research also discovered that it activates aversion. So, it depends on which emotion we assign to something that shows if we like, dislike or are half-and-half about it. Either way, it motivates us to seek out more of something, avoid it, or be ambivalent.

For example, consider David, who eats one of his favourite foods and has feelings of enjoyment. In this case, David will be motivated to seek out more of his favourite food. Now suppose David dislikes a particular food and assigns displeasure to it. This time, David will be motivated to avoid it. Finally, imagine David eating a portion of food he simultaneously likes and dislikes. This time, he attributes ambivalent feelings to it. Therefore, he will be motivated to changeability, for example, feeling undecided.

People with OCD sometimes also experience conflicting emotions about intrusive thoughts. It is also related to the NA. For example, consider Maria, who has an obsession with being gay and has an aversion to it. Consequently, Maria is motivated to avoid the obsession by doing rituals. At the same time, Maria experiences an erroneous like for her thoughts and feels conflicted. Therefore Maria is motivated by ambivalent feelings and worries her OCD is something else.

The main point is that in OCD, the brain’s pleasure centre is the targeted area for deep brain stimulation (DBS). But, of course, DBS is not carried out because of having a false desire for an obsession or aversion. Instead, it explains why some people might struggle to respond to exposure-response prevention (ERP), the evidence-based treatment for this condition. In other words, one could say DBS is another treatment choice when the habituation process fails in ERP.

Habituation Process

Fear habituation occurs when a person systematically resists the rituals linked to an obsession. However, since the conflicting feelings associated with the NA can make the disorder more challenging, it can be even more complicated to treat with ERP. For example, some people become so consumed by their obsessions that absorption affects the habituation process. For example, when they cannot get to grips with mixed feelings about the obsession, they will use self-applied exposures (testing) to find a resolution but become more enmeshed.

Let’s look at these three factors and further highlight the problem with the habituation process.


Aversion is when a person is horrified by intrusive thoughts. They cannot bear the discomfort that would potentially lead to their feared outcome, albeit that it occurs only in the imagination. Consequently, they use rituals to prevent perceived consequences and reduce discomfort. Giving in to such actions is a repressed attempt to ward off danger and reduce anxiety. 

Conflict Due to False Desire

We’ve seen that some people mistakenly think they like the thoughts or want to act on them. Still, even though they know objectively that it is mistaken, they dare not take risks. This is because the combination of loathing and erroneous desire confuses them. Thus, those who struggle with “liking” the thoughts usually think the solution is to work harder to prevent the feared outcome. But unfortunately, such cases can lead to testing and becoming more absorbed in the obsession, as mentioned earlier. In this case, understanding about the NA before OCD worsens can be helpful.


Such absorption can further lead to dissociation peculiar to OCD (Soffer-Duddek et al., 2018) and, consequently, heightened states of arousal. These increased sensations intensify anxiety symptoms and vice-versa, making people more confused. Subsequently, it directs people to more precarious rituals. For example, repeatedly watching gay porn makes Maria think she’ll prove or disprove her feelings for same-sex people. Nevertheless, she gets more involved in the obsession by experimenting with different testing activities to get certainty.

Unfortunately, these things combined mistakenly show that OCD may be treatment refractory. But contrary to that, another evidence-based therapy is now available. It is a standalone treatment or can be integrated with ERP to improve habituation. It is known as inference-based cognitive therapy (I-CBT).


In their book “Clinician’s Handbook for Obsessive Compulsive Disorder”, Frederick Aardema and the late Kieron O’Connor tell how individuals become involved in their imagination and subjective narratives. The narratives are obsessional stories. Such stories are filled with internal and external inferences that add credibility to their obsession. One of Maria’s inferences is hearsay. For example, she says, ‘I once heard of a woman who was gay but kept it secret.’

Consequently, Maria fears she is being secretive due to erroneous desire, an internal inference. Such assumptions make Maria’s story seem real to her, but it is only lived out in her imagination. Worse, testing makes her distrust her senses and common sense. Therefore, I-CBT can address this problem by reorienting Maria back to the world of reality. As a standalone treatment, it doesn’t involve exposure to one’s fears and response prevention. Instead, it helps people see the nonsensicality of performing them.

In short, I-CBT helps show that a person’s OCD is not necessarily treatment-refractory. Thus, the point is that DBS may not be required.


My two books discuss more about ERP and I-CBT. Click links below for details.

Obsessive Compulsive Disorder: Three Powerful Steps to Help You See ERP Differently eBook : Edwards, Carol: Amazon.co.uk: Books

3 Effective Ways to Treat OCD and Reclaim Your Life: Evidence-Based Treatments for Obsessive-Compulsive Disorder eBook : Edwards, Carol: Amazon.co.uk: Kindle Store

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