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 half-and-half about it. Either way, it motivates us to seek out more of something, to avoid it, or we are ambivalent.

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

People with OCD sometimes also experience conflicting emotions about intrusive thoughts. For example, consider Maria, who has paedophile-intrusive thoughts and has an aversion to them. In this instance, her amygdala attributes distaste; 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, her amygdala assigns ambivalence. Therefore Maria is motivated to changeability and worries her OCD is something else. Consequently, she becomes more absorbed in the obsession through testing and remains conflicted.

Three Reasons For Treatment Failure

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 false desire, nor aversion, for that matter. Instead, it’s linked to OCD failing to respond to exposure and response prevention therapy (ERP) because the habituation process fails.

First, the habituation process occurs when a person resists doing the rituals corresponding to the obsession and thus becomes less sensitised to it. Therefore, the second point is since the conflict noted above can make the disorder more challenging, it can be even more complicated to treat with ERP. However, that isn’t to say it is a refractory problem to ERP, even though it might appear that way. More to the point, it might be that ERP needs modifying to address variance more complicated than what is typical in OCD.

This brings me to the third point. People become so consumed by their obsession that the habituation process is affected due to high absorbance capacity. Some clients are thus referred to more expert treatment or resort to DBS.

In short, the three factors: aversion, variance due to false desire, and absorption, appear to create mixed feelings about an obsession. This mixture, as noted, can adversely affect treatment outcomes.

So let’s look at these three factors in more detail.


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. 

Variance Due to False Desire

Sometimes, people mistakenly think they like the thoughts or want to act on them. Still, even though they know objectively that the urge is mistaken, they dare not take risks. This is because they have the insight to see that the obsession has no valid meaning. However, a combination of loathing and erroneous desire confuses them. Still, while it doesn’t happen with everyone with pure-intrusive thoughts, those who struggle with false desire usually think the solution is to work harder to prevent the feared outcome. In such cases, it can lead to a term known as absorption, mentioned earlier.


Absorption involves people with OCD being so preoccupied with an obsession that they are unaware of other things around them. As a result, they tend to pay more attention to giving into rituals and preventing the feared consequence than the opposite. In other words, they lose track of response prevention. Consequently, they inadvertently fall deeper into absorption, and the repressed attempts (rituals) to ward off danger worsen. More significantly, those affected by erroneous desire wonder if their problem is another disorder, not OCD. Subsequently, these people conflict and become even more preoccupied with the obsession.

In such instances, individuals are too scared to trust their senses and thus search for further proof that their thoughts and sensations are not true about them. But it can lead to deeper absorption, known as dissociation peculiar to OCD (Soffer-Duddek et al., 2018) and consequently heightened arousal. But even though increased sensations are an intensified symptom of anxiety, people become more confused. The consequence is that the habituation process in exposure therapy fails to have the desired outcome noted before. Yet, because these individuals are unaware of high absorbance capacity and dealing with it, they worry more that they will act on their thoughts, leading to more precarious rituals when testing them out.

Treatment Success

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 their obsessional stories. Such stories are filled with inferences that add credibility to their obsession. Consequently, it makes them distrust reality-based information. In other words, they confuse reality with imagination and do not trust their senses or common sense. Therefore, inference-based therapy, another evidence-based treatment, addresses dissociation and inferential confusion and helps clients redress the difference between imagination and reality.

What’s good about the inference-based approach is that it is helpful for people who don’t take well to ERP. For example, it doesn’t involve clients having to go through tormenting exposures. Instead, the book noted above says it consists of uprooting the inferences in the obsessional narrative and replacing them with sense information in the here and now. Subsequently, it bridges the gap between imagination and reality. Therefore, clients see that rituals keep them in their imaginations or absorbed in the obsession.

Such awareness and positive action could help avert any erroneous perception that a client’s problem is treatment-refractory. But without this understanding, the consequence may lead to inpatient treatment and, failing that, DBS.


Stay tuned for a revised copy of my book “Desire-Intrusive Thoughts” that includes information on the inference-based approach.

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