ERP Therapy for Autistic Adults: When Your OCD and Autism Intersect

If you're an autistic adult who also struggles with OCD, you've probably noticed something frustrating: most resources about either condition don't quite fit your experience. The OCD content assumes a neurotypical brain. The autism content rarely mentions the intrusive thoughts that won't leave you alone. And when you try to explain to well-meaning people that your brain is doing both things simultaneously? Blank stares.

You're not making this up. The intersection of OCD and autism is real, it's surprisingly common, and it creates a unique experience that deserves specialized understanding. As a neurodivergent therapist who specializes in working with neurodivergent adults in Portland, Oregon and throughout Washington State, I've seen firsthand how traditional approaches to OCD treatment can miss the mark for autistic clients. I've also seen the profound relief that comes when someone finally receives care that acknowledges both parts of their neurology.

This post is for you if you're an autistic adult wondering whether your repetitive behaviors are "autism things" or "OCD things," if you've tried ERP therapy before and found it didn't quite work, or if you're newly discovering that OCD might be part of your picture alongside your autism. Let's talk about what ERP therapy looks like when it's adapted for autistic minds, and how finding the right fit can change everything.

Understanding the OCD and Autism Overlap

Research suggests that autistic individuals are significantly more likely to experience OCD than the general population. Some studies indicate that up to 17% of autistic adults meet criteria for OCD, compared to roughly 2 to 3% of the neurotypical population. But here's the thing: distinguishing between autistic traits and OCD symptoms isn't always straightforward. Many autistic adults spend years confused about what's actually happening in their brains, and honestly, that confusion makes complete sense.

Both autism and OCD can involve repetitive behaviors, strong preferences for sameness, and intense distress when things feel "not right." So how do you tell them apart?

The key difference lies in the function and feeling of the behavior. Autistic repetitive behaviors (often called stimming) typically feel good, regulating, or neutral. They serve a purpose: self-soothing, sensory regulation, or simply enjoyment. OCD compulsions, on the other hand, are driven by anxiety and the desperate need to neutralize intrusive thoughts or prevent feared outcomes. The relief is short-lived and the cycle continues. It's less "I want to do this" and more "I have to do this or else."

Here's where it gets nuanced: sometimes these categories blur. An originally neutral autistic behavior might become "hijacked" by OCD, transforming from something pleasant into something anxiety-driven. I've sat with many autistic clients who say something like, "I've always needed things organized a certain way, and I thought that was just my autism. But lately, if things aren't perfect, I spiral into panic." That shift from preference to fear-driven compulsion is often the signal that OCD has entered the chat.

Why Traditional ERP Can Fall Short for Autistic Adults

Exposure and Response Prevention (ERP) is the gold standard treatment for OCD. The premise is straightforward: you gradually expose yourself to triggers while resisting compulsions, and over time, your brain learns that feared outcomes don't happen. ERP works. But it was developed with neurotypical brains in mind, and that's where things can go sideways for autistic adults.

Let me walk you through some common ways traditional ERP misses the mark.

Sensory overwhelm is a big one. Standard protocols often don't account for sensory sensitivities. An exposure that's merely uncomfortable for a neurotypical person might be genuinely intolerable for someone with sensory processing differences. Therapists who don't understand this might push too hard, leading to shutdown or dropout. Not exactly a recipe for success.

Communication differences also create challenges. ERP relies on clients rating anxiety in real time, but many autistic adults experience alexithymia (difficulty identifying and describing emotions). Asking someone to rate their anxiety on a scale of 0 to 10 when they struggle to distinguish anxiety from other forms of distress isn't helpful. It's confusing at best.

Perhaps most concerning: therapists without autism expertise might target autistic coping mechanisms as if they were OCD compulsions. Trying to extinguish a helpful stim or eliminate a sensory accommodation in the name of "treating OCD" isn't just ineffective. It's harmful. Full stop.

Interoception differences matter too. ERP involves noticing physical anxiety sensations, but many autistic adults don't recognize anxiety signals until they're already in crisis. And masking compounds everything. Autistic adults, particularly women and AFAB individuals, often appear to handle exposures well while internally falling apart. We've learned that minimizing distress gets positive responses from others. That skill doesn't suddenly disappear in a therapy room.

Adapting ERP for Autistic Adults: A Neurodivergent-Affirming Approach

The good news? ERP absolutely can work for autistic adults with OCD when it's thoughtfully adapted. In my practice, I approach ERP for autistic clients with several key modifications.

Collaborative, transparent treatment planning means working together to develop an exposure hierarchy that makes sense for your unique presentation. We talk openly about why each exposure is included and what we're hoping to achieve. Autistic adults often thrive with this explicit, logical framework. The "why" matters, and you deserve to know it.

Honoring sensory needs is non-negotiable. We pace exposures differently, build in sensory breaks, and never sacrifice genuine sensory accommodations for OCD treatment. If you need noise-canceling headphones to function, those aren't on the exposure hierarchy. I help clients distinguish between sensory needs (keep these) and compulsions (these we work on).

Flexible anxiety monitoring replaces rigid scales. For clients who struggle with traditional 0 to 10 ratings, we find alternatives: colors, physical sensations, or behavioral indicators. Some prefer green, yellow, and red zones rather than numbers. Whatever works for your brain is what we use.

Extended processing time matters because autistic clients often need more space to integrate emotionally intense experiences. I build in more time between sessions and between exposures within sessions. There's no prize for rushing through this.

Addressing the autism and OCD interface directly means careful detective work to determine which behaviors are autistic and which are OCD-driven. We approach this with curiosity and adjust as we learn. It's okay if we don't have all the answers on day one.

Accounting for autistic burnout is essential. Many autistic adults seeking OCD treatment are already running on empty. We pace treatment to your actual capacity, not some theoretical ideal, and remain flexible as your capacity fluctuates. Life happens.

What to Expect from Neurodivergent-Affirming ERP Therapy

If you're considering ERP therapy as an autistic adult, here's what the process typically looks like in my practice.

We begin with a comprehensive assessment to understand your full picture: your autism, how it shows up, what accommodations you need, and your current capacity. We carefully assess your OCD and explore how these aspects of your neurology interact. This foundation makes all the difference.

Psychoeducation follows, tailored to your brain with explicit information, logical explanations, and clear frameworks. I want you to understand why we're doing what we're doing at every step. No mysterious therapeutic processes here.

We develop an exposure hierarchy that respects your neurology, carefully differentiating between OCD triggers and autistic sensitivities while considering your sensory needs and current life circumstances.

Exposures are paced to your nervous system, starting with lower intensity situations and progressing at a sustainable rate. For autistic clients, this often means a slower pace than traditional protocols suggest. That's completely fine. Sustainable progress beats pushing too hard and burning out.

Throughout, we engage in ongoing adaptation with constant check-ins about how the process is landing. Your feedback drives our approach. And we integrate this work with your broader autism experience, always considering how managing OCD intersects with sensory needs and living authentically as an autistic person.

Distinguishing Between Autistic Traits and OCD Compulsions: A Closer Look

One of the most important aspects of ERP therapy for autistic adults is accurately differentiating between autistic behaviors and OCD compulsions. Getting this wrong has real consequences: treating autistic traits as pathology is harmful, while leaving actual OCD untreated maintains suffering.

Here's a framework I use with clients to help make this distinction.

Consider the emotional quality of the behavior. Autistic behaviors often feel neutral, satisfying, or regulating. Even when driven by a need for sameness or discomfort with change, there's not typically an overwhelming sense of dread or impending catastrophe attached. OCD compulsions, by contrast, are usually accompanied by intense anxiety and a sense that something terrible will happen if the compulsion isn't performed.

Think about the flexibility of the behavior over time. Autistic preferences for routine and sameness can be strong, but they often have some flexibility built in, especially when you have input into changes. OCD compulsions tend to be more rigid and demanding, with the rules becoming stricter over time rather than more flexible.

Examine whether the behavior makes logical sense to you. Autistic behaviors usually make sense to the person doing them, even if others don't understand. "I line up my books by color because it's visually pleasing and helps me find what I need." OCD compulsions often involve magical thinking that you yourself recognize doesn't make logical sense. "I have to tap the doorframe three times or something bad will happen to my family, and I know that's not rational, but I can't stop."

Notice whether the behavior brings satisfaction or just relief. Does completing the behavior bring genuine satisfaction or pleasure? Or does it just temporarily quiet the anxiety before the cycle starts again? Autistic behaviors tend toward the former; OCD compulsions tend toward the latter.

Pay attention to the trajectory over time. Has this behavior been fairly stable throughout your life, or has it escalated, demanding more and more to quiet the anxiety? OCD tends to follow an escalating pattern where compulsions become more elaborate, more time-consuming, and more essential to functioning.

Now, I want to be clear: these are general guidelines, not absolute rules. The autism and OCD intersection is genuinely complex, and sometimes a behavior fits multiple categories or shifts categories over time. This is exactly why working with a therapist who understands both autism and OCD is so valuable. We can explore these nuances together and adjust our approach accordingly.

The Role of Autistic Identity in OCD Recovery

For many late-diagnosed autistic adults, OCD treatment happens alongside a larger process of understanding and integrating their autistic identity. These processes can support each other in profound ways.

Understanding your autism can provide context for your OCD. Many autistic adults developed OCD symptoms at least partly as a response to the stress of navigating a neurotypical world without understanding why it was so hard. Masking, suppressing stims, forcing yourself to "act normal"... these create chronic stress that can fuel OCD development. Understanding this context doesn't make the OCD disappear, but it can shift how you relate to it.

Learning to accommodate your autism can reduce OCD severity. When you stop forcing yourself to mask constantly, when you honor your sensory needs, when you reduce the chronic stress of pretending to be someone you're not, you often have more capacity to manage OCD. The overall load on your system decreases.

Building autistic self-acceptance supports ERP engagement. ERP requires you to sit with discomfort intentionally, which is hard for anyone. But it can be especially hard if you've spent your life being told your natural reactions are wrong or too much. Developing acceptance of your autistic self, including your natural ways of experiencing and processing, can actually make you more willing to engage with the discomfort of ERP. You're doing hard work from a place of self-acceptance rather than self-rejection.

Community connection matters for recovery. Autistic adults who connect with autistic community often find their OCD more manageable. There's something powerful about being around others who understand your experience, who don't require masking, and who validate that you're not broken. This sense of belonging and acceptance can be a foundation for the challenging work of OCD treatment.

Is ERP Right for You?

ERP therapy can be genuinely transformative for autistic adults with OCD, but it's not the only option, and it's not right for everyone at every moment.

ERP might be a good fit if:

You have clear OCD symptoms (obsessions and compulsions) that are distinct from your autistic traits. You have enough current capacity to engage with challenging therapeutic work. You're interested in an active, skill-building approach that requires practice between sessions. And ideally, you can find a therapist who understands both autism and OCD.

You might want to consider other options first if:

You're currently in severe burnout and need stabilization before intensive treatment. Your symptoms are primarily autistic rather than OCD-driven. You've had negative experiences with poorly adapted ERP in the past and aren't ready to try again. Or other life circumstances are making it hard to commit to the work ERP requires.

There's no shame in deciding the timing isn't right or that a different approach might serve you better. I offer other evidence-based modalities including Inference-Based CBT (I-CBT), which some autistic clients find more accessible than traditional ERP, as well as trauma-focused approaches that might be more relevant depending on your presentation.

Finding Neurodivergent-Affirming OCD Treatment in Oregon and Washington

If you're an autistic adult in Portland, Oregon or anywhere in Washington State looking for OCD treatment that actually gets your brain, I want you to know that you deserve care that honors your whole self. You shouldn't have to choose between getting help for your OCD and having your autism understood and respected.

In my online therapy practice, I work with autistic adults throughout Oregon and Washington who are navigating exactly this intersection. I bring both clinical expertise in evidence-based OCD treatment and genuine understanding of autistic experience to our work together.

If you're curious about whether we might be a good fit, I offer a free 15-minute consultation where we can talk about what you're experiencing and what you're looking for in treatment. This is a no-pressure conversation to see if my approach aligns with what you need.

Frequently Asked Questions About ERP Therapy for Autistic Adults

How long does ERP therapy typically take for autistic adults with OCD?

Treatment length varies significantly based on individual factors including OCD severity, co-occurring conditions, and current life capacity. For autistic clients, I often recommend pacing treatment more gradually than traditional timelines suggest to prevent burnout and support lasting change. Most clients see meaningful progress within several months of consistent work, though some benefit from longer-term treatment. We'll discuss realistic expectations based on your specific situation during our initial sessions.

Can I do ERP therapy if I'm not sure whether my behaviors are autistic or OCD-driven?

Absolutely. In fact, figuring this out together is often part of our early work. I don't expect you to come in with perfect clarity about what's autism and what's OCD. We'll explore this collaboratively, and our understanding will likely evolve as we work together. What matters is your willingness to engage in this exploration with curiosity.

I tried ERP before and it was overwhelming. Will this be different?

Many autistic adults have had difficult experiences with ERP that wasn't adapted for their neurology. If that's your history, I hear you, and I approach things differently. We'll pace treatment to your actual capacity, build in sensory accommodations, and never sacrifice your wellbeing for protocol adherence. That said, ERP is inherently challenging work (that's part of how it creates change). The difference is doing that challenging work in a way that respects your nervous system.

Do you work with autistic adults who are self-diagnosed?

Yes. I recognize that many autistic adults, particularly women and AFAB individuals, don't have access to formal diagnosis or were missed by assessment processes that weren't designed for them. Self-identification is valid, and I don't require formal diagnosis to work together on OCD treatment.

What if I have other conditions alongside autism and OCD?

Many of my clients have additional co-occurring conditions including ADHD, anxiety, and trauma histories. This is common, and I take a holistic approach that considers your full picture. We'll prioritize treatment targets based on what's most impacting your life and address the interconnections between different aspects of your experience.

Can ERP therapy be done online?

Yes, and many autistic clients actually prefer online therapy. You can attend sessions from your own comfortable, sensory-controlled environment, which often makes the work more accessible. All of my services are provided online to clients throughout Oregon and Washington State.

Living at the intersection of autism and OCD can feel isolating, especially when resources for either condition alone don't capture your experience. But you're not alone in this, and effective help exists. When ERP is thoughtfully adapted for autistic minds, it can provide genuine relief from OCD's grip while honoring everything that makes you who you are.

If you're ready to explore ERP therapy that actually gets your autistic brain, I'd be glad to hear from you. Reach out to schedule your free consultation and let's talk about what's possible.