ERP Therapy for Neurodivergent Brains: A Different Approach to Anxiety and OCD
Living with anxiety or OCD when your brain works differently isn't just about managing symptoms—it's about finding approaches that actually fit how you process the world. If you're autistic, AuDHD, or otherwise neurodivergent, you've probably already figured out that traditional therapy doesn't always land the way it's supposed to. That's where my approach to Exposure and Response Prevention (ERP) comes in, and honestly, it's what I've built my practice around.
I work exclusively with neurodivergent adults, particularly women and AFAB folks who've spent decades masking, achieving, and people-pleasing their way through life. Many of my clients are late-diagnosed autistic individuals who are past the "wait, am I autistic?" phase and firmly in the "okay, I'm autistic—now what?" territory. If that sounds like you, you're in the right place.
Key Takeaways
- ERP therapy is highly effective for OCD, but it requires thoughtful adaptation for neurodivergent brains, accounting for sensory needs, processing differences, and executive function variations
- Autistic and AuDHD women often need specialized OCD treatment that recognizes masking patterns, sensory sensitivities, and the complex interplay between autism traits and compulsive behaviors
- My approach to ERP honors your neurotype by creating personalized exposure hierarchies, integrating your strengths and special interests, and building response prevention strategies that work with your brain
- Common challenges include distinguishing autism traits from OCD compulsions, managing perfectionism rooted in survival strategies, and addressing internalized compulsions that developed through masking
- Online ERP therapy offers significant advantages including sensory-friendly environments, creative exposure options, and flexible scheduling that respects your energy patterns
Understanding ERP Therapy Through a Neurodivergent Lens
Exposure and Response Prevention is considered the gold standard treatment for Obsessive-Compulsive Disorder. The premise is straightforward: you gradually face situations that trigger obsessions (exposure) while learning to resist the compulsive behaviors that temporarily reduce anxiety (response prevention). Over time, your brain learns that the feared outcomes don't actually happen, or that you can tolerate uncertainty without resorting to rituals.
But here's where things get interesting—and where most traditional therapists miss the mark. Standard ERP protocols were designed with neurotypical processing in mind. They assume a certain way of perceiving sensory input, managing executive function, and regulating emotions. When you're autistic or have ADHD, those assumptions fall apart pretty quickly.
What Traditional ERP Gets Wrong
In my years of working with neurodivergent clients, I've seen the same patterns over and over. Traditional ERP often mistakes autistic regulation strategies for OCD compulsions. It pushes exposures without considering sensory overload. It assumes that "avoidance" is always fear-based, when sometimes it's actually your nervous system saying "this is too much input right now."
What looks like "resistance" to a neurotypical therapist might actually be your brain needing more explicit instructions, more processing time, or a different approach altogether. What seems like "overthinking" could be your natural pattern-recognition abilities at work. These aren't bugs in your system—they're features. My job is to work with your neurotype, not try to force you into a neurotypical mold.
The Gold Standard, Adapted
ERP remains incredibly effective for OCD because it directly interrupts the obsession-compulsion cycle. The difference in my practice is how we get there. I adapt every aspect of the process to account for how autistic and ADHD brains actually function:
- Sensory considerations first: Before we design any exposure, we talk about your sensory profile. If certain textures, sounds, or visual stimuli are genuinely overwhelming, we work around that or build up to it gradually in a way that doesn't flood your system.
- Processing speed respect: Some of my clients process information quickly and need lots of stimulation. Others need time to think through each step. I match my pacing and communication style to how your brain actually works.
- Executive function support: Managing attention, organization, and task initiation when you have ADHD or executive function differences isn't a character flaw. We build scaffolding and support systems that make response prevention actually achievable.
- Pattern recognition as strength: That detail-oriented, pattern-noticing brain you have? It's not just useful for understanding your OCD—it's a powerful tool for tracking progress and identifying what actually works for you.
Why Neurodivergent Women Need Specialized OCD Treatment
If you're a woman or AFAB person reading this, I'm willing to bet you've been told you're "fine" more times than you can count. Maybe you've been praised for being "so responsible" or "so detail-oriented" while internally drowning in compulsions and intrusive thoughts. That's the exhausting reality of high-functioning masking, and it's something I see constantly in my practice.
The Masking Factor
Autistic women and AFAB folks have often spent their entire lives learning to camouflage their neurodivergence. You've gotten really, really good at appearing "normal." The problem is, OCD loves to hide inside that masking behavior. Your compulsions become internalized, invisible, socially acceptable on the surface. You're checking things mentally, seeking reassurance in covert ways, organizing and rearranging to manage anxiety—but because you're not dramatically washing your hands 50 times or touching doorknobs in patterns, people assume you're "not that bad."
This masking makes OCD incredibly difficult to identify and treat using standard approaches. Traditional therapists might miss it entirely, or they might see your need for detailed explanations and careful analysis as "intellectualizing" or "avoiding the work" when really, that's just how your brain naturally processes information.
Sensory Sensitivities Change Everything
Here's something most OCD treatment protocols completely ignore: if you have significant sensory sensitivities, exposure exercises can quickly become cruel rather than therapeutic. Standard ERP might ask you to touch something that's not just anxiety-provoking but genuinely sensorily distressing. That's not helpful—that's just causing additional nervous system dysregulation.
In my work, we carefully distinguish between "this triggers my OCD" and "this is genuinely overwhelming to my sensory system." Sometimes they overlap, and that's when we get creative. We might start with imaginal exposures, use visual aids, or find ways to modify the exposure so it challenges the OCD without causing sensory trauma. The goal is always to work with your nervous system, not against it.
Executive Function and Response Prevention
Let's talk about something that makes neurodivergent ERP particularly tricky: executive function differences. Response prevention requires you to plan, remember, initiate, and follow through on resisting compulsions. If you have ADHD or executive function challenges common in autism, this can feel nearly impossible without the right support.
I've had clients tell me they'll commit to not doing a compulsion, fully mean it in the moment, and then find themselves doing it anyway because they forgot, got distracted, or couldn't activate the "stop" signal fast enough. This isn't failure—this is your executive function working exactly as it's wired to work.
We address this by building external support systems: visual reminders, body doubling (even virtually), breaking response prevention into micro-steps, and finding ways to make resisting compulsions more engaging for your ADHD brain. It's about scaffolding, not willpower.
When ADHD and OCD Collide
If you're dealing with both ADHD and OCD (which is common), you're navigating a particularly complex situation. ADHD impulsivity can make you act on compulsions before you even realize what's happening. Attention regulation issues mean you might struggle to consistently practice response prevention techniques. Emotional dysregulation amplifies the anxiety that fuels OCD, creating a feedback loop that's exhausting to break.
Understanding this interplay is central to how I approach treatment. We're not treating these as separate issues—we're addressing the whole system of how your brain works and where OCD has found places to take root.
My Approach: Building ERP Around Your Actual Brain
I don't believe in forcing square pegs into round holes. My approach to ERP is built around one core principle: the therapy should fit your brain, not the other way around. This means everything we do together is personalized, collaborative, and grounded in your lived experience as a neurodivergent person.
Creating Exposure Hierarchies That Make Sense
Traditional ERP uses something called an exposure hierarchy—basically a ranked list of anxiety-provoking situations, from mildest to most intense. We'll create one too, but with some critical differences.
First, we're distinguishing between OCD-driven behaviors and autistic coping mechanisms. That routine you have every morning? It might be OCD, or it might be how your autistic brain creates the predictability it needs to function. Trying to eliminate essential regulation strategies through ERP would be counterproductive and potentially harmful. We figure out what's what before we challenge anything.
Second, we're building in sensory considerations from the start. If something involves a texture you genuinely can't tolerate, we're not going to force you to white-knuckle through it. We'll either find an alternative exposure or work up to it so gradually that your nervous system can adapt.
Third, we're pacing everything with your energy levels in mind. Burnout is real, and pushing too hard too fast doesn't actually speed up progress—it just makes you exhausted and less able to engage with the work.
Using Your Strengths, Not Fighting Them
Your special interests, your ability to hyperfocus, your pattern recognition skills—these aren't obstacles to therapy. They're some of your greatest assets, and I actively incorporate them into our work.
If you're passionate about a particular topic, we can weave that into exposure exercises to increase engagement. That ability to really zone in on something (when it's interesting to you) becomes a powerful tool for practicing response prevention. Your detail-oriented thinking helps us track subtle progress and identify what's actually working versus what's not.
I've worked with clients who are deeply into data analysis, so we created detailed tracking systems for their OCD patterns that turned treatment into an engaging puzzle to solve. I've worked with people whose special interests became the reward system that motivated them through difficult exposures. Your brain's unique wiring isn't something to overcome—it's something to leverage.
Response Prevention That Actually Works
The "response prevention" part of ERP is where a lot of traditional therapy falls short for neurodivergent folks. It's not enough to just say "stop doing the compulsion." Your executive function, working memory, and impulse control might work differently, and we need strategies that account for that.
We create clear, concrete, step-by-step plans for resisting compulsions. We identify what you can do instead of the compulsion—not just "nothing," which can feel impossible, but actual alternative behaviors that help you manage the urge. We build in environmental supports, reminders, and accountability that work with your brain's natural functioning.
Sometimes this means using visual aids. Sometimes it means setting up specific times to check in with yourself. Sometimes it means finding body-based strategies that help you tolerate the discomfort. It's individualized, and it's always collaborative.
Common Challenges in Neurodivergent ERP (And How We Navigate Them)
Even with the best approach, ERP for neurodivergent brains comes with specific challenges. The good news is, when you understand these challenges, they become much more manageable.
The Autism-OCD Overlap
This is probably the most complex issue I deal with in my practice. Autism and OCD can look remarkably similar on the surface. Both can involve repetitive behaviors, intense need for sameness, distress when routines are disrupted, and rigid thinking patterns. But they're fundamentally different in their origins and functions.
Autistic routines and repetitive behaviors typically serve a regulatory purpose. They help you manage sensory input, create predictability in an overwhelming world, or provide comfort and grounding. These aren't driven by fear of specific outcomes—they're part of how your nervous system maintains equilibrium.
OCD compulsions, on the other hand, are driven by anxiety and a need to prevent feared outcomes or reduce distress from intrusive thoughts. They feel urgent and necessary in a way that's tied to specific worries.
In our work together, we carefully map out which behaviors are which. We protect and even strengthen the autistic coping mechanisms that help you function, while carefully challenging the OCD-driven compulsions that interfere with your life. Getting this distinction right is crucial—eliminating an essential regulation strategy would be harmful, not helpful.
Perfectionism as Survival Strategy
If you're a high-achieving neurodivergent woman, there's a good chance your perfectionism developed as a survival strategy. You learned early that being perfect, being helpful, being impressive was how you avoided criticism, hid your differences, and proved your worth. This isn't just personality—it's trauma-informed adaptation.
When OCD latches onto this perfectionism, it becomes absolutely exhausting. The checking, the redoing, the inability to let anything be "good enough"—it's not just annoying, it's debilitating. But we can't treat this effectively by just challenging the behaviors. We need to address the underlying belief system that says your worth depends on flawless execution.
In our work, we separate your genuine values and goals from OCD's impossible demands. We explore where the perfectionism came from and what it's protecting you from. And we gradually build tolerance for "good enough" in ways that feel safe rather than terrifying.
Hidden and Internalized Compulsions
Because of masking, many of your compulsions might be completely internal and therefore invisible to others. Mental reviewing, thought-checking, internal reassurance-seeking, analyzing conversations or situations endlessly in your mind—these can be just as disruptive as visible rituals, sometimes more so.
These internal compulsions are tricky to address because they can happen automatically and constantly. We use specific techniques to bring them into awareness first, then develop strategies to interrupt them. This might involve mindfulness practices adapted for neurodivergent brains, specific thought-stopping techniques, or ways to externalize the process so it's easier to track and modify.
The Benefits of Online ERP Therapy
I practice exclusively online, and for neurodivergent clients, this isn't just convenient—it's often therapeutically superior to in-person work.
Your Space, Your Sensory Control
When you're doing therapy in your own home, you control everything about the environment. Lighting, sound levels, temperature, seating, clothing—all of it is exactly as you need it to be. There's no fluorescent lighting, no waiting room small talk, no perfume from the person who was there before you, no unpredictable elements that drain your energy before the session even starts.
This sensory control means you can put more of your energy into the actual therapeutic work rather than managing environmental overwhelm. It's a significant advantage that makes the therapy more effective and less exhausting.
Creative and Practical Exposure Options
Online therapy opens up really interesting possibilities for exposure work. We can use screen sharing to look at triggering images or situations together. We can practice exposures in your actual environment—your kitchen, your bathroom, your bedroom—where many compulsions actually occur. This makes the practice more ecologically valid and directly applicable to your daily life.
We can also get creative with imaginal exposures, using visualization techniques while you're in a comfortable, controlled space. The flexibility of the online format lets us design exposures that might be difficult or impossible to do in an office setting.
Flexible Scheduling for Real Life
Let's be real about energy management. If you're neurodivergent, your energy levels probably don't follow a 9-to-5 schedule. You might have times of day when you're sharp and engaged, and other times when focusing on therapeutic work would be impossible.
Online therapy allows us to schedule sessions when you're actually at your best, not just when an office has availability. This flexibility means you're more likely to consistently attend and engage with the work, making therapy more effective overall. It also means we can schedule around your natural rhythms, your other commitments, and the reality of fluctuating energy levels.
What to Expect: The Intake Process and Beyond
If you're considering working with me, here's what the actual process looks like.
Starting with a Free Consultation
Before we commit to anything, we'll have a free 15-minute consultation call. This is your chance to ask questions, get a feel for how I work, and see if we're a good fit. I'll ask some basic questions about what you're dealing with and what you're hoping to get from therapy. There's no pressure—this is genuinely about figuring out if we should work together.
The Intake Session
If we decide to move forward, our first formal session is an intake. This is where I get to know you more comprehensively. We'll go over your history—when you first noticed these patterns, previous therapy experiences, how your neurodivergence shows up in your life, and what brought you to seek help now.
I take a holistic, biopsychosocial approach, meaning we look at the biological, psychological, and social factors affecting you. For neurodivergent clients, this includes understanding your sensory profile, executive function patterns, masking history, and how autism or ADHD traits intersect with anxiety and OCD.
Most importantly, we'll establish your goals for therapy. This is your journey, so your goals are what matter. Some people want to reduce specific compulsions. Others want to understand the difference between their autism and their OCD. Some are looking to unmask more and figure out who they are beneath all the coping strategies. We shape the work around what you actually want to achieve.
Ongoing Sessions and Scheduling
Once we're working together, I handle all the scheduling. Ideally, we set up recurring appointments that work with your schedule—consistency helps a lot with this kind of work. If you need to reschedule or adjust something, we can handle that via email.
Sessions involve a mix of understanding your specific OCD patterns, building and practicing coping strategies, and gradually working through exposure hierarchies. Between sessions, you'll likely have homework—practice exercises to do in your real life. We troubleshoot together, adjust approaches as needed, and build skills that become sustainable over time.
Beyond Symptom Reduction: Identity and Integration
Here's something most OCD treatment doesn't address: for late-diagnosed autistic adults, especially those who've spent decades masking, therapy is about more than just reducing compulsions. It's about identity integration, unmasking, and figuring out who you actually are beneath all the survival strategies.
Redefining Your Relationship with Uncertainty
Autistic brains often crave predictability and certainty. It's not a character flaw—it's how your nervous system regulates in a world that's overwhelming and chaotic. OCD exploits this by convincing you that if you just do one more check, one more ritual, you'll finally have the certainty you need.
My work with clients goes beyond just tolerating uncertainty. We explore what true certainty actually is (spoiler: it's mostly an illusion), and we build your capacity to trust yourself and your judgment even when things aren't perfectly predictable. This is deep work that often connects to your experience of being neurodivergent in a neurotypical world.
Building Self-Compassion
If you're like most of my clients, you've spent years—maybe decades—being really hard on yourself. The internal critic that developed through masking, through trying to fit in, through feeling like you're never quite enough. When OCD gets mixed in with this, it becomes particularly brutal.
We work on developing genuine self-compassion. Not toxic positivity or empty affirmations, but real understanding and kindness toward yourself. This includes recognizing the incredible effort you've put into surviving, acknowledging the challenges you've faced, and treating yourself with the same grace you'd extend to others.
Creating Authentic Connections
When you've spent your life masking and managing OCD, authentic connection can feel impossible. You might worry about being too much, too intense, too different. As we work on reducing OCD symptoms, we also explore what genuine relationships look like for you. This involves understanding your social needs (which might be different from neurotypical expectations), setting boundaries that protect your energy, and finding your people—folks who see and appreciate you as you actually are.
Evidence-Based Approaches I Use
My practice is grounded in evidence-based modalities that I've adapted for neurodivergent brains. Here's what that looks like:
Exposure and Response Prevention (ERP)
This is the foundation of my OCD treatment work. As we've discussed throughout this article, I adapt standard ERP protocols to account for sensory needs, processing differences, and executive function variations. The core principle remains the same—gradually facing fears while resisting compulsions—but the implementation is tailored to how your brain actually works.
Inference-Based Cognitive Behavioral Therapy (I-CBT)
This approach examines the reasoning processes that maintain OCD. Instead of just facing fears, we look at how OCD distorts your thinking and creates doubt where none should exist. I-CBT is particularly useful for people who experience primarily intrusive thoughts (sometimes called Pure-O) or who find traditional exposure exercises difficult. It leverages analytical thinking skills—something many autistic folks excel at—to understand and interrupt OCD's logic.
Cognitive Processing Therapy and Prolonged Exposure
When anxiety and OCD are tied to trauma, these approaches help process difficult experiences and reduce their ongoing impact. I adapt these trauma-focused therapies to be neurodivergence-informed, recognizing that trauma can present differently in autistic individuals and that sensory considerations are essential during processing work.
Moving Forward
If you've read this far, you probably recognize yourself in these descriptions. Maybe you're tired of feeling like anxiety and OCD run your life. Maybe you're ready to stop masking quite so hard and figure out who you are without the constant mental noise. Maybe you're just exhausted and want something to actually work.
ERP can be challenging work—facing fears and resisting long-standing compulsions isn't easy. But when it's done in a way that honors your neurotype, respects your nervous system, and leverages your natural strengths, it can be genuinely transformative. The goal isn't to eliminate anxiety entirely (that's not realistic for anyone) but to develop a healthier relationship with uncertainty and build sustainable ways of managing OCD that don't drain your energy.
I work with clients throughout Oregon and Washington State via online therapy sessions. If you're interested in exploring whether we'd be a good fit, start with a free 15-minute consultation. We can talk about what you're dealing with, answer any questions you have about my approach, and figure out if working together makes sense.
You don't have to keep doing this alone. And you definitely don't have to keep trying to fit yourself into therapeutic approaches that weren't designed for how your brain actually works.
Frequently Asked Questions
What exactly is ERP therapy?
ERP (Exposure and Response Prevention) is a therapeutic approach where you gradually face situations that trigger obsessive thoughts while learning to resist the compulsive behaviors you typically use for relief. The process helps your brain learn that feared outcomes rarely occur and that you can tolerate discomfort without resorting to rituals.
How is ERP different when adapted for neurodivergent people?
Neurodivergent-adapted ERP accounts for sensory sensitivities, processing differences, executive function variations, and the important distinction between autistic regulation strategies and OCD compulsions. It works with your brain's natural wiring rather than assuming neurotypical processing patterns.
Can ERP help with anxiety beyond just OCD?
While ERP is specifically designed for OCD, its principles of gradual exposure and building tolerance for uncertainty can be helpful for various anxiety issues. By facing feared situations and reducing safety behaviors, many people experience overall anxiety reduction.
What are compulsions in OCD?
Compulsions are repetitive behaviors or mental rituals that you feel compelled to perform to reduce anxiety or prevent feared outcomes. These can be visible (like checking, washing, arranging) or internal (like mental reviewing, counting, or seeking reassurance in your mind).
Why is response prevention important in ERP?
Response prevention—resisting the urge to perform compulsions—is crucial because it allows you to learn that you can tolerate anxiety without the ritual, whether or not the feared outcome occurs. This breaks the reinforcement cycle that maintains OCD.
What does "exposure" mean in ERP?
Exposure involves gradually and intentionally putting yourself in contact with situations, thoughts, or sensations that trigger obsessions and anxiety. This is done systematically, starting with less challenging triggers and working up to more difficult ones, always with appropriate support and pacing.
How long does ERP therapy typically take?
Treatment duration varies significantly based on individual factors, including the nature and severity of OCD symptoms, how consistently you practice between sessions, and your specific goals. Some people notice improvement within a few months, while others benefit from longer-term work.
Do I need to be formally diagnosed with autism to work with you?
No. I work with late-diagnosed and self-identified autistic individuals. If you strongly identify with the autistic experience and neurodivergent processing patterns, formal diagnosis isn't required to benefit from neurodivergence-informed therapy.