The OCD Stories – Episode #509: Ian O’Brien: OCD Story, and Research on Why People Struggle to Engage with ERP

Podcast Host: Stuart Ralph
Guest: Ian O’Brien (Psychotherapist, Dublin, Ireland)
Date: October 26, 2025

Episode Overview

In this episode, Stuart Ralph interviews Ian O’Brien, a psychotherapist specializing in OCD, about his own lived experience with OCD, his journey to becoming a therapist, and—most notably—his innovative research into why people struggle to engage with Exposure and Response Prevention (ERP) therapy. Ian’s research analyzed over 100 interviews from The OCD Stories podcast, identifying the nuanced barriers that make ERP so challenging to start, stick with, or complete. The conversation is candid, practical, and insightful, providing key takeaways for individuals, clinicians, and the wider OCD community.

Ian’s OCD Story and Becoming a Therapist (00:00–14:13)

Personal Experience with OCD

• Early years: Ian describes his OCD starting with contamination fears at age 9–10, along with nighttime checking and intense moral scrupulosity.
  • “I couldn’t carry this idea that, you know, I’d witnessed something ‘bad’ happening and I’d stayed silent. So I’d write all these confession letters to my parents and grandparents.” – Ian (03:37)
• Teenage years: OCD eased somewhat during puberty, but came back in new forms (relationship OCD and paedophile-themed OCD) in late teens and early 20s.
• Struggle for Help:
  • Early therapy (with psychologists and CBT therapists) was often ineffective due to lack of OCD-specific knowledge.
  • Officially diagnosed and started on SSRIs; effective therapy found much later, including “index card therapy” with Dr. Steven Phillipson.

Peer Support and Professional Shift

• Finding Community: Joined OCD Ireland’s support groups, which became a major part of his recovery (“that sense of community… meant the world to me at the time.” – 08:52).
• Professional transformation:
  • Left 20 years in the corporate world to retrain as a psychotherapist.
  • Focused on providing accessible, OCD-specific therapy in Ireland, becoming one of the directors of OCD Ireland.

Setting the Stage: A Shortage of OCD Specialists (11:52–13:51)

• Both Ian and Stuart note the lack of OCD-specialized therapists in Ireland, and the challenge faced by people needing local, in-person support.
  • “There isn’t enough people. It absolutely, it’s a, there’s a massive shortage and hopefully we could start to see a bit of a change over the next few years. But there’s a long, long way to go.” – Ian (13:06)

Ian’s Research: Why Do People Struggle with ERP? (14:01–19:33)

Research Genesis & Methodology

• Motivation: Inspired by years of hearing real, honest stories on The OCD Stories podcast about ERP struggles.
• Design:
  • Screened over 400 episodes using transcription tools and keyword analysis.
  • Narrowed to 103 episodes with detailed ERP discussions.
  • Used reflexive thematic analysis to identify patterns, “not just in what people said, but what their stories revealed underneath.” (16:48)
• Aim:
  • “Why is ERP, even though we know it’s proven to work, so hard for people to engage with in real life?” – Ian (17:31)
• Scope: The research is about listening to stories—not about creating fixes—but Ian adds suggestions from his follow-up reading and practice.

Three Major Themes Identified: Why ERP is Hard

1. The Inner Tug of War (21:18–37:22)

Describes the emotional conflict between wanting OCD relief and being terrified of ERP.

Subthemes:

• Afraid to Start

  • Overwhelming fear, misinformation, adverse public/therapist perceptions prevent many from starting ERP.
    • “It’s like slamming into a wall of fear before you could even begin the therapy.” – Ian (21:24)
  • Reference: Public views ERP as “dangerous, traumatizing, and unet[hical].” (22:51)

• A Leap of Faith

  • Those who start but don’t fully trust or understand ERP; especially struggle if ERP clashes with personal values or is misunderstood.
    • “It’s not about giving this kind of one size fits all explanation of ERP, it’s about helping people make sense of OCD and ERP in the context of their values, their fears, their language.” – Ian (27:30)

• The Grind of the Work

  • The day-to-day ERP process is “grueling, relentless, emotionally draining.” Motivation suffers if expectations are unclear.
  • “It’s not a one-off intervention. It’s a daily, deliberate practice of facing what you fear.” – Ian (30:09)

• Step Too Far

  • Exposure tasks mismatched to what the person can tolerate can be overwhelming and shut people down.
    • Key solution: Tailoring exposures, doing them in-session, live feedback.

• Exposed by Exposure

  • Shame and fear of being “seen”—especially for stigmatized or taboo themes—prevents full engagement.
    • “For many people, doing exposures meant not just facing fear, but the fear of being seen, of exposing parts of themselves kept hidden for years.” – Ian (35:01)
    • Beautiful quote cited:
      • “The act of revealing oneself fully to another and still being accepted may be the major vehicle of therapeutic help.” – Irvin Yalom (36:17)

Key Suggestions for Therapists:

• Provide personalized psychoeducation and sample hierarchies.
• Address personalization—show how ERP fits (or can align) with client’s beliefs.
• Validate and empower the client’s input and preferences.
• Model and review exposures together in session for tailored support.
• Emphasize the importance of safety and de-shaming within the therapeutic relationship.

2. A Mind of Its Own (37:30–41:32)

Recognizes that co-occurring psychological conditions and the “shape-shifting” nature of OCD impact ERP engagement.

Subthemes:

• Past and Present Burdens

  • Depression, trauma, deep-rooted self-worth issues make ERP harder.
  • Sometimes foundational work (e.g., self-compassion) is needed first.
  • Reference to the “clinical decision-making model for assessing ERP readiness” (Craig Gordon et al.), prioritizing other supports when necessary.
    • “We can’t treat OCD in isolation. We have to consider the full emotional and psychological landscape.” – Ian (39:19)

• A Shifting Target

  • OCD is “slippery”—fears morph, mental compulsions are hard to spot.
  • People may become perfectionistic and compulsive about “doing ERP right”, which can actually maintain the OCD cycle.
    • “They’d write out dozens of scenarios, analyze every exposure, constantly questioning whether they were kind of doing it right or wrong. This kind of perfectionism can turn therapy into a compulsion itself.” – Ian (41:09)

3. The Gap Between Theory and Practice (41:32–48:53)

Theoretical knowledge alone isn’t enough; real-life challenges, logistical issues, and poor therapy delivery can undermine ERP.

Subthemes:

• Life in the Way

  • Work, school, family, illness complicate maintaining ERP; family accommodation is a persistent problem.
  • “People talked about family members inadvertently reinforcing the OCD cycle by providing reassurance or accommodating the OCD.” – Ian (43:00)

• Out of Reach

  • Some feared triggers are almost impossible to simulate (e.g., relationship OCD, existential worries), making imaginal exposures necessary yet unsatisfying for many.
  • “They felt fake and lacked the emotional punch.” – Ian (44:13)

• Let Down

  • Standard ERP sometimes isn’t enough for severe OCD; lack of intensity/structure, unpreparedness for relapse makes people feel the therapy failed them.
  • “Relapse is not only possible, it’s quite normal…help clients prepare for these setbacks not as a ‘what if’ but as a very expected part of the process.” – Ian (45:11)

• Harmful “ERP”

  • Reporting therapy labeled as ERP that skipped crucial elements (e.g., exposure without response prevention, or told to use distraction instead), or therapists falsely claiming OCD expertise, causing more harm.
    • “CBT trained clinicians, many of them lack sufficient ERP training. And unfortunately that is all too common.” – Ian (45:54)

Key Takeaways & Recommendations (48:53–51:09)

• Most people don’t struggle with ERP because it’s the wrong therapy, but because it’s delivered in the wrong way for them.
  • When therapy feels generic, too fast, or inflexible, people feel stuck and misunderstood.
• The solution is a more personalized approach: therapy that adapts to the client’s emotional, psychological, and social context.
• There is a need for better clinical guidance on personalized ERP that maintains its evidence-based rigor.
  • Reference again to Gordon et al.’s “clinical decision-making model” as a promising tool.
• “These people weren’t looking for an easier path. They were willing to do the hard work, but they needed something more responsive.” – Ian (47:00)

Resources for Listeners

• Ian offers practical resources for people and therapists based on his findings, available on his website.
  • “I've created a set of resources… I wanted to actually give people something, some kind of insights and options they could maybe take to their therapists and say, ‘maybe this is what's getting in the way.’” – Ian (50:29)
  • [Link to Ian O’Brien’s website provided in show notes]

Notable Memorable Quotes

• “Start where you are. I’ll meet you there. Because I think good therapy shouldn’t demand that you be anyplace else.” – Ian (52:50), on what he’d want on a Dublin billboard
• “The act of revealing oneself fully to another and still being accepted may be the major vehicle of therapeutic help.” – Irvin Yalom, cited by Ian (36:17)
• “You're not alone. You're not the only one who thinks this way and feels this way, because I think that is one of the cruelest parts of OCD.” – Ian, on what he'd tell his 20-year-old self (51:41)

Timestamps of Key Segments

• 00:00–14:13 Ian’s personal OCD story and journey to therapy
• 14:13–19:33 Research motivation, design, and ethical considerations
• 21:18–37:22 Theme 1: Inner Tug of War (subthemes: afraid to start, leap of faith, the grind, step too far, shame/exposed by exposure)
• 37:30–41:32 Theme 2: A Mind of Its Own (co-occurring conditions, shifting target, compulsions)
• 41:32–48:53 Theme 3: The Gap Between Theory and Practice (logistics, hard-to-simulate fears, relapse, harmful ERP)
• 48:53–51:09 Big-picture conclusions, recommendations for personalization, resources for listeners
• 51:09–54:36 Reflections, personal messages, and podcast wrap-up

Final Thoughts and Resources

• Ian’s research helps demystify and humanize the real-world challenges of ERP, offers actionable ideas for clinicians and those struggling with OCD, and argues passionately for a more tailored, compassionate approach to OCD treatment.
• [Ian O’Brien’s website – resource link in episode notes]
• [Reference studies: Johnson et al. (2024); Craig Gordon et al. on ERP readiness]

This summary captures the main substance, knowledge, and spirit of the episode, with the voices of both Stuart and Ian central throughout. For deeper dives into the themes and to access resources, listeners are encouraged to visit Ian’s website or The OCD Stories podcast archives.