151. OCD Specialist: The Shocking Truth About In Vivo ERP Therapy for OCD

Summary

---

The OCD Whisperer Podcast with Kristina Orlova

Episode 151: OCD Specialist – The Shocking Truth About In Vivo ERP Therapy for OCD
Date: September 23, 2025
Guest: Natalia Aissa, OCD Specialist, Kairos Wellness Collective

---

Episode Overview

This episode dives deep into in vivo (live) exposures as part of Exposure and Response Prevention (ERP) therapy for OCD. Host Kristina Orlova and OCD specialist Natalia Aissa explore what in vivo ERP is, how it differs from imaginal exposures, practical strategies for implementing it, and important considerations for tailoring exposures to individual needs and lived experience. Personal anecdotes, core principles, and nuanced clinical insights are shared throughout.

---

Key Discussion Points & Insights

1. What is In Vivo ERP?

• In vivo (live) exposure involves bringing real-world experiences and situations into therapy, expanding treatment beyond traditional therapy rooms.
• Natalia: “We are either with our clients or through assigning them, taking the real world and making it our therapy room. So much of OCD can’t actually be treated within these four walls. We really want to expand the therapy into the realms where the OCD actually lives.” (01:29)

2. Setting Up and Approaching In Vivo Exposures

• The process often begins with imaginal/script exposures and a fear hierarchy before moving to live exposures.
• Live exposure is most effective when the client is emotionally prepared and has developed some belief that their fears are OCD-based, not reflective of their true self.
• Example: For someone with harm OCD (e.g., POCD), live exposure might mean agreeing to babysit or taking care of children, situations OCD tries to make them avoid.
• Natalia: “What we’re doing is relearning that we can do anything and everything that other people can do even though we have these intrusive thoughts.” (02:34)

3. Gradual Engagement and Preparation

• Clients often don’t start with the most challenging exposures; readiness is built through preliminary work.
• Kristina: “So somebody already might have done work beforehand to get ready to do a live exposure… they may not necessarily start there. …they could, sounds like, build up that kind of knowledge base through doing exposure and response prevention.” (04:41)

4. Intentional vs. Organic (Spontaneous) Exposures

• Intentional exposure: Deliberately setting out to confront feared situations.
• Organic exposure: Occurs naturally as part of daily life when clients stop avoiding situations or an unexpected opportunity arises.
• Natalia: “The key is to do the response prevention. So we don’t actually count it as an exposure if we don’t actually resist compulsions during and after.” (06:14, 07:12)

5. The Role of Compulsions and True Learning

• Actual progress comes from staying in the situation without safety behaviors or mental rituals.
• Kristina: “If I engage in something, but I’m still mentally maybe somehow avoiding… then essentially I’m not really learning, right?” (07:12)

6. Addressing Core Fears

• Effective in vivo exposure requires understanding and targeting the core fear (e.g., “I’m a bad person”, “I could lose control”).
• Natalia: “We have to break down our avoidance into many different parts and expose to every side of it… Anything that really activates that core fear of ‘I’m a bad person’.” (08:34)

7. Habituation and Inhibitory Learning

• The goal is habituation—getting used to discomfort—and inhibitory learning, teaching our brain that feared outcomes aren’t dangerous.
• Natalia: “If we spend 20 minutes to sit with the discomfort, urge surf, and allow our nervous system to re-regulate…that’s when our brain and our body learn that we aren’t actually going to do the thing we are afraid we’re going to do.” (10:18)

8. Tolerating Uncertainty and Identity-Related Themes

• In vivo exposures can be especially challenging for identity- and orientation-related OCD (e.g., Sexual Orientation OCD, SO-OCD).
• Kristina: “That just feels so counterintuitive when it’s like, ‘No, but I need to know because this is about me’… What would you say to that?” (12:38)
• Natalia: “If we were to address, for example, sexual orientation OCD with in vivo exposures, we would be going to bars that are a different orientation than the one you are currently identifying with…We’re actually going to lean in to exposures and being around that thing that you have a doubt about rather than avoiding it…” (12:57)

9. Urge Surfing and Individual Contexts

• Urge surfing: Allowing urges/feelings to peak and subside without acting on them, a skill transferable from small urges (scratching an itch) to bigger ones (compulsions).
• Natalia: “It’s all about trusting yourself that you will be able to get through the peak of that desire and that eventually your brain will get tired of it…” (14:27)
• Cultural and contextual customization: Exposures must be tailored to each person, especially for marginalized groups or those with religious concerns.
• “We really need to understand what their context is, what their experience of the world is before we start to build something that could potentially lead to them being further marginalized.” (14:27)

10. Working with Religious and Value Systems

• It’s critical that ERP plans respect personal faith systems; ERP is not about pushing clients out of their religion.
• Natalia: “I just want to, you know, state that that is absolutely not the intention. We create a structure that actually fits in your value system, in your faith system, and are never pushing the boundaries outside of that.” (17:14)

11. The Ultimate Goal: Reclaiming Life and Self-Trust

• The aim of ERP is not actual danger but helping the brain recalibrate what is truly safe versus what OCD mislabels as danger.
• Kristina: “You start to kind of separate from the OCD brain, if you will, to see it differently and recognize, wow, like, this thing produces so many sticky thoughts and these feelings, but I don’t have to respond to them all.” (18:32)
• Natalia: “We’re not trying to expose anyone to actual danger ever. That’s never the goal…Our job is to habituate the brain to see, like, not dangerous things as not dangerous and dangerous things as dangerous. Because the OCD brain is truly confusing safety in how it’s evaluating the world.” (19:06)

---

Notable Quotes & Memorable Moments

• On the nature of in vivo ERP:
  • “We are either with our clients or through assigning them, taking the real world and making it our therapy room…” (01:29, Natalia)
• On readiness and gradual progress:
  • “By the time we get to in vivo exposures, my hope is that my client is at least somewhat emotionally prepared for this undertaking and actually believes that nothing bad is going to happen.” (03:48, Natalia)
• On urge surfing:
  • “If we sit with that feeling, we can actually within 20 minutes resist the urge to do the thing by sitting with the waves of desire to act and not act.” (14:27, Natalia)
• On respecting faith:
  • “The OCD specialist is not there to, you know, be against your religion or tell you that your religious belief is bad…We create a structure that actually fits in your value system, in your faith system.” (17:14, Natalia)
• On the universal difficulty of OCD themes:
  • “When people sometimes say like, well, which OCD is the worst? …It’s whichever one you’re dealing with.” (12:22, Kristina)
• On the goal of ERP:
  • “We’re not trying to expose anyone to actual danger ever. That’s never the goal…Our job is to habituate the brain to see, like, not dangerous things as not dangerous and dangerous things as dangerous.” (19:06, Natalia)

---

Important Timestamps

• 01:29 – Natalia explains in vivo exposure and its creative, real-life approach
• 02:34 – Example of harm OCD/POCD in vivo exposures
• 04:41 – Readiness for in vivo exposures, role of imaginal exposures
• 06:14, 07:12 – Intentional vs. organic exposures, importance of response prevention
• 08:34 – Exploring core fears through exposures
• 10:18 – Habituation, urge surfing, and inhibitory learning
• 12:57 – In vivo exposures for identity-related OCD themes
• 14:27 – Clarifying urge surfing and contextual sensitivity for marginalized clients
• 17:14 – An ERP plan that respects faith and values
• 19:06 – Setting safety boundaries in ERP and recalibrating the OCD brain

---

Final Thoughts

This episode offers an in-depth, compassionate look at what makes in vivo ERP therapy for OCD both powerful and nuanced. Natalia and Kristina underscore that ERP is not “one size fits all”—it’s an art that balances structure and individual context, always with the guiding principle of never introducing real danger. Listeners are left with hope, clarity, and practical wisdom on both the science and the humanity of doing hard things to reclaim their lives from OCD.

Connect with Natalia:

• Instagram: @letstalkocd
• Center: kairoswellnesscollective.com

---

Transcript

[A]

Hi, I'm Kristina Orlova, host of the OCD Whisperer podcast. As someone who lives with ocd, I understand the struggles firsthand. If you're here, you're not alone. Before we start, grab your free OCD survival kit at www.corresults.com to help you take control. That's K O R results dot com. Now let's dive into today's episode.

[B]

Welcome to OCD Whisperer podcast. So I have Natalia, who's back with me for a third series at four where we're talking all about ERP and we're going to dive into in vivo and live exposures. That kind of means the same thing. Welcome back, Natalia. And just remind us, please, a little bit about yourself.

[C]

Hi. Thank you so much for having me again, Christina. I'm Natalia Aissa. I work here in Boulder, Colorado as an OCD specialist. I run a center called Kairos Wellness Collective where we are doing ERP all day long.

[B]

I love it. Well, I know that before we were kind of talking about just the introduction of exposure response prevention for ocd, we talked a bit about imaginal and script work. And today let's dive into nvivo or live exposures. Can you tell us a little bit about what does that really actually mean? And then we'll get a little bit more into different ways how people can do it.

[C]

Absolutely. And so I am incredibly excited to talk about this topic because this is where exposure response prevention can get really fun and creative. So in vivo therapy is basically, we are either with our clients or through assigning them, taking the real world and making it our therapy room. So so much of oc, it can't actually be treated within these four walls. And we really want to expand the therapy into the realms where the OCD actually lives.

[B]

Got it. So how would somebody go about doing something like that? Because if you're thinking about, you know, like, the first things that come to my mind are the people I think of who deal with things like Paraphrasia or, you know, some. Something horrible like maybe I'm some violent person or some other content. Those tend to be kind of the more morally, you know, really irrepressible and difficult topics. And of course, there's. There's religious topics as well. But how would somebody go about something like that?

[C]

Yeah. So just a reminder, the basic premise with POCD or harm OCD is that you're not actually a harmful person. And so what we're doing is we're relearning that we can do anything and everything that other people can do even though we have these intrusive thoughts. So an in vivo exposure for someone with POCD might be to babysit their neighbor's kids or actually say yes when their church asks them to volunteer in the baby room doing the things that OCD tells them not to do because they fear that they are a bad person. So it's a lot of saying yes.

[B]

That's funny. So if somebody though is really scared, Right. How would they break this down? I suppose if we're thinking about like, like one example you gave, right. That they might say yes to, let's say babysitting. I'm, I'm already thinking about, you know, some folks I have that I know that, you know, just the thought of that would be like, oh my gosh, by myself with a kid. Are you kidding me? Why would I ever do that? How would you apply ERP to that?

[C]

Yeah, so that's why in the last recording we talked about imaginals and how we practice story. We practice like talking about the exposures, even sometimes creating the whole fear hierarchy. Writing down saying yes to babysitting the kids is going to be an exposure by the time we get to in vivo exposures. My hope is that my client is at least somewhat emotionally prepared for this undertaking and actually believes that nothing bad is going to happen. So that's the, that's the part that, you know, people reach at, at different stages, especially with the harm based ocd, the actual belief that this is not your true nature, this is OCD trying to scare you about your true nature.

[B]

Yeah. So that's interesting you say that. Right, because now it kind of brings up this topic of dealing with uncertainty or at least not having to answer something in the moment where OCD doubts come in when they're so intense. So what you're saying though is somebody already might have done work beforehand to get ready to do a live exposure, so they may not necessarily start there. They could, I guess, if they want to or if they were open to it, but they don't have to. So they could, sounds like, build up that kind of knowledge base through, through doing exposure and response prevention to start to learn about what's actually happening.

[C]

Yes, yes, absolutely. And the, the rapidness with which we enter into in vivo exposures also depends on how, how much a person has sort of withdrawn from their life and the people that need them. So for example, you know, it's one thing to babysit your neighbor's kids, but we work with a lot of people who have pocd about their own children, who they are avoiding bathing or changing diapers or being alone with. And case I might actually accelerate the in vivo in order to have that habituation process as quickly as possible so that there isn't harm done to the family system.

[B]

Got it. And so what. So it sounds like there would be, you know, intentional exposure, and then there sounds like there's some kind of organic situational. Can we talk a little bit about what are those differences?

[C]

Yes, absolutely. So an intentional in vivo exposure is something you truly set out to do. An organic is you. You stop saying no to something that very much is part of your life or would be part of your life if your OCD wasn't telling you to say no. Another example of an organic exposure would be when life gives you an exposure which, once you're paying attention, is all the time. And so we consider that an exposure if, for example, somebody drops off their toddler for 10 minutes at your house while they run to the store, and you're just kind of like, stuck in that situation. We call that an organic exposure. But the key is to do the response prevention. So we don't actually count it as an exposure if we don't actually resist compulsions during and after.

[B]

Yeah. So it sounds like if I. If I engage in something, but I'm still mentally maybe somehow avoiding or maybe saying something to myself to try to prevent some. Something bad from happening, then essentially I'm not. I'm not really learning. Right. I'm not really getting a chance to see what happens without those safety behaviors.

[C]

Exactly. So it's all about habituation. So we want to be in a position where we're breaking the OCD rules and we're also allowing ourselves to sit in the discomfort of the new situation and just get used to it.

[B]

Yeah. So I kind of want to ask you. This is something that's been on my mind, at least, you know, when we're talking about going into something that intentionally and on purpose that we know is activating us, and we want to practice just kind of being with whatever those feelings are. If we're not going to actually try to resolve it or solve it or do anything about it, would you say at that point, then that really becomes the exposure we're exposing to, then the feeling. Feeling.

[D]

Right.

[B]

Because we talk a lot about core fears and erp and so part of. Part of designing a live or in in vivo exposure would be to also understand, well, what's the core fear here that I'm addressing? What would you say to that?

[C]

I I mean, I completely agree. It's, you know, we have to, we have to break down our avoidance into many different parts and expose to every side of it. So if we use our, my, my imag. Our last episode where I'm afraid that I am going to throw my children out a window. Well, the actual fear is this like core idea that I'm a bad person. I'm going to do something violent. So perhaps before I do the in vivo exposure of holding my children by a window, which you know, I do have to do, I might do an exposure to holding my animal next to a window. I might do an exposure to something as innocuous as not tipping at a coffee shop. Anything that really activates that core fear of I'm a bad person, I'm not doing kind things or I'm not doing good things.

[B]

Got it. And so the aim, you said a couple of things. One is to habituate. So for folks who are listening to me, you don't know what that means. That means you get used to something. So get used to the state of discomfort, get used to the feeling off. Get used to I think even the physiological changes that happen in the body because there's a lot of that that's activated that we tend to misinterpret. And then you're talking about also you know, learning something. So learning, you know, would you say this is where inhibitory learning model comes in or is this more just in general afterwards to pause and reflect? Can you speak a little bit about that?

[C]

Yeah. So if, if we, if we utilize the example because I, this is how my brain really functions. But the example of me holding my animal near a window, so I, I might do that in vivo exposure and also notice all the intrusive thoughts that are coming in. I might notice where my body, I'm experiencing anxiety. I might notice that my arms are tensed up because I'm afraid that I'm going to move them. I might notice my heartbeat. And I also most importantly am going to notice my desire to compulse and basically escape from that situation. And so if we spend the 20 minutes to sit with the discomfort urge surf and allow our nervous system to re regulate despite the fact that we're feeling like something bad is going to happen, that's when our brain and our body learns that we aren't actually going to do the thing that we are afraid we're going to do. And also that we can tolerate that feeling of anxiety. We can tolerate all the what if statements that are coming into our mind. While we're exposing ourselves.

[B]

Yeah, I mean, I think it's beautiful stuff you're saying. And I, and I definitely know that for some folks, you know, listening to this, it could feel insurmountable in the beginning. It could feel like I can't tolerate this, but this feels so urgent. I, I have to figure this out. I'm also thinking about things like, you know, identity related themes about, you know, who I am or who I might be or not be or you know, if I'm one orientation or another or you know, even more than just a bad person, which of course is also equally. I mean, they're all, none of them are pleasant.

[D]

Right.

[B]

Like we, you know when people sometimes say like, well, which OCD is the worst? I've heard it said many, many times. But it's whichever one you're dealing with.

[D]

Right.

[B]

Because that's the one that, that's the most important for you and it's extremely distressing. But if we get back to like sexual orientation themes, for example.

[D]

Right.

[B]

Or identity related, like how could somebody sit with, with that?

[D]

Right.

[B]

Because that just feels so counterintuitive when it's like, no, but I need to know because this is about me. And then, and then if, you know, if this isn't, if this is true. Right. Then I have to make a whole lot of different decisions or I have to, you know, I don't know, maybe break up with my current partner or. Right. Things like that. So what would you say to that?

[C]

Yeah, I mean, it's, it's complicated and it's different for each person. But if we were to address, for example, sexual orientation OCD with in vivo exposures, like we would be going to bars that are a different orientation than the one that you are currently identifying with. If we were working on it, we might watch some, some movies that exemplify that orientation of love that perhaps have more sexualized scenes. We're actually going to lean in to exposures and being around that thing that you have a doubt about rather than avoiding it, rather than like interfering with access to that thing.

[B]

Interesting. So you, you said a couple of things that I want to also circle back on you. You use the word urge surfing. So I don't know that people know what that means, but. And also, you know, we're talking about exposures. Just want to, I don't know if like your take on this, but I've, I've certainly, you know, been Caitlin Penciati. She's done some work around like justice based ERP and things like that where we're talking about like, well, would we have people go to a bar, let's say of a different. Or regardless which it is. Right. But definitely, I think this goes towards people who, you know, are more marginalized. Like, what do you think about that? And how would then erp be adjusted, you know, with, with that notion?

[C]

Yeah. So to break the question up into two parts. So one, the urge surfing, that is a concept that I believe is from DBT if I'm not mistaken. But it's this general principle that our brains get bored. It's really, it's actually really simple that when we have an urge to do something, whether it's pick our skin or do a compulsion or you know, even something as simple as scratch and itch, if we sit with that feeling, we can actually within 20 minutes resist the urge to do the thing by sitting with the waves of desire to act and not active. So it's something that we can practice on, on itches and we can practice on these like smaller, smaller urges and then build up to our bigger urges, our, our urges to compulse. So urge surfing it, it's all about trusting yourself that you will be able to get through the peak of that desire and that eventually your brain will get tired of it, will move on to something else without you even forcing yourself to change course. To answer the second half of the question in terms of justice based ocd, that is so complex. I think that this is where we really have to create unique and bespoke exposure plans for each individual. So, you know, I don't just have like blanket exposures that I do with every person with SOD SOCD that come into my room. I really need to understand what their context is, what their experience of the world is before we start to build something that that could potentially lead to them being further marginalized.

[B]

Yeah, that's awesome. I totally second that. And I think too as a field in general, you know, I think we're, we're definitely doing a lot better and continuing to evolve in really understanding how to, you know, have more finesse. I think with ERP, it is an art form 100 and I love that you said that because it is, it's so individualized. And you're also so on point in terms of context. Like for every person that's different. I think the way OCD functions like that process is pretty much the same. But the, the how it shows up or the things you get kind of stuck on, those are so individual to each person's unique experience. Of life.

[C]

And it's worth saying that because I think this issue comes up a lot in religious OCD that the OCD specialist is not there to, you know, be against your religion or tell you that your religious belief is bad. I just really, really want to emphasize that because I know a lot of faiths, especially less mainstream faiths, are sometimes afraid to see secular OCD therapists because they're afraid that they will get pushed out of or pushed away from the rules of their religion. And I just want to, you know, state that that is absolutely not the intention. We create a structure that actually fits in your value system, in your faith system, and are never pushing the boundaries out outside of that.

[B]

I love that. I'm so glad you said that. I think that that's really true and I think that's really important that people hear that and know that that's what you want to look for. Yeah. Because really, it's. At the end of the day, it's about you and your experience and helping you build out a good ERP plan. And especially if you're going to engage in doing things live and intentionally on purpose now, interacting with and getting back into your life.

[D]

Right.

[B]

And giving up the avoidances so that you can feel comfortable and like, okay, yeah, like, I'm getting a grip on this and I'm. And. And really the goal, I think, and tell me what you think. But I. I think the goal with all this is that you. I love that use the word trust. Right. That you start to trust yourself again. You start to kind of separate from the OCD brain, if you will, to see it differently and recognize, wow, like, this thing produces so many sticky thoughts and these feelings, but I don't have to respond to them all. I don't have to give them all this attention.

[C]

Yes, yes. And as OCD specialists, we might do in vivo exposures, but we're not trying to expose anyone to actual danger ever. That's never the goal. And it might feel like that. It might feel like driving over that bridge is real danger. But this is where we have to build that therapeutic trust and that understanding that our job is not to introduce danger. Our job is to habituate the brain to see, like, not dangerous things as not dangerous and dangerous things as dangerous. Because the OCD brain is truly confusing safety in how it's evaluating the world.

[B]

I love that you said that. I think that's such a great point to. To end this on. And so I'd love to thank you for so much for coming, first of all. And just having this conversation about NVivo Live ERP and I know there's so much more in but how can people find you if they'd like to find you?

[C]

Oh, I think the easiest way is letstalk ocd my my Instagram handle and my center if you happen to be here In Colorado it's www.kairoswellnesscollective.com. i'd love to hear from you.

[B]

Awesome. Thanks so much for coming on the show.

[C]

Thank you.

[A]

Thanks for listening to the OCD Whisperer podcast. Remember, freedom from OCD is a journey.

[B]

And you're not alone.

[A]

Visit www.coraresults.com to explore self help masterclasses like Sneaky Rituals with Jenna Overbaugh or ICBT Masterclass with Christina Inabe. Don't forget to grab your OCD CBT journal tracker and planner while you're there. If you found this episode helpful, please subscribe, share and leave a five star review to help others find the podcast. Together we can make a difference.

[B]

Keep going and I'll see you in the next episode.