Telehealth: The “Happy Accident” that Quietly Revolutionized Exposure Response Prevention for OCD

Exposure and response prevention (ERP or EX/RP) is widely regarded as a first-line psychological treatment for obsessive-compulsive disorder (OCD; Foa et al., 2012; Mao et al., 2022; Reid et al., 2021; Romanelli et al., 2014). ERP requires patients to intentionally confront obsessional triggers while refraining from rituals, compulsions, avoidance, reassurance seeking, or other behaviors that maintain the obsessive-compulsive cycle (Foa et al., 2012). Although ERP has a strong evidence base, its delivery has historically been constrained by the artificiality of the clinic setting. Clinicians attempting to implement ERP in traditional outpatient environments often encounter a central limitation: many of the patient’s most prominent triggers, rituals, avoidance patterns, and reassurance-seeking behaviors occur outside the therapy office and cannot be easily recreated within an outpatient therapy setting. For those of us who do this work daily, the ability to create conditions in which to do exposure work is often very difficult, involves a lot of creativity, and at times can be impossible. For example, when a patient fears touching contaminated objects, attempting to recreate those conditions in a sterile clinic environment can feel artificial, imprecise, and only partially connected to the patient’s actual fear structure. Similarly, when a patient struggles with compulsive checking of locks, light switches, appliances, or other household objects, it can feel clinically insufficient to spend a 53-minute office visit discussing and preparing for exposures that the patient will later be expected to complete alone at home without support.

As a result, therapists have frequently depended on homework assignments, worksheets, family reports, apps, or patient self-monitoring to extend treatment into the settings where symptoms occur and to support treatment fidelity between sessions. This limitation not only reduces patients’ access to the therapist’s guidance but also negates the emotional support provided by therapists during early exposures which has been shown to be so critical to early treatment success (Wheaton et al., 2016; Simpson et al., 2011)

For context, many OCD symptoms occur most predominantly in the patient’s home, bathroom, kitchen, bedroom, car, computer, family routines, or in relation to personal belongings. During the COVID-19 pandemic, psychologists were forced to rapidly adopt telehealth technologies to maintain continuity of care. Many clinicians were understandably concerned about what this shift would mean for in-vivo exposure, which had historically been conducted in the therapy office. However, for those providing care for patients with OCD Spectrum Disorders, telehealth created an unexpected “happy accident.” It offered clinicians a new vantage point into patients’ lived environment and allowed exposure work to occur in the very contexts where symptoms were most impairing. What was lost through in-person sessions was, in many cases, offset by the discovery that telehealth could allow a depth of in vivo exposure that had previously been limited by travel time, office constraints, privacy concerns, and professional boundaries.

As care rapidly migrated to online platforms during the pandemic, the OCD focused psychologist community witnessed a quiet revolution in ERP treatment as telehealth increased the “ecological validity” of behavioral treatment. In traditional outpatient care, the patient may describe checking the stove, avoiding contaminated laundry, arranging items until they feel “just right,” repeatedly seeking reassurance from a family member, or engaging in mental rituals before bed. These descriptions are clinically useful, but incomplete and based on self-report (and therapist interpretation of self-report). Through video calls, the psychologist can observe the patient’s actual environment and collaboratively design exposures using the real stimuli that maintain OCD. For example, a patient with contamination fears can practice touching household surfaces in their kitchen while delaying handwashing. A patient with checking compulsions can practice leaving appliances, locks, or lights unchecked for the duration of the session, and a patient with symmetry or ordering symptoms can practice disorganizing objects in their own room while on the call with their therapist.

This turns the home from a site of symptom maintenance into an active treatment setting. The ability to accurately assess concerns has also markedly changed with the telehealth platform. Being able to interact with the feared stimuli along with the patient can provide valuable clinical insights. For example, seeing the mechanics of a lock, examining a “dirty” space that a patient fears, or viewing rooms affected by hoarding can give the therapist important clinical insight while also strengthening trust, understanding, and collaboration. In our experience at UT Southwestern, hoarding cases specifically have made a major shift as we now get to work with the patient within the hoarding environment which can be incredibly powerful for implementing change.

Although research related to online use of ERP for OCD is not entirely new, the sudden mass adoption of this new modality has made a notable shift. Fletcher et al. (2022) found that video telehealth ERP was feasible and acceptable, with patients reporting comfort engaging in ERP from home and therapists noting that access to the home environment improved their understanding of symptoms and exposure planning. Similarly, research on online video teletherapy for OCD has found clinically meaningful symptom reduction in large real-world samples, suggesting that remote ERP can be delivered effectively outside of conventional specialty clinic settings (Feusner et al., 2022). These findings are significant because ERP remains underused despite its strong evidence base, partly due to geographic barriers, limited availability of trained clinicians, transportation demands, time constraints, and cost (Feusner et al., 2022). Telehealth addresses several of these barriers while preserving the active ingredients of ERP. At our OCD Specialty Clinic at UT Southwestern in Dallas, Texas, telehealth has made it possible to provide insurance-covered, therapist-guided in vivo exposure to patients in El Paso (a full 10-hour drive away), in ways that once would have seemed nearly impossible. Providing access to specialty OCD care in rural communities, in a format that can feel like an in-home visit, represents a remarkable new opportunity, especially in a state as vast as Texas.

Traditionally, advances in psychotherapy have often occurred through improvements in treatment modality. New theories, protocols, manuals, and mechanisms of change have shaped the evolution of psychological treatment and set the standard of knowledge for board certification (ABPP) in psychology. However, telehealth with OCD spectrum disorders represents a somewhat different type of innovation as it changes the context and environment of the treatment, instead of the treatment itself. It is rare for a technological and contextual shift to so fundamentally improve clinical care, particularly when that improvement emerged as an unintended consequence of rapid adoption of technology. This is especially important for OCD treatment, which is one of the few interventions in which the specific components of treatment have shown unique effectiveness outweighing common factors that underlie the therapeutic alliance (Himle et al., 2024; Wolf et al., 2022; Simpson et al., 2008). Telehealth turns ERP from a clinic-based “lab test” into bedside medicine. Instead of asking patients to describe symptoms from memory, the therapist can enter the environment where OCD operates, observe rituals in real time and real context, and intervene at the point of contact. It is like assessing asthma while the patient is climbing the stairs that trigger shortness of breath, rather than relying only on their recollection of symptoms from last week.

Telehealth’s impact on ERP for OCD may ultimately be remembered less as a planned innovation than as a clinical discovery born out of necessity. What began as an emergency solution to preserve access during the pandemic revealed something larger about the nature of effective psychotherapy, namely that sometimes the setting of treatment matters as much as the treatment model itself. For ERP, this was especially consequential because OCD lives in context. It lives in the rooms, routines, objects, relationships, and private moments that are often difficult to reproduce in the therapy office. Telehealth allowed clinicians to meet OCD where it actually occurs, transforming the home from a place where symptoms were merely reported into a place where healing can happen. Future research should continue to test telehealth ERP directly against in-person ERP, not simply to declare one format superior, but to better understand for whom, when, and under what conditions each approach works best. The larger lesson of this “happy accident” is that psychotherapy advances not only when we develop new treatments, but also when new technologies allow us to deliver established treatments in more powerful, precise, and contextually meaningful ways.