Beyond One-Size-Fits-All ERP: Cultural Context in Ethical Exposure Therapy

By: Felix Murad, LPC-S, LMHC, CMHC, NCC

Keywords: OCD treatment, ERP therapy, culturally responsive therapy, BIPOC mental health, inhibitory learning, OCD in minority communities, harm OCD, scrupulosity OCD

A Call to the Field for Culturally Responsive OCD Treatment

There is a quiet gatekeeping problem in the OCD treatment world, and it is costing people their lives slowly, through compulsion cycles and avoidance, shame and isolation. It does not wear the face of malice. It wears the face of standardization. It looks like training programs that teach Exposure and Response Prevention (ERP) well but teach it to a default client who is white, English-speaking, and Western in their orientation to distress, religion, family, and identity. It looks like a field that has mastered the mechanics of inhibitory learning but has yet to fully grapple with the cultural variables that determine whether those mechanics land or blow up in the room.

This is a call to the field. Not a cancellation. Not an ideological declaration. A clinical one.

OCD does not care about your zip code, your language, your religion, or the color of your skin. But the way it speaks to you, the content it selects, the shame it weaponizes, the fears it inflates absolutely does. And if we are serious about expanding access to quality ERP, we have to stop pretending that the standard protocol is culturally neutral. It is not. It was built on samples that have historically underrepresented Black, Indigenous, and People of Color (BIPOC), as well as immigrants, LGBTQ+ individuals, and those from collectivist cultural backgrounds (Williams et al., 2017).

The science of ERP is not the problem. The inhibitory learning model grounded in Craske and colleagues’ expectancy violation framework remains the most empirically supported treatment for OCD-spectrum conditions (Craske et al., 2014). The problem is not what. The problem is the how, and the who, and the deep humility required to hold both simultaneously.

The Scope of the Problem: Who Has OCD and Who Gets Treated

The lifetime prevalence of OCD in the United States is estimated at approximately 2.3%, translating to roughly 7.7 million people (Ruscio et al., 2010). Obsessive-compulsive and related conditions including Body Dysmorphic Disorder (BDD), hoarding disorder, trichotillomania (hair-pulling), excoriation (skin-picking), and related Body-Focused Repetitive Behaviors (BFRBs), affect an additional significant proportion of the population. Studies consistently suggest that OCD prevalence is broadly similar across racial and ethnic groups; OCD does not preferentially strike white, Western populations (Williams et al., 2017).

And yet. Access to evidence-based ERP remains drastically unequal. A 2017 meta-analysis by Williams and colleagues the most rigorous systematic review of OCD treatment outcomes across racial and ethnic minority groups found that BIPOC individuals are significantly underrepresented in OCD clinical trials. Of the 34 randomized controlled trials reviewed, only 15.5% of participants were non-white. The field has been building and refining its treatment evidence primarily on a sample that does not reflect the diversity of those it claims to serve.

The downstream consequences are real and documented: later detection, higher symptom severity at first presentation, higher dropout from treatment, lower treatment utilization, and disproportionate reliance on crisis intervention rather than preventive and evidence-based outpatient care (Williams et al., 2017; Himle et al., 2008). This is not a pipeline problem alone. It is a relevance problem. When ERP does not speak to a client’s actual lived experience, the client experiences the treatment as foreign, dismissive, or even harmful and they leave. Clinicians then misread that leaving as resistance or poor motivation, compounding the harm.

Same Disorder, Different Lens: How Culture Shapes OCD Presentation

The diagnostic criteria for OCD do not change across cultures. Obsessions remain unwanted, intrusive, ego-dystonic thoughts, images, or impulses that cause marked distress. Compulsions remain repetitive behaviors or mental acts performed to neutralize that distress. The anxiety cycle intrusion, appraisal, distress, compulsion, temporary relief, reinforcement is neurobiologically consistent across populations (American Psychiatric Association, 2022).

The content, however, is culturally saturated. And content matters clinically. It shapes assessment, case conceptualization, the selection of exposures, and critically the therapeutic relationship.

Harm OCD: A Case Study in Cultural Differential

Take harm OCD, one of the most common and distressing OCD subtypes, characterized by intrusive thoughts about causing harm to others, stabbing a family member, running a pedestrian over, or poisoning food. In a majority-culture, white, Western clinical context, these presentations are increasingly recognized. Psychoeducation is available. Destigmatization narratives exist. When a white, middle-class client says, ‘I keep having thoughts about hurting my baby,’ a trained clinician can often mobilize ERP treatment in a relatively supportive environment. Shame is present, but the cultural scaffolding around mental health disclosure exists.

Now place that same presentation in a Black family navigating generations of medical mistrust rooted in documented historical abuses the Tuskegee Syphilis Study (Brandt, 1978) forced sterilization, J. Marion Sims. Place it in a Latino family where mental illness is conceptualized as a spiritual failing or ‘susto,’ where the extended family network is a central protective factor but also a source of enormous shame pressure. Place it in a South Asian household where the family’s social standing depends on projecting collective wellness, where the first generation has already sacrificed everything so the second generation could succeed, and where disclosure of psychiatric illness let alone thoughts about harming one’s child is experienced as a threat to the entire family system.

The phenomenology of the harm OCD is the same. The stakes of disclosure, the cultural meaning of the intrusions, the shame architecture around those thoughts, the help-seeking barriers, the risk of genuine harm from mishandled disclosure these are not the same. Not even close.

Scrupulosity, Contamination, and Identity-Based Obsessions

Scrupulosity OCD a common obsessions I see in practice, related to religious or moral perfectionism presents differently in Evangelical Christian, Catholic, Jewish, Islamic, and Indigenous spiritual frameworks. The specific fears, the rituals, the meaning-making systems, and the ways that religious community either supports recovery or reinforces compulsions vary substantially (Abramowitz et al., 2017). A clinician who pathologizes all religious practice or who, conversely, cannot distinguish faith from compulsion, will cause harm either way.

Contamination fears in many East Asian and South Asian cultural contexts intersect with deeply embedded purity norms that are not inherently pathological. LGBTQ+ individuals with OCD may present with sexual orientation obsessions (SO-OCD) in contexts where their orientation is already stigmatized by their family and religious community, adding a layer of genuine external threat to what the clinician must carefully disambiguate from internal ego-dystonic OCD content.

Pedophilia OCD (POCD) in immigrant communities may never be disclosed at all, because in some cultural contexts there is no language that separates ‘I have an intrusive thought about harming a child’ from ‘I am a person who harms children.’ The absence of that distinction is not the client’s failure. It is ours.

The Inhibitory Learning Model Cannot Be Culturally Agnostic

Here is where the clinical argument becomes precise. The inhibitory learning model of ERP developed by Craske, Treanor, Conway, Zbozinek, and Vervliet (2014); posits that the mechanism of change in exposure therapy is not the erasure of the original fear memory (the excitatory association) but the formation of new, competing inhibitory associations. The client learns that the feared outcome either does not occur or, if it does, is more tolerable than predicted. This new learning competes with the old fear memory and, under the right conditions, becomes accessible and generalized.

Expectancy violation is the engine of this model. The client enters the exposure with a prediction ‘If I do not check, my mother will die.’ The exposure disconfirms that prediction in a way the nervous system can encode. Over time, the inhibitory memory becomes the go-to retrieval when the cue arises.

But here is what inhibitory learning theory requires that is rarely stated explicitly in training programs: the feared outcome and its anticipated consequences must be identified with precision, and they must be the client’s feared outcome, not the clinician’s culturally default assumption of what the client should fear.

When a clinician works with a Nigerian-American client with harm OCD without understanding how shame, family honor, and community standing operate in that client’s specific cultural context, the clinician cannot accurately identify the catastrophic prediction driving the compulsion cycle. The prediction may not be ‘I might hurt someone.’ It may be ‘If these thoughts are real, my entire family will be destroyed, God will abandon me, and I will be permanently separated from my community.’ The exposure hierarchy must address that catastrophic prediction not a sanitized, culturally stripped version of it.

Culturally responsive ERP is, therefore, not a departure from the inhibitory learning model. It is the fullest expression of it. You cannot violate an expectation you have not accurately identified.

Fidelity Does Not Require Cultural Rigidity

Some clinicians worry that cultural adaptation of ERP will dilute treatment fidelity. This is a legitimate concern and should not be dismissed. There is a documented history in the mental health field of ‘cultural responsiveness’ being used as cover for avoiding the hard, anxiety-provoking work of ERP telling clients that exposure is too harsh for their cultural values, or that the confrontation of intrusive thoughts is disrespectful to their spiritual framework. That is not cultural responsiveness. That is accommodation of compulsions with an ethnic or religious gloss. It causes harm.

Treatment fidelity to ERP means maintaining the core mechanism: planned, graduated, repeated contact with feared stimuli, combined with prevention of compulsive responses, with the explicit goal of expectancy violation. Nothing about cultural responsiveness changes that structure.

What cultural responsiveness changes is how you build the therapeutic relationship, how you conduct psychoeducation, what metaphors you use to explain inhibitory learning, whose voices are centered in treatment planning, and how you understand the social and familial context in which compulsions are embedded. These are not threats to the model. They are the model, executed with competence rather than assumption.

The field’s obligation is to maintain fidelity to ERP while relentlessly expanding who receives it, in what forms, and under what conditions. Those are not competing obligations.

A Direct Call to Clinicians: What Culturally Responsive ERP Requires

The following is not an exhaustive competency list. It is a floor. If you are providing ERP or training others to do so, this level of cultural competence is not optional:

• Learn the specific OCD themes most prevalent or most stigmatized in the communities you serve. Scrupulosity in Muslim communities. Harm OCD in postpartum women of color. POCD in immigrant communities without mental health language frameworks.
• Conduct assessment that explicitly explores cultural meaning-making. The Y-BOCS and OCI-R are valid and useful screening tools, but they do not capture the cultural architecture of shame and catastrophizing that shapes the OCD cycle. Ask directly.
• Understand the difference between cultural practices and compulsions. Prayer is not inherently a compulsion. Asking for reassurance from a religious leader becomes a compulsion in context. Learn that context, do not assume, or seek consultation.
• Build the therapeutic alliance before the hierarchy. Research consistently shows that therapeutic alliance predicts treatment outcomes, and that alliance formation with BIPOC clients in historically marginalized groups requires attention to historical distrust of healthcare systems (Sue et al., 2019). This is not soft work. It is clinical work.
• Examine your own cultural assumptions. What does mental illness mean to you? What assumptions do you carry about religiosity, family enmeshment versus healthy interdependence, the expression of distress? These assumptions are in the room whether or not you acknowledge them.
• Use culturally resonant psychoeducation. Metaphors from Western individualism ‘the brain sending false alarms,’ ‘you are not your thoughts’ may require translation. Some clients respond better to frameworks that situate the mind within a relational, spiritual, or communal context.
• Do not gatekeep ERP from clients because you are uncomfortable with their cultural context. Referring out is sometimes appropriate. Reflexively doing so for every client whose cultural background differs from yours is a failure of training, not a clinical decision.

Reflective Questions for Clinicians

Use these during supervision, peer consultation, or continuing education. Discomfort is clinical information.

• What cultural assumptions am I making about this client’s catastrophic prediction, and have I explicitly checked them?
• Have I distinguished between this client’s compulsions and their culturally normative practices? Who told me what ‘normative’ looks like for this person’s community?
• Am I avoiding culturally complex content (religious harm, family shame, intergenerational trauma) in exposure planning because it makes me uncomfortable?
• Does my psychoeducation assume Western, individualist frameworks? How might this client conceptualize the relationship between mind, body, spirit, and community?
• Have I acknowledged, directly or implicitly, any historical reasons this client might distrust the mental health system and their right to do so?
• Would my ERP protocol look the same if this client were white, English-speaking, and culturally Western? If not, what does that tell me?
• Am I maintaining exposure fidelity while doing this work, or am I permitting cultural context to become a therapeutic out from the hard exposures?

Reflective Questions for Clients Seeking OCD Treatment

These are not diagnostic. They are invitations to bring your full self into treatment — which is the only way treatment works.

• What does having intrusive thoughts mean about you in your family, your religious community, your culture? Have you shared that with your therapist?
• Have you been told that your intrusive thoughts are a spiritual failing, a character flaw, or evidence of danger? How has that shaped how you understand OCD?
• Is there any part of your OCD content you have not disclosed because you fear how your therapist will react, or because it feels too culturally charged to say out loud?
• Do the metaphors and explanations your therapist uses feel relevant to your life? If not, have you told them?
• Are any of your compulsions invisible to your therapist because they look like cultural or religious practice from the outside?
• What would it mean for your family, your community, your faith, if your OCD got better? Are there reasons that recovery itself might feel threatening?

The Work Ahead

Expanding access to ERP is not accomplished solely through training more clinicians in the protocol mechanics. The protocol mechanics are necessary but not sufficient. Access is also about belonging about whether a client who walks into a session believes their full self, their culture, their history, their community, their God or lack thereof, can be present in the room without being pathologized, dismissed, or stripped away in the name of treatment fidelity.

The OCD and related conditions field has done extraordinary work in building an evidence base that saves lives. The next chapter of that work if we are serious about it must be to build the cultural infrastructure that ensures those lives include everyone whose neurology has been hijacked by the OCD cycle, regardless of their background.

That means training programs that teach clinicians how to explore cultural meaning, not just symptom content. It means supervision models that explicitly process cultural countertransference. It means continued investment in research that oversamples BIPOC and other historically underrepresented groups to build an evidence base that actually represents the population.

Most of all, it means clinicians who are willing to be uncomfortable. Who can sit with a client whose cultural context they do not fully understand and say, with Rogers’ unconditional positive regard as a foundation and Craske’s inhibitory learning as a map: Tell me more. Tell me what this means in your world. Let’s build the hierarchy from there.

The field of OCD treatment has the tools. The question is whether we will expand the hands that hold them.

Want to challenge your assumptions?

Harvard’s Project Implicit offers free tasks that highlight how fast your brain makes associations. Both clinicians and clients can benefit from seeing the gap between what we believe and how we automatically respond.

Take it here: https://implicit.harvard.edu/implicit/

Don’t be surprised if the results catch you off guard. Mine did. The point isn’t the score. It’s what you do next.

References

Abramowitz, J. S., Taylor, S., & McKay, D. (2009). Obsessive-compulsive disorder. The Lancet, 374(9688), 491–499. https://doi.org/10.1016/S0140-6736(09)60240-3

American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.). https://doi.org/10.1176/appi.books.9780890425787

Craske, M. G., Treanor, M., Conway, C. C., Zbozinek, T., & Vervliet, B. (2014). Maximizing exposure therapy: An inhibitory learning approach. Behaviour Research and Therapy, 58, 10–23. https://doi.org/10.1016/j.brat.2014.04.006

Himle, J. A., Baser, R. E., Taylor, R. J., Campbell, R. D., & Jackson, J. S. (2008). Anxiety disorders among African Americans, blacks of Caribbean descent, and non-Hispanic whites in the United States. Journal of Anxiety Disorders, 22(3), 426–437. https://doi.org/10.1016/j.janxdis.2007.05.010

Ruscio, A. M., Stein, D. J., Chiu, W. T., & Kessler, R. C. (2010). The epidemiology of obsessive-compulsive disorder in the National Comorbidity Survey Replication. Molecular Psychiatry, 15(1), 53–63. https://doi.org/10.1038/mp.2008.94

Sue, D. W., Sue, D., Neville, H. A., & Smith, L. (2019). Counseling the culturally diverse: Theory and practice (8th ed.). Wiley.

Williams, M. T., Mugno, B., Franklin, M., & Faber, S. (2013). Symptom dimensions in obsessive-compulsive disorder: Phenomenology and treatment outcomes with exposure and ritual prevention. Psychopathology, 46(6), 365–376. https://doi.org/10.1159/000348582

Williams, M. T., Wetterneck, C. T., Thibodeau, M. A., & Sönmez, C. C. (2017). Racial and ethnic differences in OCD presentations. In J. S. Abramowitz, D. McKay, & E. A. Storch (Eds.), The Wiley handbook of obsessive compulsive disorders (Vol. 2, pp. 157–174). Wiley Blackwell.