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Key Takeaways
- OCD and autism often overlap in ways that can lead to misdiagnosis or misunderstood treatment, especially when clinicians don’t recognize neurodivergent traits.
- Exposure and response prevention (ERP) therapy is effective for autistic adults with OCD, but it must be adapted to reflect neurodivergent communication, processing, and sensory needs.
- Clinicians can make ERP more neurodivergent-affirming for autistic clients by using clear, literal language, respecting routines and special interests, and working together to build exposures that feel manageable.
Living with both autism and obsessive-compulsive disorder (OCD) can be challenging, especially when it comes to getting the right diagnosis and support. Because symptoms can overlap, it’s easy for one condition to be misdiagnosed or misunderstood. Exposure and response prevention (ERP) therapy is the most effective treatment for breaking the OCD cycle, but when it’s not adapted for neurodivergent people, it can leave autistic adults feeling misunderstood or dismissed.
The good news is that ERP can work for autistic adults when it’s delivered in an affirming and collaborative way. You can still achieve symptom relief without having to choose between effective treatment and staying true to who you are.
To explore how ERP therapy can be more inclusive and effective for autistic adults, we spoke with Glen Veed, PhD, a licensed clinical psychologist at Prosper Health, and April Kilduff, LCPC, LMHC, LPCC, LPC, an autistic therapist at NOCD.
Understanding OCD in autistic adults
OCD can look different in autistic adults, and overlapping traits often complicate it. “Behaviors might be internal thoughts – that can be obsessive thoughts, but could also be preservative thoughts for autistic adults,” Dr. Veed says. Preservative thoughts are repetitive, difficult-to-control thoughts that focus on the past or future. “Repetitive interests and pursuit of a narrow set of special interests can look compulsive at times.” He also adds that an autistic adult’s desire for sameness, routine, and sensory activities can also resemble certain OCD compulsions, such as rituals and avoidance.
“For autistic adults, routines are part of who they are and what makes them happy. [These routines] don't respond well to exposure the same way compulsions do,” Dr. Veed says. “ERP providers hear the word ‘routine’ and immediately think it might be a compulsive routine, and they need to disrupt it as part of exposures.”
That’s why clinicians need to collaborate with autistic clients by respecting their identity while also targeting OCD symptoms in a thoughtful, individualized way.
Why misdiagnoses and misunderstandings happen
Many clinicians haven’t received the proper training to recognize or differentiate between autism and OCD, which can contribute to improper diagnosis and care. “Therapy in general is just not set up to be very affirming of neurodivergence,” Dr. Veed explains. “In the last 15 to 20 years, our understanding of neurodivergence has exploded, so many therapists were never trained on this.”
Communication styles can also contribute to misdiagnosis. Some autistic adults may have difficulty identifying or verbalizing their internal experiences, and some therapists may be unable to catch those cues. “In my experience, that's a reason why a lot of autistic adults with OCD are missed,” Dr. Veed says. “They can't clearly articulate what's going on because they don't understand it themselves.”
How does ERP work?
ERP is a form of cognitive behavioral therapy (CBT) that involves gradually and carefully confronting fears head-on while resisting the urge to engage in compulsions. Over time, ERP teaches you how to sit with the discomfort from intrusive thoughts without resorting to compulsions.
ERP is scientifically shown to be effective for all OCD subtypes, but for those managing both OCD and autism, the treatment can fall short. This doesn’t mean that ERP itself is ineffective, but the way it’s delivered may overlook key differences in how autistic people process information, communicate, and experience the world.
Unspoken rules and neurotypical assumptions
Many standard therapy practices—ERP included—can rely on unspoken social cues or assumptions that some autistic people may not understand. “Almost all mainstream therapy has a neurotypical bias,” Dr. Veed explains. “There are a lot of things that a therapist implies to the client rather than just saying explicitly.” An autistic client may not be able to pick up on these unsaid messages.
For example, a therapist might use silence as an opportunity for reflection—a tool that’s rooted in traditional therapy approaches. However, that silence might be confusing or even anxiety-inducing for an autistic person, Dr. Veed says. “They might be wondering, ‘Why is no one talking?’ or ‘What am I supposed to be doing at this moment?’”
Lack of clarity around ERP techniques
The core concept of ERP—not engaging in compulsions like reassurance-seeking—may also backfire if therapists don’t explain the technique clearly to autistic clients. “If a client is asking us if they’ve run someone over on their drive and we make the therapeutic choice not to reassure that comment, we’re not telling the client what we’re doing,” Dr. Veed explains. “If they’re autistic or neurodiverse and don’t have the social language to pick that up, it can be a confusing and bad learning experience for them.”
Key adaptations for ERP in autistic adults
ERP can be highly effective for autistic adults, but it often needs to be adapted to honor a client’s neurodivergent ways of thinking, processing, and communicating.
Below are several adaptations clinicians can make to create a more affirming and collaborative ERP experience:
Clarifying language and session expectations
When therapy isn’t clearly explained, it can feel overwhelming, especially for autistic clients who prefer predictability. “We like roadmaps and knowing what to expect, and we appreciate people who take the time to do that,” Kilduff says. “I remind my autistic clients that we will go very gradually and that it’s up to them what they’re willing to do or not do. I won’t be forcing anything on them.”
Dr. Veed adds that clinicians should normalize uncertainty and difficulty with self-expression in the first sessions. “It may be difficult for the client to articulate, and they may need some support in understanding themselves before they can be a full collaborator in the therapy process.”
Recognizing what’s OCD and autism
Because autism and OCD symptoms can overlap, it’s crucial for therapists to affirm their client’s neurodivergence while also clarifying what’s OCD and what’s not. “When doing ERP, I think it’s really valuable to tell autistic clients with OCD, ‘Yes, you do have autism, and the characteristics of that are real. But, there are also these OCD things, and for those, we have something that can relieve you of that anxiety,’” Dr. Veed explains.
Building exposure hierarchies collaboratively
ERP exposures work best when they’re customized to the individual, and that’s especially true for autistic adults. “Doing exposures tends to be fairly similar when you have a well-designed hierarchy that (expsoure) works about the same for an autistic adult as a neurotypical adult,” Dr. Veed says. However, he adds that autistic clients may have different types of triggers or ways those fears show up, so it’s important to be flexible and collaborative in structuring exposures.
Being flexible about what progress looks like
Progress in ERP can look different for autistic adults, not in what is achieved, but in how and how long it can take to get there. “For most autistics, things like habituation and generalization simply take longer,” Kilduff explains. She explains that in some cases, the goal of ERP isn’t to make anxiety go away, but to help the person sit with the distress and keep going. Being able to tolerate discomfort rather than try to eliminate it is still a meaningful and successful outcome for autistic adults.
Respecting sensory and communication needs
While therapists often advise against accommodations in treating OCD, accommodations can make a big difference in keeping autistic adults engaged in ERP. “I let people stim, use fidgets, and/or have a comfort item while we are doing ERP,” Kilduff says. “These might seem like distractions, but they are actually helping the autistic person emotionally regulate so that they can stay in ERP longer.”
Using special interests as assets, not barriers
Rather than being seen as obstacles in treatment, special interests can be a powerful tool in ERP. “A client’s special interests are default starting points for developing rewards,” Dr. Veed says. “They’re tremendously rewarding for the client.”
He adds that rewards can look different for autistic clients, and that must be taken into consideration before therapy starts. “I’ve met with several clients who were told, ‘Once you get through this, you’ll be able to go to parties and be more social.’ For an autistic adult, those can be aversive experiences. Being able to be around a group of people may not be intrinsically rewarding.”
How to find support
If you have autism, OCD, or both, you’re not alone, and affirming care is available. With the right support, you can manage symptoms and lead a life that aligns with your values and needs.
Exploring an autism diagnosis
If you think you’re autistic, a diagnostic evaluation from a clinician is a good first step. That said, many autistic adults were missed early in life, so self-diagnosis is also valid. Autism-affirming therapists, such as the ones at Prosper Health, can help you better understand yourself and get you the support you need. Peer groups and online communities are also helpful spaces for connection and self-discovery.
Getting support for OCD
OCD is often overlooked in autistic adults, especially when symptoms overlap. Working with a therapist trained in ERP can help you identify what’s really OCD versus autism. NOCD offers access to licensed therapists who specialize in both ERP and neurodivergent-affirming care.
When autism and OCD co-exist
If you have both autism and OCD, finding a therapist who understands the interaction between the two is crucial. Look for someone who will honor your identity while using evidence-based tools like ERP in a flexible, respectful way.
How Prosper Health and NOCD can help
Seeking care for autism, OCD, or both doesn’t have to mean choosing affirming care over feeling understood. Prosper Health offers neurodivergent-affirming therapy for autistic adults, helping people better understand themselves, build coping strategies, and receive support that truly fits their needs. For those looking to break the OCD cycle, NOCD provides virtual ERP through a network of over 650 licensed therapists. NOCD accepts most insurance plans and currently reaches over 155 million Americans.
Whether you need support for autism, OCD, or both, there are providers who understand and are here to help.
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