By Karla Pineda, LPC | Last reviewed October 2026
"I know exactly what to do between sessions. I just never remember to do it."
Maya said it like a confession. She's a fictional client, an example I created to show what this often looks like, so no real person's details appear here. In the story, she was thirty four and three weeks behind on her exposure practice. Her worksheet was still folded inside her planner.
Maya has Obsessive-Compulsive Disorder (OCD), unwanted thoughts paired with rituals meant to make them stop. Most of her rituals happen in her head, the mental compulsions nobody else can see. She also has Attention-Deficit/Hyperactivity Disorder (ADHD), a difference in how attention, impulse and activity are regulated.
People in Maya's spot usually decide they're bad at therapy. A more useful question is whether the plan was ever cut for their brain. Good OCD and ADHD treatment starts with that question, and skipping it is why so many standard plans stall.
Obsessive-Compulsive Disorder (OCD) and Attention-Deficit/Hyperactivity Disorder (ADHD) often show up together. Exposure and Response Prevention (ERP), the therapy that practices facing a fear without doing the ritual afterward, still works when both are present. The plan around it has to change, especially how practice gets remembered, started and kept fresh.
Yes, and the pairing is common enough that good OCD clinicians screen for it.
From the outside, the two can look like opposites. Maya could lose her keys three times before lunch, then spend twenty minutes making sure the stove was off. One part of her brain lost track of everything. Another part couldn't let a single thing go.
The thoughts feel different too. ADHD thoughts tend to scatter and jump. OCD thoughts stick, and they arrive with dread and an urge to fix something right now.
Many people with both describe a mind that wanders all day, then snags on the same worry. If that's familiar, you're in good company.
A standard ERP plan is a suit bought off the rack. It's cut for average measurements, and for a lot of people it fits well enough. It also assumes a few things about the person wearing it.
Most plans take for granted that you will:
ADHD makes every one of those harder. So practice slips, and the slipping starts to feel like a verdict on you.
Here's the thing about that verdict. Some treatment settings still call missed homework "noncompliance," and people with ADHD hear the subtext loud and clear: you must not want this enough. Missed practice is usually an executive function problem, meaning the brain's system for planning and starting things, and it calls for a practical fix.
The research matches what clients feel. In a study of kids and teens with OCD, those who also had ADHD were less likely to respond to cognitive behavioral treatment. A 2023 study of adults found the same pattern after six months of standard OCD treatment.
Read those numbers as a fitting note for the tailor. A 2024 study came to a similar conclusion, recommending that clinicians change their approach when OCD and ADHD show up together.
I see the same pattern again and again with clients who have both. In session, they can usually do the exposure with me just fine. The struggle starts when they have to practice on their own, outside of session.
Maya fit that pattern exactly. In session she did fine, and she'd stay with the discomfort longer than she expected to.
The breakdown came outside the office. First the practice had to be remembered, and then it had to be started. Starting is a real pain point for a lot of my ADHD clients, and it was for Maya.
Then came the fourth round of the same exposure. It was boring, and a bored ADHD brain wanders. Hers wandered straight into mental review, a ritual dressed up as thinking.
With ADHD in the mix, the exposure is often the easy part. The hard part is everything that has to happen before it starts.
Impulsivity adds one more snag. A ritual can be finished before you notice the urge at all. You've already reread the email four times by the time you realize you were checking it.
When practice slips, a lot of people with ADHD turn on themselves.
Maya did. Every skipped day became more proof that she was lazy, that she'd mess this up too. By the time she came back to session, she was carrying a week of harsh inner criticism along with the unfinished worksheet.
Beating yourself up doesn't help, and I tell my ADHD clients that often. I also understand where the habit comes from. Years of missed deadlines, people expecting more, and expecting more of yourself can leave a deep layer of shame. Being hard on yourself starts to feel like the only way to get anything done.
So I weave self compassion into treatment. We look at a missed day with curiosity, and then we adjust the plan. The goal is getting back to practice tomorrow, and shame makes that harder.
OCD and ADHD treatment at Layers keeps ERP at the center and changes the fit around it.
Think of it as taking that suit to a tailor. The fabric stays. The cut changes. These are the alterations I make most often:
Values matter here too. I build exposures around what you care about, using Acceptance and Commitment Therapy (ACT), which means acting on what matters to you even while the discomfort is there. A reason you care about gives an ADHD brain something to hold on to. For Maya, that reason was being fully present at dinner with her family.
My ERP training and my caseload overlap here more than you might guess. Many of the adults I see for OCD turn out to have ADHD as well, so I plan for it from the first session.
If you're autistic as well, living with autism and ADHD together shapes the plan in its own ways, and we account for that too.
You might need a better fitted plan if:
A few months in, the worksheet had moved out of Maya's planner and into a practice log she shared with me. Most days had an entry. She often did her exposures on the couch while her partner worked nearby.
For a lot of my ADHD clients, simply doing exposures consistently is real progress. Starting things may have been a struggle for years. The more they practice, the better they feel, which brings its own motivation, plus the reward of knowing they started and followed through.
Maya still lost her keys on a Tuesday. A few days in the log stayed blank, and she didn't spend those evenings beating herself up. A plan that fits can survive a missed day.
Maya is a fictional example created for this article. She is not based on any real client.
If this sounds like you, our OCD therapy team in Plano can help you build a plan that fits the brain you actually have.
Many of our clients drive in from Frisco and the surrounding area. We see clients in person in Plano, Texas, and online anywhere in Texas. Request an appointment here.
About the author: Karla Pineda, LPC, is the owner and Executive Director of Layers Counseling Specialists in Plano, Texas. She treats OCD and anxiety in adults, in English and Spanish. Her training includes ERP certification, Rumination-Focused ERP, and Advanced Accelerated Resolution Therapy.
This article is for educational purposes and is not a substitute for professional medical advice. If you or someone you know is in crisis, call or text 988 (Suicide & Crisis Lifeline) or text HOME to 741741.
Our Plano therapists specialize in OCD, anxiety, ADHD, autism, ARFID and trauma, in person or online anywhere in Texas. Every clinician starts with a free 15-minute consultation, so you can see whether it feels like a fit before you commit.
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