Overview: Therapeutic Approach
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• My approach to treatment has changed over time as I encounter new learnings and complete more diverse trainings in therapeutic modalities. Where, like most therapists, I first trained in Cognitive-Behavioural Therapy (CBT; including specific treatment protocols like Exposure & Response Prevention [ERP] for OCD), before training in a similar approach called Acceptance & Commitment Therapy (ACT).
   

  • As I liked ACT as a modality and its underlying model of supporting the development of psychological flexibility, this led to me learning more about a similar approach called Metacognitive Therapy, which I continue to find very valuable to help individuals gain control over their ruminating, obsessing, and worrying.
     

  • In wanting a more comprehensive understanding of the mind, I then trained in Schema Therapy, which offered me a deeper understanding of the origins of some individuals OCD behaviours, and in identifying the reinforcing factors for OCD existing within people’s relationship patterns. Where interestingly, research shows there are links between OCD themes and specific schemas (i.e., ways of relating to oneself, others, the world) the individual might have developed early in life, e.g., Kasalova et al., 2020.

 

• With schema therapy helping me to recognise the influence of early-life experiences in OCD symptom development, this lead me to learning more about Attachment Theory, where again, insecure attachment styles are related to OCD onset and perpetuation (Van Leeuwen et al., 2020).
   

  • This in turn, was the prompt for me to complete further training in Emotion Focussed Therapy (EFT), a similar approach to schema therapy, albeit with perhaps a deeper focus on emotions and working relationally in therapy, while also offering a more specific emphasis on attachment styles.
     

• Further, within a sizeable number of the OCD patients I’ve worked with, I realised they have also suffered from traumatic experiences in early life and in adulthood, where these traumatic experiences are often clearly linked to OCD symptom expression; where again, research consistently shows this to be the case too, e.g., Destrée et al., 2021.
   

  • In recognising this link to trauma, I decided to train in a modality called Eye-Movement Desensitisation & Reprocessing Therapy (EMDR), an approach initially designed as a treatment for PTSD. While I was sceptical of this modality at first despite its strong evidence base, my hesitance quickly dissipated as I saw how effective it can be in rapidly processing traumatic experiences, becoming an important part of treatment in some cases to address some of the roots fuelling the obsessive-compulsive cycle.
     

    • In completing the advanced EMDR training too, I learnt about the ways that EMDR can be used specifically for OCD – not just as a means of processing related traumatic experiences, but as a way to enhance an individual’s capacity and belief in themselves to effectively resist compulsions, where this is another area of emerging research in the OCD literature.

     

• At this point, after having widely expanded my therapeutic approach via the above modalities in pursuit of being able to offer my clients a treatment that can address the cognitive, metacognitive, relational, interpersonal, emotional, and developmental features in OCD, this led me toward a framework that has had the most significant influence on my approach, called Intensive Short-Term Dynamic Psychotherapy (ISTDP).
   

  • ISTDP is a therapy framework with roots in attachment theory, focusing on emotional experiencing and shifting maladaptive relational/interpersonal patterns, aiming to develop more adaptive ways of responding to feelings and relating to others.

 

• ISTDP is a well-established, evidence-based treatment proven to be effective in treating a broad range of psychological disorders (Abbass et al., 2012), with there now being over 200 published articles in peer-reviewed journals, including 120 randomised-clinical trials (RCTs) demonstrating its effectiveness. However, the evidence base for the use of ISTDP with OCD specifically, is still emerging. This is not to say that ISTDP is ineffective for OCD, where I have not encountered any indication of this being the case in the scientific literature.
   

  • Where, ISTDP research so far has predominantly been broader in scope, rather than focussed on specific presentations like OCD. Although, preliminary studies of the effective use of ISTDP for OCD certainly do exist (e.g., Becker et al., 2019; Jamali et al., 2020; Sudejani et al., 2017; Hosseini et al., 2025), with additional research available from highly related therapy frameworks (from the same family of therapies to which ISTDP belongs) reporting success (e.g., Garcia, 2008; Woon et al., 2017; Thomas, 2020; Vyjayanthi, 2014). Larger studies have also found ISTDP effective in reducing obsessive-compulsive beliefs, cognitive avoidance (Sudejani et al., 2017), alexithymia and OCD symptoms (Hosseini et al., 2025).

 

• Further, more robust research including systematic reviews and meta-analyses, also indicate heightened prevalence of features within OCD of direct relevance to ISTDP. That is, the underlying factors seen in OCD, are in accordance with what ISTDP considers to be transdiagnostic factors underlying psychopathology more generally, including insecure-attachment (e.g., Van Leeuwen et al., 2020); traumatic experiences during development (e.g., Destrée et al., 2021); and maladaptive pathways of emotional-processing (e.g., See et al., 2022).
   

  • In other words, while OCD specific research in the context of ISTDP is still emerging, there is strong evidence showing that 1); OCD is related to attachment insecurities, emotional processing issues, and trauma; and 2); ISTDP is effective in treating attachment insecurities, emotional processing issues, and trauma.

 

• I should clarify too, that OCD appears to exist on a continuum, from cases where symptoms are more neurological in nature, to those that are more influenced by psychological factors, with everyone else falling somewhere between these two poles.
   

  • Accordingly, while in some cases (i.e., more psychologically driven symptoms), emotion-focussed therapies alone can be effective in treating OCD, in other cases (featuring a mixture of psychological and neurological factors), I find that incorporating an emotion-focussed approach with cognitive-behavioural interventions is best, and in rarer cases where symptoms are more heavily influenced by neurobiological factors, a greater emphasis on behavioural therapy approaches might be indicated.

 

Why not CBT/ERP?

 

• So, you might be wondering: why do I work from therapy frameworks which are not typically used for, or only have emerging evidence for their use with OCD, when I have trained in other frameworks such as Cognitive Behaviour Therapy (CBT) or Exposure & Response Prevention (ERP) that already have established effectiveness in treating OCD?
   

  • Which is a good question, and my answer, in short is: while I previously exclusively focussed on methods like ERP, within the scientific literature, CBT/ERP have been critiqued for inadequately attending to the developmental and affective (i.e., emotional) factors underlying OCD (Doron, 2020), where there is therefore benefit in using (or at the very least incorporating) other frameworks that are able to address these factors.
     

    • Although, that's not to say that I reject, or do not use these methods, instead, it is more about integrating other frameworks into treatment, where I will always incorporate the principles of ERP and other cognitive-behavioural interventions into my treatment approach for OCD. Yet, I have found over time, that while interventions like exposure are indeed effective tools, there are numerous barriers to utilising them effectively for many individuals. 

 

• Beyond my anecdotal evidence though, when we look at the research on treatment outcomes, what we also discover is that despite ERP being an effective treatment for OCD:
   

  • Around 30% of OCD patients prematurely terminate ERP (i.e., they drop out before treatment has finished), and roughly 25% refuse to start ERP exercises altogether (Öst et al., 2015).
     

  • Further, once a course of ERP treatment has been completed; relapse is common (Bloch et al., 2013), where remission rates are significantly lower than once thought (Geiger et al., 2024), with only 11-26% of patients staying in remission over time (Tibi et al., 2020).
     

• These findings are particularly concerning, as these underwhelming success rates seen in clinical studies might be even poorer in actual practice, as participants in clinical studies often do not represent the entire spectrum of OCD sufferers. Where, prospective participants are often excluded from clinical trials for being too complex, severe, or due to having comorbid mental health issues (despite most individuals with OCD experiencing secondary mental health issues in a real-world setting).
   

• In other words, the active ingredient of ERP works (whether attributed to extinction learning or habituation), but for a majority of patients, they will struggle to engage, only partially benefit, or their improvements might not be stable. In my view, these research findings indicate that attempts to address OCD symptoms in this singular way, is often inadequate – where, the emotional and developmental features underlying OCD have been neglected.
   

  • Indeed, OCD does not exist within a vacuum, it exists within a human being, who is much more complex than their OCD. To illustrate this: individuals with OCD tend to experience certain difficulties that are not encapsulated within diagnostic criteria, e.g., difficulties surrounding emotional processing (e.g., See et al., 2022).

 

• For example, research shows that people with OCD are more likely to respond to the emotion of guilt as an indication that they are bad and need to punish themselves (Chiang et al., 2016). Where, this kind of phenomenon is not necessarily described in the limited diagnostic criteria.
   

  • Yet, you can see this trait within the symptoms – e.g., individuals relating to themselves as guilty and bad for experiencing intrusive thoughts, or feeling responsible for harm, etc. That is, although almost everyone in the general population experiences intrusive thoughts, not everyone feels like a bad person or a pull toward self-punishing acts to atone for their experiencing of these intrusions.
     

  • While we could help this hypothetical individual with OCD to face their obsession (e.g., using exposure to an intrusive thought) while resisting the urge to engage in their compulsions (i.e., response prevention), and in doing so, reduce or eliminate the anxiety associated with this particular intrusive thought. Yet, in having done so, while we may have achieved a specific symptom relief – the underlying attitudes relating to guilt likely remain unchanged, risking symptom reemergence.
     

  • So, if we can focus instead on shifting this maladaptive response (i.e., self-punishment) to an everyday human emotion such as guilt, it may shape the way the individual responds to guilt inducing obsessions – i.e., without self-punitiveness, e.g., compulsively confessing for “wrongdoings”, subjecting themselves to scrutinise unpleasant memories and thoughts, or forcing themselves to repeat unpleasant behaviours over and over again to keep others “safe”.
     

    • And sure, maybe we could shift these conscious attitudes toward the emotion of guilt with cognitive-behavioural interventions – but even there, we have perhaps only altered the way that an individual responds to an automatic impulse to punish themselves, rather than addressing the deeper issues that have formed this self-punishing part of their mind that they’re now trying to respond differently to. Where, the individual might be left with the experience of “I rationally now know I don’t deserve to be punished, but I still emotionally feel that way”. Consequently, when stressors overwhelm this more adaptive coping, the dominance of the punitive part of the mind might take over for a period, where symptoms become exacerbated.

 

• This kind of experience often requires deeper emotionally focussed work to shift, working toward understanding and restructuring this pattern of automatic emotional processing. This is where I particularly value frameworks like ISTDP in the way that it offers ways of accessing and working through anxiety provoking emotions often underlying these self-punitive reactions. This is just one example of course. Where, in drawing from the scientific literature on the associated features of OCD, some of the underlying difficulties I consider important to address for treatment to offer more stable change are outlined below.
   

Where, research shows:
 

• There are elevated rates of non-acceptance of negative emotions in OCD (See et al., 2022), which in turn, predicts exacerbated OCD symptomatology (Cougle et al., 2012; Fergus & Bardeen, 2014; Khosravani et al., 2020; Wu et al., 2018). In other words, people with OCD are more likely to have learnt to reject negative emotions and not let themselves experience these feelings, and in processing their feelings in this way, they may relate to themselves as “bad” for experiencing everyday human emotions, and in turn, their OCD becomes exacerbated.

 

OCD is also associated with difficulties surrounding:
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• Emotional awareness (Yazici & Yazici, 2019): 

  • ​i.e., trouble recognising what emotions they are feeling. This likely reflects a learnt tendency to ignore or “tune out” from their feelings and prioritising thoughts to the neglect of feelings.

 

• Interoceptive awareness (O’Kearney & Nicholson, 2008): 

  • ​i.e., difficulty looking inward and noticing sensations in their body. Again, this likely (at least in part) reflects a learnt tendency to fear looking inward and to ignore their emotional experience

 

• Emotional clarity (Berman et al., 2018): 

  • ​i.e., trouble understanding why they are feeling a certain emotion. Again, the tendency to ignore or dismiss their feelings, gets in the way of listening to themselves and making sense of their emotions.

 

• Emotion regulation (Khosravani et al., 2020): 

  • ​i.e., struggling to let their emotions come and go rather than becoming overwhelmed, as they’ve learnt to be anxious about their feelings and feel driven to avoid experiencing them. Yet, when stressors cause adaptive coping to fail, the distressing feelings emerge and more destructive ways of coping are relied on (e.g., compulsions).
     

    • In my experience, this difficulty is in part due to the learnt propensity of OCD sufferers to attempt to cope with the physiological experience of anxiety, by retreating into their thoughts (e.g., worrying/ruminating), and thus they might not be paying close attention to how their anxiety is actually manifesting (or recognising its existence at all), making it much more difficult to self-regulate.
       

• Impulse-control (Yap et al., 2018): 

  • ​i.e., emotions guiding their behaviours (compulsions are one example) rather than feeling in charge of their emotions. Again, likely a result of their feelings being a source of anxiety and exacerbated by the propensity to “tune out” from their bodily emotional responses, making it much more difficult to observe and sit with emotions, impulses, and anxiety until they subside.

 

• Recognising and describing emotions (Pozza et al., 2015; Wu et al., 2018): 

  • ​i.e., describing how an emotion feels physically in their body, and recognising these bodily sensations as part of their emotional experience. Likely a result of feelings automatically becoming covered in anxiety, making it difficult to differentiate from the anxiety itself.
     

    • For example, often when I ask someone with OCD to describe their experience of emotions, I find they tend to describe a physiological anxiety symptom instead. Where, many individuals have never experienced certain feelings without anxiety, and therefore assume their anxiety is their feeling. 
       

      • Further, in having learnt to ignore their emotional reactions over time, the physical components of their feelings may no longer be recognised as the physiological component of their emotion, i.e., “I feel hot, and I don’t know why” e.g., if feeling angry.

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• In fact, issues such as problematic emotion suppression, difficulties with emotional clarity and controlling emotion driven impulses are uniquely correlated with all types of OCD symptom dimensions (Stern et al., 2014). That is, these difficulties are seen across every “subtype” of OCD, not just in particular obsession themes.
   

What does this mean for treatment? 
 

• So again, what we can take from these research findings, is that these difficulties appear to be highly prevalent among OCD patients – which invites many questions: if these are occurring in the context of OCD, are they (at least in part) the reason that OCD is there in the first place, or why it won’t go away, or why it keeps coming back? We certainly observe this in OCD – someone begins making progress, symptoms begin to subside, then life gets stressful, and OCD symptoms reemerge at their previous intensity. Likely because compulsions, including worrying/ruminating, are actually often ways of trying to escape the bodily experience of anxiety and feelings that arise in response to stressors – which is not unique to just OCD, but a characteristic of repetitive thinking patterns more generally (Borkovec, et al., 1991; Borkovec & Hu, 1990).
   

  • Accordingly, research on OCD patients undergoing emotion-focussed treatment has shown significant symptom reduction (e.g., Tenore et al., 2020), where emotional acceptance facilitates more adaptive responses to negative emotions, and in turn, reduced obsessive-compulsive symptomatology (Cosentino et al., 2012).
     

    • i.e., likely because they learn to recognise their feelings, and to face them without trying to suppress them, and in doing so, letting them subside, and thus not needing to “tune out” from the feelings into a self-reinforcing cycle of repetitive thinking patterns which exacerbate distress.
       

• Studies have also found that treatment interventions aimed at facilitating increased capacity to tolerate the bodily sensations of emotions, are effective in reducing obsessive-compulsive symptomatology (Allen & Barlow, 2009; Macatee & Cougle; 2015; Shaw et al., 2020). 
   

  • ​In other words, within these studies, helping people develop greater emotional capacity, reduced OCD symptoms, even though the OCD symptoms themselves were not the direct focus of treatment. This kind of emotion-focussed exposure forms a big part of frameworks like ISTDP as a means to develop greater emotional capacity and to extinguish the anxiety that has become conditioned to emerge in response to emotions. Or at least, in response to complex emotions, in specific contexts, at certain degrees of intensity.

 

• What I also find very compelling is the link between attachment insecurities and OCD (where EMDR; Schema Therapy; EFT; and particularly ISTDP) draw heavily from attachment theory). That is, OCD has consistently been found by high-quality studies to be associated with anxious-attachment and avoidant attachment styles (Van Leeuwen et al., 2020; Nielsen et al., 2025). Where accordingly, parent-child relationship dynamics are considered to be a developmental determinant for OCD (Xu & Zhu, 2023; Cui et al., 2023; Barcaccia et al., 2015; Lennertz et al., 2010; Krebs et al., 2019). 
   

  • This is not to suggest that parents aren’t doing their best, in most situations, parents are doing their absolute best to help their children grow up to feel confident, competent, worthwhile, and loved – but often, parents’ own automatic attachment patterns result in children developing beliefs about themselves that are unhelpful or even destructive (Arthey; retrieved 2026).
     

    • Rather, let me describe a simplified example I like to use to encapsulate some of the more covert ways this might occur: Maybe a parent sees their young child’s shoelaces are undone, and out of love, goes straight toward tying them up “oh no your shoelaces are done, let me tie them up, so you don’t trip over”. Now, let’s consider the same scenario with a different approach: where, instead of taking charge here, the parent points out to their child that their shoelaces are undone, and invites collaboration “what should we do about those laces? Okay, we should tie them up. Good idea. Would you like my help? Okay see how you go trying it yourself first, and I’ll be here to guide you if you get stuck”.
       

      • In this example, this response fosters the development of self-agency and autonomy. iii.Both responses come from a place of love, and yet in the first example, while appropriate at certain developmental stages, will eventually cease to be an effective response if it is a consistent pattern in the relationship (sometimes a parent has to take charge of course).
         

        • Where, at a certain age, the child will feel frustrated by their core need for developing autonomy not being met if this approach exists within a pervasive pattern, where they might make sense of their negative feelings arising in this experience in a self-blaming way: i.e., “maybe mum/dad won’t let me tie my own shoelaces as I am incapable” – in doing so, they can avoid experiencing confronting negative feelings that might upset the caregiver that they love and want to keep close.
           

      • These are the kinds of implicit messages a parent might inadvertently communicate in their behaviour, even if not at all what the parent believes or intended to communicate by helping. Where, maybe this loving parent was only anxious about helping right away by tying up the shoelaces, as they were simply repeating (“this is what parent’s do, or at least that’s what I learnt from my own parents”) or conversely, did not want to repeat their own early life experiences where they experience the opposite (a lack of support and guidance).
         

      • It can be these kinds of moments, which, while seemingly insignificant as isolated incidents, can lead to entrenched patterns of self-doubt about one’s own capacities, which develop into relational scripts that cause problems over time, e.g., feeling incapable to manage anxiety, needing reassurance from others due to not trusting their own capacity to make a judgement or decision, or experiencing the notion of resisting compulsions as something beyond their capabilities.

 

• Indeed, the “dependence/incompetence” schema is prevalent in OCD and influential in treatment response (Kasalova et al., 2020). This link between attachment styles and OCD particularly interesting, as many of the symptoms of attachment insecurities, mirror the experience of those with OCD – where the notion has been raised that perhaps OCD and attachment insecurities develop from a shared root, or perhaps, attachment style could facilitate the transition from predisposition to symptom onset (Van Leeuwen et al., 2020).
   

• In other words, some researchers propose that while there is indeed a genetic predisposition for the development of OCD (contributing about 40%; Brander et al., 2016), maybe for this genetic vulnerability to become expressed (i.e., for OCD to emerge and develop from this genetic susceptibility), we first need an environmental factor, such as the development of an insecure-attachment style.
   

  • ​Where this “bridge” so to speak between attachment insecurities and OCD onset, might occur via the conditioned automatic maladaptive emotional processing pathways developed within an insecure attachment system (e.g., Nielsen et al., 2025). Accordingly, attachment-nurturing interventions have found success in reducing OCD symptoms (e.g., McGehee, 2005; Rezvan et al., 2013; Ali et al., 2024).
     

  • Furthermore, the attachment insecurities in OCD, predict a lesser response to treatment, with more securely attached individuals showing a greater treatment response (Hodny et al., 2022; Tibi et al., 2020).
     

    • i.e., attachment insecurities, will actually affect the treatment outcome, as these patterns will pervasively emerge outside of awareness within the therapeutic relationship and influence the process of the therapy throughout its course.
       

      • ​For example, if someone has difficulty in being vulnerable or depending on others/asking for help as a result of past relationship experiences, then this is going to add another layer of complexity beyond the OCD itself requiring exploration and intervention within the therapeutic relationship for treatment to be as effective as possible.
         

• Or, using the shoelaces example this unconscious script might be something along the lines of: “when you (the therapist) try to help me, this initiates my script for relationships where I can expect you to relate to me as someone incapable who needs you to do everything for me, and I don’t want to upset you with my negative feelings about this problematic relationship dynamic where my autonomy is discouraged, so I will instead automatically relate to myself as incapable (without even knowing myself that this is occurring) to avoid becoming aware of these feelings that might jeopardise our relationship, and will even invite you to start treating me this way as I expect you to need this”. 
   

  • ​Where, addressing these kinds of underlying factors affecting the process of treatment is another main focus of some of these other frameworks like Schema Therapy and EFT, although perhaps especially within ISTDP.

 

Summary
 

So, to recap, we have a few ideas outlined so far:

 

1. ERP and other CBT methods are effective in reducing symptoms of OCD, however these approaches typically neglect the automatic relational scripts that may underlie and perpetuate symptoms, while also inadequately attending to underlying emotional processing patterns driving symptoms and ineffective coping responses. As a result, there is a risk for symptom re-emergence once life gets stressful again and someone’s new ways of coping as learnt in therapy, are overwhelmed, prompting reliance on more maladaptive coping styles (i.e., OCD itself).
    

2. As individuals with OCD tend to struggle with emotions, helping them develop more adaptive responses to their emotions, can reduce their OCD symptoms directly.
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3. As people with OCD tend to display attachment insecurities, helping them develop more secure attachments and thus more healthy relational “scripts”, can reduce their OCD symptoms directly.
    

4. As individuals with OCD in the context of attachment insecurities, may not respond as well to therapy, these attachment patterns are important to address as a part of treatment to maximise effectiveness.
    

5. Therefore, a treatment that brings these difficulties to light, and targets these vulnerabilities directly, is perhaps a means to facilitate more stable change. Where, frameworks like ISTDP (and others mentioned) have a strong evidence base for their effectiveness in addressing these kinds of underlying issues that are not unique to OCD.
    

6. In cases where symptoms continue to remain, independent of these underlying factors having been addressed, by having increased emotional capacities and developed a safe therapeutic alliance that does not conform to old relational scripts, we will be in a far better position now to address these residual symptoms through behavioural interventions like exposure therapy as needed.

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Final Words:
 

• With all this said – I will note too, that I have shaped my approach to be tailored toward the needs of OCD, where typically, the course of treatment might start more cognitively, helping individuals to recognise and change the cognitive and behavioural factors perpetuating suffering, to provide some more immediate symptom relief, before moving into deeper emotion-focussed work. However, every step of treatment will always be collaborative, where in forming a safe therapeutic alliance, I will repeatedly invite patients to give themselves permission to have autonomy in what they want and don’t want to focus on throughout the course of therapy.
   

• If you have any questions not covered by the FAQ section below, feel free to let me know via the email exchange through which I sent this document, where I’ll be happy to offer any further information or clarification. If the contents of this document have caused any undue distress, I do apologise, so please also let me know, and while I will endeavour to get back to you, in the meantime, if needed, please do not hesitate to seek support through a crisis service such as Lifeline’s 24-hour crisis counselling service (call 13 11 14).

 

I look forward to hearing your thoughts and potentially working with you.

 

Sincerely,

 

Caspar Wenn,

BPsych(Hons), MProfPsych, MClinPsych(Post-Reg)
Director & Principal Psychologist​

The OCS Clinic

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