Beyond OCD: What the Framework Does and Doesn’t Travel With

In Chapter 13, Closing Reflections, of Intrusive Thoughts and Compulsions in Adolescent OCD: A Psychoanalytic Framework for Treatment (Routledge, 2026), I argued that what mattered most clinically was not the content of an adolescent’s obsessions or compulsions, but the relationship they had with them. Beneath the surface themes of contamination, harm, morality, sexuality, checking, reassurance, and ritual, I claimed there existed something deeper: a psychic position from which the young person encountered their OCD.

Since finishing it, one question has stayed with me.

Could this framework apply more broadly?

At first glance, the answer seems obvious. Every clinical presentation involves some relationship to symptoms, defences, and patterns of coping. Yet the more I have reflected on this, the more cautious I have become. I increasingly suspect that what makes the framework useful in adolescent OCD is precisely what may limit its transferability elsewhere.

I think the reason tells us something important, not only about OCD, but about clinical theory itself.

One thing that has struck me repeatedly is how variable the psychic organisation can be beneath a similar symptom surface. Take ten adolescents referred with contamination fears. They may all avoid door handles. They may all wash, seek reassurance, check, avoid, confess, and mentally review. On paper they look almost identical.

Sit with them over months, and the picture changes entirely.

For one, the OCD functions as a fortress against psychological collapse. For another, it operates as a retreat from emotional complexity. For another, the experience is persecutory and urgent, danger constantly approaching from outside. For another, there are already tentative signs of mourning, a loosening of identification with the disorder.

Same symptom surface. Profoundly different psychic organisations.

That distinction became clinically useful to me because it changed everything downstream. It altered timing, pacing, interpretation, parental guidance, and the emotional atmosphere of the room. It helped me understand why some adolescents appeared “resistant” when the OCD was functioning as psychological survival equipment. It helped me understand why standardised interventions worked beautifully with one adolescent and failed entirely with another who technically had the same disorder.

Now here is where I think the nuance matters.

I do not think this framework can simply be exported wholesale onto other presentations.

Take severe adolescent anorexia. Not disordered eating broadly, but the serious presentation. In my experience, the relational architecture there is far less variable. The world narrows into a closed, controlled system organised around monitoring, calculation, exclusion, and retreat from intrusion. Calories, weighing, exercise, ritualised management of intake. The sealed room metaphor emerges naturally, because psychologically very little is allowed in. In the more technical language of the book, it has a distinctly claustral quality. But I do not encounter the diversity of configurations I see in OCD. The architecture appears more singular, more rigidly organised around enclosure.

Health anxiety looks different again. The central experience is often persecutory and bodily. Something dangerous is imagined as already inside the self. Catastrophe is unfolding internally, rather than approaching from outside. That is a different psychic texture, even when the compulsive quality of reassurance-seeking looks superficially similar to OCD.

Adolescents with severe affect dysregulation present differently again. Functioning can appear intact until emotional rupture occurs. When the external world feels manageable, the young person may seem thoughtful, socially engaged, even reflective. But when attachment injury, shame, or rejection emerge, overwhelming affect floods a system that had no quiet way to hold it. Something close to a psychic retreat is often present, but the collapse is of a different order entirely.

So yes, psychoanalytic ideas can still help us think about these presentations.

But no, my OCD framework does not cleanly map onto them.

Clinicians sometimes make a mistake when they find a compelling framework. They become tempted to universalise it. Every clinical encounter starts to look like an example of the same theory. I have become increasingly cautious of that impulse, partly because I have felt it myself.

I suspect every major clinical presentation has its own architecture.

Some have relatively fixed organisations. Others shift and evolve. But I think the task is to discover the architecture through sustained clinical contact rather than impose one prematurely because it feels intellectually satisfying.

Which brings me to the more important point underneath all of this.

Theory without lived clinical experience becomes dangerous precisely because it is seductive. Anyone can read papers. Anyone can memorise psychoanalytic concepts, generate terminology, synthesise frameworks, produce diagrams. That is not the same thing as understanding a mind from the inside.

Good clinical theory emerges from prolonged contact with patients over years. It develops through uncertainty, supervision, emotional reactions, failed interventions, and the particular experience of sitting in silence with somebody and not knowing where the therapy is going. It emerges from repeatedly finding yourself emotionally inside a presentation until patterns begin organising themselves naturally.

That is partly why I would feel uncomfortable writing with authority about psychosis, despite finding it genuinely fascinating. I have not spent years under supervision with specialists in that territory. I have not immersed myself in the emotional texture of that work. And without that, even something theoretically interesting would not feel clinically honest. It would be theory detached from emotional reality.

Good therapy teaches the same lesson. People can memorise interventions. They can learn therapeutic phrasing. They can reproduce models and frameworks with apparent fluency. But genuinely understanding another person psychologically requires entering their experience dynamically enough that you are changed by the encounter too. Sometimes that means tolerating confusion. Sometimes it means resisting the urge to organise material too quickly because uncertainty feels unbearable.

And often, ironically, those moments of uncertainty are precisely what deepen the work.

So where have I currently arrived?

I think theories should emerge from participation rather than distance. I think clinical models earn their legitimacy through repeated lived contact with the presentations they describe. And I think there is something quietly protective about remaining humble enough to say:

“This framework works here because this is where I have lived clinically. Beyond that, I do not yet know.”

In a profession increasingly seduced by instant expertise and polished conceptual systems, that may be the most honest position available.​​​​​​​​​​​​​​​​