Beyond Right or Wrong: Two Hidden Structures Beneath OCD

Why do some young people with OCD fear catastrophe if they don’t act, while others feel an unbearable sense of wrongness, even when they know nothing bad will happen?

Contemporary models of OCD—particularly those grounded in CBT—have rightly highlighted mechanisms such as thought–action fusion, inflated responsibility, and safety behaviours. These frameworks help many young people make sense of their experience and begin recovery.

But in our clinical work with adolescents, especially those with intense internal shame or moral distress, we often find that something else is going on beneath the surface.

And here, surprisingly, an older voice in psychoanalysis remains startlingly relevant.

Writing in The Psychoanalytic Theory of Neurosis, Fenichel proposed a little-known but deeply useful distinction. He observed that while many obsessional symptoms function to avoid a feared situation or impulse, others do the exact opposite—they compel the individual to confront or repeat what they fear, as if something within the psyche is trying to break through.

“In other cases an obsession does not provide the avoidance of what was originally feared but compels the person to do just that which he originally was afraid of… not caused by a need for maintaining a phobia but rather by a fight of the original impulse or of the personality against the phobia.” —Fenichel, 1945

Fenichel’s insight still holds today. At UITS, we think of this as the difference between:

Responsibility-Driven OCD

(Avoidance)

• Driven by thought–action fusion and catastrophic responsibility

• Often responds well to ERP and psychoeducation

• Ego position: “I must not do this or something terrible will happen”

Rightness-Driven OCD

(Protest)

• Compulsion is driven by an unbearable feeling of internal wrongness

• The thought doesn’t protect the young person—it protests something deeper

• Ego position: “I know it won’t cause harm, but I still have to do it”

Why This Matters

These two internal structures look similar on the surface—repetition, anxiety, rituals—but require different listening.

For example:

• A young person avoiding stepping on cracks because “something bad might happen” may need containment around responsibility, harm avoidance, and tolerance of uncertainty.

• A young person who must align every object on their desk “just right,” even though they know nothing bad will happen, may be caught in a structural protest—against an internalised demand, a buried rage, or a split-off desire.

Understanding whether the obsession is an appeasement or a rebellion helps us know:

• Where to intervene

• How to frame our language

• And when to support the adolescent in symbolising, rather than challenging, the thought

The UITS Adjunct

We fully support evidence-based approaches. CBT and ERP have helped thousands. But for some young people—especially those with severe shame, early relational trauma, or internalised moral attack—something deeper must be heard.

The UITS model adds a structural layer:

• We ask not just what is the thought? but what position is the mind in when it has it?

• We help clinicians map whether the obsession is defending against, expressing, or displacing unformulated emotional life

• We use symbolic listening, informed by psychoanalysis, but applied in CAMHS-ready language

Closing Lines

Otto Fenichel wrote in 1945. His language may be old—but the structural clarity of his insights remains. At UITS, we stand with both the evidence base and the symbolic tradition.

We believe OCD is more than a disorder of thought—it is a cry from a structure.

And if we listen well enough, we can hear what part of the self is trying to be defended, expressed, or even freed.