“Do They Really Need to Understand It?”

A Conversation Between Dr. Marcus Lewton and a Senior CBT Consultant

Section 1: The Opening Challenge

Dr. Elin Masters (CBT Consultant):

“Let me be direct, Marcus. I respect what you’re doing with the symbolic model—it’s thoughtful, elegant, sometimes even moving. But what I don’t see is this: where’s the empirical threshold for ‘symbolic readiness’? Because what I’m hearing is that we should delay ERP until a child is ‘symbolically alive’—whatever that means. And that flies in the face of everything I’ve been trained to do.”

Dr. Marcus Lewton:

“You’re right to challenge the term. But symbolic readiness isn’t vague—it’s the difference between a mind that’s using the symptom to communicate something, and a mind that’s using the symptom to survive. ERP treats the symptom. The symbolic approach asks: what’s the symptom doing psychically?

Two adolescents might have the exact same compulsion—say, tapping three times before bed. But for one, it’s about controlling guilt over a sick sibling. For the other, it’s an expression of symbolic collapse after parental separation. You apply ERP in the same way to both, and you’ll get wildly different results. Same behaviour—completely different architecture underneath.

Symbolic readiness means the child can reflect, tolerate affect, and allow the therapist into the system, even if just slightly. Without that, ERP becomes something that’s done to them, not with them.”

Section 2: The Data Clash

Dr. Masters:

“Let’s come back to evidence. ERP has one of the strongest evidence bases in child mental health. Meta-analyses, RCTs, systematic reviews—you name it. Remission rates across large samples show significant improvement for most young people. If it works, why wait?”

Dr. Lewton:

“Because ‘most’ doesn’t mean this one. Take the meta-analyses—you’re right, they show effectiveness. But even in the strongest studies, 30–40% of young people do not remit. In some trials, up to half remain clinically symptomatic after full protocol completion. And that’s in structured, controlled conditions. In real-world clinics? The numbers slip even lower.”

Dr. Masters:

“But those non-responders might need booster sessions, medication, family work. That’s not a fault of the model—that’s complexity.”

Dr. Lewton:

“Of course. But we keep saying ‘complexity’—when what we often mean is symbolic overload, unformulated grief, or defence that isn’t behavioural—it’s architectural. ERP fails not because it’s the wrong tool, but because we misread the terrain. We assume readiness when the symbolic system is in collapse.”

Dr. Masters:

“So what are you proposing? That we assess symbolic structure before beginning ERP?”

Dr. Lewton:

“Yes. That’s exactly what I’m proposing. A position-based formulation. You ask: Can this young person reflect? Can they tolerate feeling without ritualising? Can they name anything without retreating or attacking? If not—we wait. We build that readiness. We treat structure before sequence.”

Section 3: The Clinical Case

Dr. Lewton:

“Let me give you something real.

A 13-year-old girl was referred with harm OCD. She had a thought: ‘What if I stab my sister in her sleep?’ It horrified her. She cried in session. She begged her mum to hide all the knives. Classic intrusive thought. By the book, she was ready for ERP: insight intact, motivation high, rituals observable.

But something felt off. When I asked her what the thought might be protecting, she froze. Her eyes blanked. It wasn’t avoidance—it was collapse. A few sessions later, she revealed that her sister had recently come home from hospital. Suddenly the house was full of grief, attention, guilt. She hadn’t said it aloud, but she was no longer the centre. And part of her hated that.”

Dr. Masters:

“So you’re saying the thought wasn’t the fear—it was the defence against envy?”

Dr. Lewton:

“Exactly. She couldn’t say, ‘I need love too.’ That would have overwhelmed her. So the mind gave her something more survivable: ‘I’m dangerous.’ The thought wasn’t the wound. It was the scar tissue. If I’d started ERP on Day One, she would’ve complied. She might even have improved—superficially. But underneath, we’d have missed the psychic event entirely.”

Dr. Masters:

“But you’re not arguing against ERP, are you?”

Dr. Lewton:

“Not at all. We used ERP—eventually. But by then, the thought had already started to loosen. Because the symbolic scaffolding had returned. The symptom didn’t need to hold the guilt anymore—we could.”

Section 4: Common Ground (With Pressure)

Dr. Masters:

“Look, I hear you. I do. But there’s something you haven’t addressed yet—and that’s the reality on the ground. We don’t have the luxury of symbolic scaffolding in many services. We have 12 sessions, max. A waiting list of 300. A team of therapists already stretched to breaking.”

“You want to slow things down. I want to make sure they don’t fall through the cracks. Behavioural protocols are efficient, scalable, and evidence-backed. You start ERP on Session 2, you move. You don’t wait for poetic insight.”

Dr. Lewton:

“And that’s exactly where we part ways—not in principle, but in urgency. Because if we mistake ‘movement’ for progress, we start prescribing exposure to children whose psychic systems are already in collapse. They might attend 12 sessions. They might even comply. But you’ll see them again in 6 months, more defended, more dissociated, more convinced that therapy doesn’t work.”

Dr. Masters:

“But what’s the alternative? A model that requires months of rapport-building, symbolic formulation, and a therapist who’s fluent in projective containment? That’s not scalable.”

Dr. Lewton:

“I’m not proposing an analytic utopia. I’m proposing a triage tool. A symbolic screener that takes five minutes, not five months. One that helps us ask: is this child symbolising, or evacuating? Are we working with a metaphor, or a motor response?”

Dr. Masters:

“And you think that can be taught?”

Dr. Lewton:

“I know it can. Because we’re already doing it. Our clinicians aren’t choosing between evidence and empathy—they’re learning to sequence their interventions based on position, not just symptom.”

Dr. Masters:

“So you’re not saying delay ERP. You’re saying listen before you launch.”

Dr. Lewton:

“Exactly. Behaviour is the destination. Structure tells you how to get there.”

References Authors based their arguments on

March, J. S., Franklin, M. E., Leonard, H. L., Garcia, A., Moore, P., Freeman, J., & Foa, E. (2004). Cognitive-behavior therapy, sertraline, and their combination for children and adolescents with obsessive-compulsive disorder: The Pediatric OCD Treatment Study (POTS) randomized controlled trial. JAMA, 292(16), 1969–1976. https://doi.org/10.1001/jama.292.16.1969

McGuire, J. F., Piacentini, J., Lewin, A. B., Brennan, E. A., Murphy, T. K., & Storch, E. A. (2015). A meta-analysis of cognitive behavior therapy and medication for child obsessive-compulsive disorder: Moderators of treatment efficacy, response, and remission. Depression and Anxiety, 32(8), 580–593. https://doi.org/10.1002/da.22389

Reid, A. M., Freeman, D., & Lambe, S. (2021). Cognitive behavioural therapy with exposure and response prevention for obsessive-compulsive disorder: A systematic review and meta-analysis. Journal of Anxiety Disorders, 77, 102341. https://doi.org/10.1016/j.janxdis.2020.102341

Franklin, M. E., Sapyta, J., Freeman, J., Khanna, M., Compton, S., Almirall, D., … & March, J. S. (2015). Cognitive behavior therapy augmentation of pharmacotherapy in pediatric obsessive-compulsive disorder: The Pediatric OCD Treatment Study II (POTS II) randomized controlled trial. JAMA, 314(11), 1049–1057. https://doi.org/10.1001/jama.2015.10563