“Not Every Child Can ‘Just Do ERP’": A Conversation About Intrusive Thoughts, Support, and What Needs to Change”

An interview with Dr. Marcus Lewton by Hannah Joyce

Disclaimer:

The views expressed in this interview are those of Dr. Marcus Lewton in his independent capacity and do not necessarily reflect the views of any NHS organisation. The content is intended for reflection, education, and open dialogue around OCD and intrusive thoughts in young people.

Hannah:Let’s start at the beginning. What drew you to work with children and young people experiencing intrusive thoughts? I know your clinical psychologist who works with such a wide range of presentations including trauma, psychosomatic disorders, depression etc. but your known for your interest on unwanted intrusive thoughts.

Dr. Lewton:I felt initially it was the degree of distress and power these thoughts had. They were tortuous for many young people. I noted they derailed their typical development and caused so much misery. It was difficult to see to be honest. I’ve seen so many families literally torn apart by it.

Hannah:Most parents hear about CBT or ERP as the “gold standard.” Why doesn’t it work for every child?

Dr. Lewton:That’s a really important question. CBT stands for Cognitive Behavioural Therapy, and ERP means Exposure and Response Prevention. They’re both widely used treatments for OCD and can be incredibly effective—but they’re not always the right starting point for every child. Some young people aren’t yet emotionally ready to face the fears behind their rituals. Others don’t fully understand why they’re doing what they’re doing—they just know it feels urgent and overwhelming. If we jump into exposure work before the child feels safe or understood, I risk deepening their distress rather than helping them move through it. So it’s not about saying CBT or ERP is wrong—it’s about making sure the child is ready for it first.

Hannah:Is it ever okay for a child not to start ERP straight away? Aren’t I risking them getting worse?

Dr. Lewton:It’s not only okay—it’s sometimes essential. The idea that therapy must begin with ERP assumes the child is already symbolically intact, emotionally resourced, and has a supportive system behind them. Many don’t. And here’s the crucial part: clinicians sometimes misunderstand what readiness really means. They think it’s about motivation, so they use pep talks, motivational interviewing, or therapy fads that encourage ‘buy-in.’ But this isn’t about reluctance or attitude. It’s about whether the child’s internal world has the structure to tolerate what exposure will demand of them. Without that structure, ERP becomes overwhelming. It’s not resistance—it’s protective. I’d rather spend time building a container than watching one collapse.

Hannah:You talk about “psychic readiness” and symbolic formulation—what does that mean in practice?

Dr. Lewton:It means taking seriously what the rituals are doing. Are they protecting the child from overwhelming guilt? Are they holding in grief? Are they masking a deep sense of inner badness? We try to map out the internal geography before we intervene. That way, we know what we’re really asking the child to give up—and what we need to help them build in its place. We don’t treat the symptom. We treat the structure beneath it.

Hannah:If a child says they want to stop their rituals but can’t, what’s really going on inside?

Dr. Lewton:Often, it’s a split between the part that wants to grow and the part that’s terrified of what will happen if they let go. The ritual becomes a kind of mental scaffolding. It gives shape to something that would otherwise feel chaotic or unbearable. So the child may want to stop, but the mind says: “Not yet. Not until it’s safe.” That’s not ambivalence. That’s survival logic.

Hannah:There’s a lot of frustration among families—why are many public and even private services still so rigid about its treatment models? Like in England where IAPT is dominant?

Dr. Lewton:Because services are under pressure, and systems reward what’s measurable. ERP has decades of outcome data. But data can’t always see what’s missing—children who drop out, who aren’t ready, who say yes but dissociate during exposure. The rigidity isn’t born of bad intentions. It’s a system trying to offer something helpful, but without enough room to ask, “Why doesn’t this work for everyone?”

I believe we urgently need a more integrative approach—one that doesn’t pitch CBT and psychodynamic thinking as opposites, but sees them as mutually enriching. It’s deeply frustrating to watch services discharge children simply because they don’t respond in a textbook way to ERP. Some clinicians still believe it’s a matter of motivation or compliance, but what if it’s a matter of psychic structure? What if readiness isn’t something you inspire with a prep talk—but something you help develop over time? That’s the kind of thinking we need to protect children from being prematurely labelled as resistant—or worse, untreatable.

Hannah:What should parents do if they feel the service their child is getting doesn’t feel right?

Dr. Lewton:First, trust your instincts. If your child is getting worse, shutting down, or feeling punished by therapy, it’s okay to speak up. Ask the clinician what they think the rituals are protecting. Ask whether they’ve considered the child’s emotional readiness. The best clinicians will welcome that question. If you don’t feel heard—keep looking. The right support is out there, and you deserve it.

Hannah:Can you give an example of a child who wasn’t ready for ERP, and how you worked with them differently?

Dr. Lewton:I remember a young person who had thoughts about being a monster. Everyone around them was trying to convince them they weren’t. But the more they were reassured, the more convinced they became that something inside was deeply wrong. We didn’t start with exposures. We started with metaphor. We talked about the “monster” as a part that held fear and shame. Over time, the child could talk to that part, not just fight it. Only then could ERP make sense—because now they knew why the thought was there.

Hannah:Do you ever worry that your approach is too slow, too symbolic, or too different from the mainstream?

Dr. Lewton:Sometimes. Yes, I do worry. Especially in private practice, where the financial implications of long-term work are real and can be challenging. But I’ve also seen cases where I initially thought, this is too severe, too complex. And yet, with courage—both mine and the young person’s—we made progress. Deep, meaningful, lasting progress that went far beyond symptom reduction.

I remember one such case I worked with experimentally two years ago. Recently, I received a letter from that young person. They told me they still think about our conversations and are convinced I saved their life. But the truth is, they saved something in me—my desire to never give up on this work. They reminded me that this way of working matters. They helped me more than they will ever realise.

Hannah:What would you want every parent of a child with OCD or intrusive thoughts to know—even if they never meet you?

Dr. Lewton:That your child is not broken. That their thoughts are not who they are. That the rituals are not nonsense—they are signals. And that even when it looks like nothing is working, something is always happening underneath.

Never give up on them. And for adolescents especially, when they talk about distressing or taboo thoughts—don’t ever think that those thoughts define who they are. They are struggling with a condition that is often terrifying and misunderstood.

Hannah: Thank you Dr Lewton and thank you for anyone taking the time to read this conversation. If you’re a parent, a clinician, or simply someone trying to understand—know that your presence in this dialogue matters. Stay curious, stay compassionate, and above all, stay close to the young person behind the symptom.

Dr Lewton: My pleasure. Thank you Hannah.