The Illusion of Efficacy

At first glance, the numbers look promising. Exposure and Response Prevention (ERP) reduces symptoms. In the short term, people feel relief. The system logs this as success.

But what if we zoom out?

A major longitudinal study in the Netherlands followed 213 individuals with OCD over six years. The headline result? Only 14% achieved full remission. Other long-term studies paint a similar picture: even after 8–10 years, only 20–27% reach true recovery.

This isn’t just a drop in efficacy. It’s a structural failure.

Relief Isn’t Remission

Most studies define “response” as a reduction in scores—not a return to psychic freedom. ERP teaches skills. It helps manage behaviours. But it often leaves the structure of mind untouched.

That structure—the one that generates obsessive doubt, magical guilt, and repetitive absolution—is still active, even when symptoms abate.

So what are we missing?

The Symbolic Blind Spot

OCD isn’t just a fear of germs, or harm, or sin. It’s a symbolic defence: a way to stabilise overwhelming inner conflict. A ritual is not simply avoidance—it is a psychic compromise between what cannot be borne and what must not be known.

When therapy focuses solely on exposure and habituation, it may bypass the deeper emotional logic of the symptom. ERP can be powerful—but if the adolescent is still caught in unconscious moral self-punishment, the relief is fragile.

What If This Isn’t Just About Treatment?

This is also about epistemology. What does it mean to understand OCD?

If we measure success by symptom charts and spreadsheets, we miss the soul of the work. We turn minds into data-points, not living psychic structures.

When we ask, “Are we really understanding OCD?”, we are asking if the system, the therapist, the training, and the research paradigm—have truly listened to what this illness is trying to symbolise.

A Call for Depth

It’s time to reframe the clinical conversation.

Not ERP versus psychodynamic work, but a depth-informed synthesis: one that holds symbolic listening alongside procedural skill. One that treats symptoms not as enemies to erase, but as messengers carrying meaning from the depths of the self.

If we do not hear the message, the symptom returns.

🔗 Source study: https://doi.org/10.1016/j.jocrd.2023.100783