Treating OCD

Obsessive-Compulsive Disorder (OCD) is not rare. It is not benign. And it is not something we can afford to misunderstand.

In my work across CAMHS services, I’ve seen too many young people misdiagnosed, minimised, or given interventions that overlook the depth of their distress. Clinicians—whether psychologists, counsellors, therapists or nurses—need more training in OCD, not less. They need more confidence, more nuance, and more capacity to sit with what OCD really brings into the room: a mind in turmoil, often masked by surface compliance or perfectionism.

So what do we need to teach?

First, we need to teach that OCD is not “just” anxiety.

Yes, fear plays a part. But behind the compulsions and rituals, we often find something much darker—an internalised cruelty, a self-policing mechanism that doesn’t allow for doubt, mistakes, or even thoughts that fall outside a rigid moral code. For adolescents, this is especially destructive. At a time when identity is fluid and still forming, OCD can arrest development by turning every thought into a moral test.

We must teach clinicians to ask not only what the obsession is, but what position the young person has been placed in. Is the intrusive thought protecting them from a deeper feeling? Is the compulsion functioning as a symbolic safeguard against guilt, shame, or disintegration? This is where psychodynamic perspectives can deepen and enrich the formulation—moving us beyond surface symptom management into something transformative.

Second, we need to teach that OCD is not a behavioural quirk—it is a structure of experience.

Many professionals still associate OCD primarily with contamination fears and hand-washing. But the true clinical picture is far more diverse and often hidden. Intrusive thoughts can take the form of violent images, sexual doubts, existential spirals, or taboo moral dilemmas. What unites them is not content, but form: the circularity, the stuckness, the desperate search for certainty.

Teaching clinicians to recognise this structure is key. A young person with “relationship OCD” may look like they’re obsessing about love—but the real story is their mind’s struggle to metabolise uncertainty and loss. Without this lens, we risk chasing content and missing the symbolic function.

Third, we must teach how to stay in the room.

Working with OCD can provoke discomfort. Clinicians may feel attacked, trapped in loops, or unsure how to respond to endless questioning. We need to equip them with internal resources to tolerate these dynamics—to remain thoughtful rather than reactive. This includes teaching how to hold the therapeutic frame in the face of compulsive reassurance-seeking, and how to avoid becoming another cog in the adolescent’s system of mental checking.

Importantly, we must help clinicians resist the urge to be too certain themselves. Offering premature interpretations or surface-level normalisation (“Everyone has weird thoughts”) can backfire. The young person needs us to stay near their experience, not tidy it away.

Finally, we need to teach what treatment can look like when it works.

For some young people, structured ERP (Exposure and Response Prevention) will be crucial. For others, especially those in complex developmental contexts or with symbolic entrenchment, a more relational, reflective approach is needed. This might include tolerating uncertainty, exploring unconscious guilt, or surviving the projections of a young person who experiences the therapist as persecutory.

There is no single method. But there is one shared principle: we must treat OCD with seriousness, with curiosity, and with a willingness to see beneath the surface.

Because when we do, we don’t just reduce symptoms—we free the young person to become more fully themselves.