What Meltzer can teach us about adolescent OCD in modern day services

I have been returning to Donald Meltzer’s 1986 chapter on the analytic encounter and the gathering of the transference. Indeed, this is something I talk to trainee clinical psychologists about when working with adolescents in general. Meltzer’s chapter was written nearly twenty years after his original account of the psychoanalytic process and has the feel of someone revisiting his own certainty. The later account is more accommodating of clinical reality. Meltzer is interested in what happens when psychoanalytic work takes place in hospitals and clinics, where the clinician and patient are surrounded by other people, other demands and a great deal of information. Perhaps no different from the NHS cupboards we find ourselves in!

Meltzer was writing about the analytic process in general. Yet, for me at least, I think his observations have particular force when working with adolescents who have OCD.

By the time a young person reaches public services, their OCD has usually been described many times. Parents have explained the rituals. A referral may list intrusive thoughts, risk concerns and the amount of reassurance being sought at home. School might have reported lateness, avoidance or repeated visits to pastoral staff. Several professionals may already have discussed whether the thoughts indicate danger. The clinician can enter the first meeting knowing an extraordinary amount about the young person’s symptoms while knowing very little about the young person.

This creates a peculiar emotional situation. An adolescent with intrusive thoughts about harming somebody may already fear that thoughts reveal character. They may believe that disclosing an image or impulse will lead another person to decide what kind of person they really are. The clinician then arrives with access to records, parents and a wider professional system. Even a gentle question can feel like an examination. The young person may experience the clinician as another representative of an adult world that observes, records and reaches conclusions.

This is one way in which the institution enters the transference. It is present through the referral letter and the risk assessment. It appears in the question of what will be shared with parents. It may be felt in the possibility that something said in the room will travel into an MDT meeting later that week. None of this means that communication should stop. Clinical responsibility remains. We do, however, need to think about the meaning that communication acquires for this particular adolescent.

OCD makes this especially difficult because the disorder pulls everyone towards certainty. The young person wants to know whether the thought means anything. Parents want to know whether their child is safe. The clinician may feel pressure to decide quickly whether the material belongs to OCD or indicates genuine intent. The team may want a clear formulation and treatment plan. Each demand is understandable. Together, they can create a room in which there is very little space left for thought.

Meltzer’s later view of interpretation helps here. He had become less convinced that change depended upon the analyst arriving at a precise understanding and communicating it successfully. Interpretation could bring richness and clarity to the work. The deeper change occurred through the development of the transference itself. As the relationship changed, the patient’s anxiety could change with it.

For work with OCD, this moves us away from the fantasy of the perfect explanation. Clinicians can become caught in trying to produce an account that will finally persuade the adolescent that the intrusive thought is meaningless. We explain thought action fusion. We distinguish an unwanted thought from an intention. We point to the distress as evidence that the thought conflicts with the young person’s values. Much of this can be useful. It can also become reassurance dressed in clinical language.

A young person may understand every explanation and still return the following week needing to hear it again. The problem was never a lack of information. The problem concerns what happens inside the relationship when doubt appears. Does the clinician become a source of moral certainty? Does the adolescent use the clinician’s mind to feel safe for a few hours? Can the clinician bear being unable to give the answer OCD demands?

The transference gathers through these ordinary moments. The adolescent watches what the clinician does with uncertainty. They notice whether disturbing material changes the clinician’s face. They discover whether silence leads to hurried questioning. They may test whether the therapist can keep thinking when an intrusive thought feels unbearable. This is where the relationship begins to acquire curative value. The young person has an experience of their thought entering another mind without becoming a command, a confession or an emergency.

Meltzer also writes sensibly about the beginning of treatment. He suggests treating the first term as an experiment in which both people discover whether an analytic process can develop. I like the modesty of this. The word experiment loosens the idealisation that can gather around a new treatment. It allows the clinician to have hope without promising too much. It also gives the patient some room to find out what the work actually feels like.

There is an obvious connection with adolescent OCD assessment. A young person may arrive believing that treatment will involve being forced to confront their worst fear immediately. Their parents may expect a set of techniques that will remove the symptoms. The clinician may already be thinking about exposure and response prevention. Sometimes that is exactly the treatment required. Even then, the emotional conditions for exposure matter.

An experimental beginning allows us to ask how the adolescent currently uses OCD. We can notice what happens when a compulsion is questioned and what sort of terror emerges when reassurance is withheld. We can see whether the symptoms form a sealed world, organise a retreat from development or become a desperate attempt to prevent imagined damage to loved objects. These observations do not replace behavioural assessment. They tell us something about the young person’s capacity to use it.

Meltzer’s flexibility about frequency also feels relevant. He no longer insists that meaningful analytic work must begin with five sessions each week. Treatment might begin with two or three, with the need for greater frequency becoming apparent through the work. CAMHS rarely offers this sort of freedom, of course. Contact is shaped by waiting lists and service thresholds. Still, the underlying principle survives. Frequency should have a clinical meaning. A weekly appointment may contain one adolescent and leave another alone with a rapidly closing internal world. More contact can support the work. It can also become another form of reassurance if its purpose has not been thought about.

His observations about adolescence are equally useful. Meltzer believed that the transference often gathers slowly with adolescents because vulnerable parts of the self may be located within the adolescent community. Peer relationships can hold experiences that the young person cannot yet bring into contact with an adult therapist. This has become more complicated in the online world. Adolescents now encounter vast communities organised around mental health language, diagnostic identity and shared accounts of intrusive thoughts.

These spaces can reduce shame. A young person who believed they were uniquely monstrous may discover that other people experience harm thoughts, sexual intrusions or religious fears. That recognition can be profoundly relieving. Yet the community can also suspend development. The adolescent may borrow a complete explanation of themselves and use it to prevent further curiosity. Online discussion can become reassurance seeking on an enormous scale, with strangers repeatedly confirming that a thought is “just OCD”. The peer world then contains the frightened parts of the young person while the therapist is kept at a careful distance.

It would be clumsy to interpret this as resistance and leave it there. Adolescents need a world that belongs to them. They need distance from adults. The clinical question concerns how the community is being used by this young person at this point in their development. Does it make emotional contact more possible, or does it keep the most dependent parts of the self in suspended animation?

Meltzer finally returns us to the analyst’s state of mind. He values kindness and patience, with an unintrusive quality that leaves room for the patient’s own development. These are ordinary words for difficult achievements. Kindness can collapse into reassurance. Patience can conceal therapeutic drift. A clinician who tries so hard to avoid intrusion may become absent at the moment they are most needed.

The parental quality Meltzer describes is more active than that. It involves remaining emotionally available while resisting the wish to take over the young person’s mind. With OCD, this may mean recognising the terror without confirming the feared conclusion. It may mean helping an adolescent approach what they avoid while staying interested in what the avoidance has protected them from. The clinician trusts that development belongs to the young person. Our task is to help create conditions in which it can begin again.

Modern day services cannot reproduce Meltzer’s analytic setting. The institution will remain in the room. Parents need involvement, teams need communication and questions of safety cannot be wished away. The useful question is what sort of encounter remains possible inside those conditions.

For an adolescent with OCD, that encounter may begin when their most frightening thought can be spoken without the room becoming frightened on their behalf. The clinician does not rush to cleanse the thought of meaning or treat it as a hidden declaration. They remain curious. Over time, the adolescent may become curious too.