When Evidence Meets the Room: A Response to the BMJ Review on OCD

I recently read the British Medical Journal article titled "Management of obsessive-compulsive disorder in adults." It is, in many ways, an excellent paper. Clear, comprehensive, and grounded in the best available evidence. It offers a careful and convincing account of CBT and ERP in the treatment of OCD.

For those interested, I wrote a short formal response to the editor, which you can read here:

https://www.bmj.com/content/392/bmj-2024-083443/rapid-responses

What follows are some additional reflections from the clinic.

When I read the paper, I had a familiar feeling.

It describes what works.

But it does not quite describe when it becomes possible.

That distinction sounds subtle on paper. It is anything but in the room.

Because in clinical practice, the problem is rarely that ERP doesn't work. The evidence is strong, and most clinicians who have delivered it properly have seen its effects. The difficulty is that some young people simply cannot use it.

The paper focuses on adults, and that matters developmentally. But even setting that aside, something important sits just outside the frame of most reviews like this.

When a young person cannot engage with exposure, it is often assumed to reflect reluctance, avoidance, or a lack of motivation. Occasionally it is framed as a problem of understanding, as though more psychoeducation might unlock the work.

But this is not usually what is happening.

The difficulty lies in the position the young person occupies in relation to the thought itself.

Some are able, even if only slightly, to step back from it. They can recognise the intrusive thought as a thought, not a fact. For them, exposure is frightening but it remains thinkable. There is just enough distance to approach it.

Others cannot find that distance at all.

The thought feels too close, too real, or too dangerous to approach as an object. It does not sit alongside them. It feels as though it speaks from within, or concerns something that must not be tested. In these moments, asking for exposure can feel less like therapy and more like asking them to walk directly into something annihilating.

This is where the work often stalls.

When we describe this as "poor engagement" or "low motivation," we locate the problem in the young person rather than in the psychological conditions that make engagement possible in the first place. The issue is not effort. It is not willingness. It is structure.

Until there is enough distance between the young person and the thought, the core mechanisms of ERP simply cannot be engaged. The intervention is not being refused. It is not yet usable.

In practice, this means that the early phase of therapy is not always exposure. It is the quieter, often less visible work of helping the young person shift their relationship to the thought just enough that exposure becomes possible.

In my clinical work with adolescents, and in my book Intrusive Thoughts and Compulsions in Adolescent OCD: A Psychoanalytic Framework for Treatment (Routledge, June 2026), I describe a set of recognisable psychological positions that young people can occupy in relation to their intrusive thoughts. These positions shape how threatening the thought feels, how much distance is available, and whether engagement in treatment is yet possible. Identifying where a young person is sitting psychically does not replace ERP. It tells you when to begin it, and how.

Sometimes the shift is small. Almost imperceptible.

But when it occurs, something changes. The same intervention that previously felt impossible can suddenly be approached, even if cautiously.

The question is not only whether ERP works. We know that it does.

The more pressing clinical question is: under what psychological conditions does it become usable?

If we can answer that more clearly, we are not replacing existing treatments. We are making them more precisely deliverable to the young people who most need them.

Because until that point, even the most robust evidence-based intervention can sit quietly in the room, waiting for a mind that is ready to meet it.

Intrusive Thoughts and Compulsions in Adolescent OCD: A Psychoanalytic Framework for Treatment (Routledge) publishes June 25th 2026.

Available to pre-order: https://www.amazon.co.uk/dp/1041219199