Published March 2025
In Malan’s Model of OCD, we introduced the idea that OCD functions as a defense mechanism that negotiates an emotional conflict. In this article we’ll go into further detail regarding the origins of emotional conflicts and how OCD functions as a defense. We’ll then use that understanding to conceptualize a psychoanalytic approach to treatment. Finally, we’ll think about what it means to integrate ERP with psychoanalysis in the treatment of OCD.
Digesting Emotions (1)
When we are infants, we don’t have any understanding of our feelings. We just experience the physical sensations of those feelings. For example, when a baby is hungry, they experience the painful, distressing sensations associated with hunger – but they don’t have any understanding of what’s happening to them (or even that there is a ‘them’). They don’t have any idea what those sensations mean, or even an idea that they could mean something. In other words, they physically experience hunger, but have no thoughts about it.
If all goes well, the baby cries and the parent
- Understands that the baby is hungry, and
- Responds in a way that
- Reflects that understanding to the baby (e.g., feeding the baby, or saying ‘I think someone’s hungry!’), and
- Conveys that the feeling in no way threatens the relationship between the baby and the caregiver (e.g., by remaining calm and engaged, rather than reacting with anger, distress, dismissal, or withdrawal).
Over time and through repetition of this process:
- The parent’s understanding of what the baby is feeling helps the baby to develop their own understanding of what they are feeling (i.e., thoughts to go with the physical experience), and
- The parent’s calm engagement with the baby while the baby experiences that feeling develops the baby’s sense that the feeling can be experienced within relationships, without overwhelming or alienating the other person.
- This combination of understanding the feeling, and experiencing it as acceptable within relationships, allows the baby to acknowledge the feeling as part of themselves.
This same process is how we come to understand and manage any of our feelings: They each start as a physical sensation in our bodies, and if all goes well, we express them and then our caregivers:
- Understand them
- Share their understanding with us
- Convey that the feeling is acceptable (i.e., does not threaten our relationships)
Over time, this cultivates our capacity to understand our feelings and acknowledge them as parts of ourselves.
Metaphorically, this process develops our ability to digest those feelings. When we can do so, experiencing them is painless and easy: We feel the feeling and we effortlessly move on to the next moment – in Winnicott’s (1956, p. 303) language, we simply go on being. There’s no problem and no need to do anything. We may not even notice the feeling, like we don’t notice many ingredients that we’re able to digest.
Emotional Intolerances
If the above process is what makes feelings tolerable, breakdowns in this process are what make certain feelings intolerable. For example, if we don’t have a caregiver who understands a particular feeling, we can’t develop an understanding of that feeling. We remain like a hungry baby who is in pain but doesn’t know what hunger is. Or, if our caregiver reacts with anger, distress, dismissal, or withdrawal, we may develop the sense that that feeling threatens our relationships with other people. (2)
Depending on where the breakdown is, the feeling might never be understood at all, or might feel overwhelming or threatening. Either way, the feeling can’t be acknowledged as part of the self. Metaphorically, the feeling can’t be digested – and like with some food intolerances, when we can’t digest something, we have to get rid of it.
The difference between food and feelings is that we can’t actually get rid of a feeling. The most we can do is use defense mechanisms to keep the feeling out of our conscious experience – what we’re aware of feeling. Defense mechanisms accomplish this by either preventing us from consciously experiencing the feeling, or by preventing us from understanding what we are feeling (3). Notably, all of this happens unconsciously, meaning outside of our awareness and control.
As explained in Malan’s Model of OCD, psychological symptoms, including OCD symptoms, are actually defense mechanisms. This means that OCD symptoms serve to keep intolerable feelings out of our conscious experience.
In a moment, I’ll explain how OCD accomplishes that, but first I’ll issue the usual assurance to any reader with OCD: No, this does not mean that your obsessive fear is true. It means that your obsession is actually there to protect you (perversely, to be sure) from some completely natural and healthy feeling that is intolerable to you because you never developed the capacity to digest it.
So how does OCD keep intolerable feelings out of consciousness?
Displacement
‘Displacement’ is a defense mechanism that moves our feelings away from their original context to a new context (McWilliams, 2011, p. 140). As explained in our discussion of Malan’s model of OCD, a defense mechanism needs to both express and hide the original feeling (Malan, 1979, p. 8). Displacement accomplishes this by moving the feeling to a symbolic context that in some way captures the feeling. This allows the feeling to be given expression in a safely dislocated and disguised way, at a safe distance from its original context and meaning.
An example of the above is someone who has an intolerable feeling of anger at their family, and becomes preoccupied with an obsession that they have left the stove on and will burn down the house.
Undoing
While many different psychological symptoms could be conceptualized as involving displacement, it’s ‘undoing’ that is the real hallmark of OCD.
Undoing is exactly what it sounds like: an attempt to neutralize an intolerable feeling. In its simplest form, undoing might entail thinking, saying, or doing something in an attempt to counteract an unacceptable thought or feeling (McWilliams, 2011, p. 137).
In OCD, undoing often happens in the context of displacement. After the person unconsciously dislocates and disguises the feeling using displacement, they then attempt (again, unconsciously) to neutralize that feeling within its new, symbolic context.
Returning to the example above, the person who becomes preoccupied with an obsession that they may have left the stove on (displacement) then repeatedly turns the stove off (undoing).
Needless to say, turning the stove off over and over again can never actually get rid of a person’s anger. That’s why a compulsion never feels satisfactory and never makes the obsession go away – because it was never about the stove.
That’s why even though ERP can be tremendously helpful, it’s also limited, because it has no way of conceptualizing, let alone addressing, the underlying emotional conflicts driving symptoms.
It’s also the reason for symptom substitution: As long as we need to get rid of intolerable feelings, we will find some obsession onto which we can displace them.
And it’s why OCD gets worse in times of stress – not simply because a person is depleted generally, but because whatever experiences are causing the stress are also evoking certain intolerable feelings, and the person’s need to displace those feelings inflates their OCD symptoms.
In summary, OCD symptoms reflect an unconscious effort to rid ourselves of certain feelings. But actually getting rid of feelings is impossible. So we will continue to experience symptoms until we develop our capacity to digest our intolerable feelings instead of trying to get rid of them.
How Psychoanalytic Treatment Works
As discussed above, we develop the ability to acknowledge our feelings by experiencing those feelings with a caregiver who understands and accepts them.
In the simplest terms, having someone hold us while we experience a feeling is what develops our capacity to hold that feeling within ourselves. And in the simplest terms, psychoanalysis is about being held by someone while we hold our feelings. Through this process, we develop the ability to digest feelings instead of trying to get rid of them, and in this way feelings that were previously intolerable become tolerable.
Discerning the Underlying Feelings
Psychoanalysis thus entails helping the patient to access previously intolerable feelings in the context of the therapeutic relationship. But as discussed above, our intolerable feelings are disguised by our defenses. Therefore, one goal of psychoanalytic theory and methodology is to help discern these underlying feelings.
It’s beyond the scope of any article, as well as beyond me, to provide an authoritative guide to discerning what feelings are being displaced onto an obsession. Nonetheless, I’d like to describe some of the places a therapist might look for clues.
Content
As discussed above, obsessions are often symbols or metaphors for the feelings they express. Thus, one of the first places to look for hints about the displaced feelings is in the content of the obsession (Malan, 1979, p. 10). For example, obsessions about driving can sometimes symbolize conflicts about autonomy or competition; all things scatological can symbolize aggression; a parasite can symbolize dependency.
Context
Another place to look for hints about displaced feelings is in the context of the obsession, both in the patient’s life and within a therapy session.
When considering the context of obsessions within a patient’s life, we would look at the situations in which the person’s symptoms tend to get worse, or in which the person tends to become more fixated on a given obsession. We would try to discern what feelings these situations might be evoking that are remaining unconscious while being displaced onto obsessions. For example, does the person become concerned about getting into a car accident when they are going to do something for themselves, or feeling competitive? Do they become afraid of poisoning their children when they are going past their limits in caring for them? Do they dysmorph part of their partner’s appearance when they can’t acknowledge some other ambivalent feeling towards them?
We would pay special attention to feelings that seem to be missing. For example, if a patient is describing experiences that would tend to evoke anger, distress, or grief, but isn’t feeling these feelings, we might consider a possible connection between these unconscious feelings and their obsessions.
Within a therapy session, as the patient is talking, we would pay attention to when they tend to become more fixated on a given obsession. What were they talking about beforehand? Where were they about to go? Did the obsession help them to (unconsciously) avoid a certain topic or feeling? We would also pay attention to what else they were talking about in the same session. Is there some theme across the topics that might shed light on the emotion underlying the obsession?
Effect
One more place to look for hints about displaced feelings is in the effect of the obsession (Malan, 1979, p. 9). For example, does it serve to set a boundary the person can’t set consciously? Does it serve to distance them from something or someone? Does it serve to protect them from vulnerability? Does it serve to communicate aggression?
Unfortunately, it’s not that simple
My goal in this article is to provide an accessible framework for beginning to think psychoanalytically about OCD, but I want to acknowledge that symptom formation is more complex than what I’ve described, and involves the interaction of any number of different feelings and defenses. Thus, while displacement and undoing do play central roles in OCD, symptom formation also involves other defenses, such as identification, projection, reversal, reaction formation, enactment, and tons of splitting (4). Moreover, conflicts and defenses coalesce into more complex phenomena that this article doesn’t even touch, such as Oedipal dynamics and internal object relations (5).
People with OCD favor simple explanations of our problems that proffer simple solutions to them. We want a quick fix – or put more psychoanalytically, we need to believe that a quick fix exists. In contrast, a psychoanalytic perspective recognizes that, unfortunately, our feelings and defenses are anything but simple.
Omnipotence
In addition to the need to acknowledge complexity, another aspect of psychoanalytic treatment that is unappealing to obsessive-compulsives is that we can’t treat ourselves. As Margaret Little (1951, p. 33) wrote, and as I’ve quoted elsewhere, “to try to observe and interpret something unconscious in oneself is rather like trying to see the back of one’s own head.” Put another way, we obviously can’t acknowledge feelings we can’t acknowledge – so trying to figure out what feelings our OCD is displacing doesn’t work. Further, even if we could figure it out, an intellectual understanding of our unconscious feelings is of limited effect: Developing the capacity to digest these feelings requires us to experience them with another person who understands and accepts them.
Obsessive-compulsives’ desire to treat ourselves reflects, among other things, our defensive tendency towards ‘omnipotence,’ or needing to experience ourselves as having more control than we really do. This need plays a central role in obsessive-compulsive personalities and in OCD.
Indeed, OCD symptoms themselves facilitate this need in multiple ways. For example, the defenses of displacement and undoing, described above, enable us to take an emotional problem that we can’t even understand, let alone solve, and transform it into a problem that we can understand and address. Returning again to the example above, the person who is preoccupied with turning off the stove is certain that they know what the problem is (they may have left the stove on), and that they know what to do about it (go back and check). In reality, they don’t understand what their actual (emotional) problem is, and they are consequently completely helpless to do anything about it. An obsession thus takes a person who is completely helpless in the face of a problem they don’t even understand, and turns them into someone who knows exactly what needs to be done.
This is one reason it is so hard for someone with OCD to let go of believing that their obsession is their real problem. Letting go of that belief involves a loss of control, because it means that the person can’t solve (or even understand) their problem on their own. Being able to let go of believing that our obsession is our real problem requires a deep trust that we have someone (i.e., a therapist) who can help us with our emotional problem. (This is also why a patient may become more fixated on an obsession when their therapist feels less dependable, such as when the latter takes time off or when there is an empathic breach in the therapeutic relationship. Ironically, a patient may also become more fixated on an obsession when their therapist has been especially helpful, making the patient uncomfortably aware of their dependence and threatening their omnipotence.)
As an aside, another manifestation of omnipotence in OCD is a person’s belief that their symptoms can protect them from their core fear, and even achieve the opposite. For example, the person who is afraid that eating certain foods could cause cancer also has some sense that they can prevent cancer by not eating those foods. The person who is afraid that behaving imperfectly could lead to being hated, might even hope that behaving perfectly will achieve love. Thus, the flipside of every core fear is an omnipotent fantasy. People may present for treatment when something happens that punctures their omnipotent fantasy (e.g., making partner and still feeling like a disappointment).
Integrating RF-ERP and Psychoanalysis
How do we reconcile the above, which emphasizes the need for help, with RF-ERP, which emphasizes agency? Technically, there’s no contradiction: We can control our behavior even when it feels like we can’t, and we can’t control our unconscious feelings. Still, the two approaches reflect different mindsets. Integrating RF-ERP with psychoanalysis requires holding both in mind, moving between them, and allowing them to influence each other.
Conclusion
I’ll conclude with the following, which sums up much of what’s been said:
The psychoanalyst could say to the behaviorist: Congratulations! Your patient has stopped checking the stove … but they still can’t tolerate being angry at someone they love, so have you really addressed their problem?
And the behaviorist could say to the analyst: Congratulations! Your patient is beginning to acknowledge angry feelings in their relationships … but you’ve been seeing them for quite a while and they’re still spending hours each day checking the stove, so have you really addressed their problem?
And both of them would be right. Each of these approaches has an advantage and a limitation. For many people with OCD, ERP can be enormously helpful in a short period of time, in a way that psychoanalytic treatment cannot. But ERP cannot treat, or even conceptualize, the emotional problems underlying OCD symptoms.
I propose that there is no need to choose between them, and that we can help our patients the most by bringing these approaches together.
Notes
- This model is based on the work of Freud, Klein, Winnicott, Bion, Fonagy, and others, but isn’t perfectly loyal to any one of them. It’s my effort to provide a framework that is ‘good enough’ to serve as an introduction to psychoanalytic thinking about this topic. Thank you to Dr. Karen Beard and Dr. Aaron Thaler for reviewing it to ensure that it remained consistent with psychoanalytic thinking despite the liberties I took in my efforts to make it accessible.
- This does not mean a caregiver needs to get it right all the time for their child to be okay. This is impossible, and it would actually be harmful to the child’s development in its own way (Winnicott, 1965, p. 87). Winnicott (1965, p. 145) referred to the ‘good enough mother’ to convey that what is needed is a caregiver who gets it right-enough, enough of the time.
- While defense mechanisms prevent us from being conscious of the feeling, the feeling remains in our unconscious. In other words, it is still fundamentally how we feel, even though we don’t know it.
- ‘Splitting’ can refer to several related but distinct phenomena, all of which play such important roles in OCD that the topic of splitting in OCD really warrants its own article. Until I have time to write that article, I’d like to offer the following summary: In its most basic form, described by Klein (1946), splitting is a defense mechanism that involves mentally separating the good and bad parts of another person, experiencing that person as only bad when one feels an aggressive feeling towards them. This allows one to direct their aggression towards someone they hate while protecting someone they love, by not consciously recognizing that these are actually the same person, with good and bad parts, and towards whom one has ambivalent feelings. When splitting is generalized, it becomes a worldview in which things are either idealized (denying the bad) or devalued (denying the good), rather than recognizing that everything and everyone is both good and bad, and that our life experiences are therefore characterized by ambivalence that we must learn to tolerate. The term splitting can also refer to any similarly dichotomous thinking or feeling, beyond just good and bad, such as oppressor and victim, controller and controlled, caregiver and care receiver, competent and incompetent, etc. This type of splitting avoids complexity and ambivalence, at the expense of being able to see the world and other people realistically. (When a person splits in this way, if person or thing A is any amount X, then they are all X and no Y, and then person or thing B is all Y and no X.) Finally, the term splitting can also refer to a lack of integration among different parts of a person’s personality or experience. For example, people with OCD often feel as though how they feel in a given moment is the only way they have ever felt or will ever feel. When someone with OCD is acutely triggered, they are in touch with only one part of their experience, which in that moment is split off from the rest. All of these forms of splitting are highly characteristic of obsessive-compulsives and OCD, and addressing them is a core component of treatment.
- For further reading about Oedipal dynamics, consider:
- Grier, F. (Ed.). (2005). Oedipus and the couple. Karnac Books.
- Davies, J. M. (1994). Love in the afternoon: A relational reconsideration of desire and dread in the countertransference. Psychoanalytic Dialogues, 4(2), 153–170.
For further reading on internal object relations, consider: - Ogden, T. H. (1983). The Concept of Internal Object Relations. International Journal of Psycho-Analysis 64: 227-241.
Works Cited
Klein, M. (1946). Notes on some schizoid mechanisms. The International Journal of Psychoanalysis, 27, 99–110.
Little, M. (1951). Counter-transference and the patient’s response to it. International Journal of Psycho-Analysis, 32, 32–40.
Malan, D. H. (1979). Individual psychotherapy and the science of psychodynamics. Butterworth.
McWilliams, N. (2011). Psychoanalytic diagnosis: Understanding personality structure in the clinical process (2nd ed.). Guilford Press.
Winnicott, D. W. (1956). Primary maternal preoccupation. In Through paediatrics to psycho-analysis (pp. 300–305). Hogarth Press.
Winnicott, D. W. (1965). From dependence towards independence in the development of the individual. In The maturational processes and the facilitating environment: Studies in the theory of emotional development (pp. 83–92). International Universities Press.
Winnicott, D. W. (1965). Ego distortion in terms of true and false self. In The maturational processes and the facilitating environment: Studies in the theory of emotional development (pp. 140–152). International Universities Press.