I wrote this composite clinical example to highlight the transformative potential of combining psychodynamic psychotherapy with Cognitive Behavioral Therapy (CBT) and Exposure and Response Prevention (ERP) in treating severe Obsessive-Compulsive Disorder (OCD). While psychodynamic therapy helps uncover the emotional roots and unconscious conflicts driving obsessive thoughts, CBT and ERP offer practical tools to disrupt the OCD cycle. This integrated approach not only deepens self-understanding but also empowers individuals with strategies to manage and overcome debilitating symptoms, offering a holistic path to recovery.
When Sam first contacted me in January 2020, she was hesitant. At 34, Sam—a Canadian software developer living in Berlin—was well aware of the stigma around seeking help for mental health. Yet she couldn’t deny how deeply her obsessive thoughts had taken hold of her life.
Sam had built a thriving career in tech, loved her partner of six years, and was deeply connected to her family back in Montreal. But behind her achievements was a constant, relentless fear that something terrible would happen to the people she loved.
At the time, Sam’s primary fixation was her younger sister, a 28-year-old living with a manageable but persistent heart condition.
“It’s not life-threatening,” she explained during one of our early video sessions. “But I can’t stop myself from thinking about it. I spend hours researching treatments, calling specialists, and reading the same articles over and over again.”
A Legacy of Guilt
As our sessions continued, Sam began to unpack the deeper roots of her obsessive thoughts. Her father’s sudden death from a stroke several years earlier had left her feeling overwhelmed by guilt. Diagnosed too late to intervene, he had passed away within weeks.
“I was living in Berlin, thousands of miles away,” Sam said tearfully. “I didn’t notice the signs. I should have known. I should have done something.”
Her father had been a larger-than-life figure: disciplined, successful, and deeply caring. His sudden death shattered the illusion of control Sam had built her life around. Unable to reconcile her grief, she had unconsciously taken on a new role as her family’s protector—a responsibility that felt both necessary and impossible.
From Insight to Action
Our early work focused on helping Sam understand the origins of her obsessive thoughts. Using a psychodynamic approach, we explored how her guilt and unresolved trauma had shaped her current behaviors. She began to see how her father’s loss had created a need to control situations that felt uncertain, interpreting external challenges as imminent threats.
But insight alone wasn’t enough. While the psychodynamic framework helped Sam understand the “why” behind her struggles, it didn’t equip her with the tools she needed to manage her anxiety or block the intrusive thoughts that dominated her mind.
This is where Cognitive Behavioral Therapy (CBT), and specifically Exposure and Response Prevention (ERP), became essential.
The CBT and ERP Intervention
To break the cycle of obsessions and compulsions, we developed a structured plan:
1. Dedicated Worry Time: Sam was instructed to resist engaging with intrusive thoughts in the moment. Instead, she scheduled a specific time each day—her “worry time”—to confront these fears in a controlled way.
2. Exposure Without Response: During her worry time, Sam practiced sitting with her anxiety instead of acting on it. For example, instead of searching for new articles about her sister’s condition or emailing doctors, she would allow herself to fully experience the discomfort of “not knowing” without trying to resolve it.
How ERP Works
ERP operates on a simple but powerful principle: by repeatedly exposing oneself to a feared thought or situation without engaging in compulsive behaviors, the brain learns that the anxiety isn’t dangerous. Over time, this process builds tolerance to anxious thoughts and reduces their power.
At first, Sam found this practice excruciating. “It feels like I’m abandoning her,” she admitted. But as she stuck to the plan, something remarkable happened: her brain began to adapt. Each time she resisted the urge to act on her obsessions, she grew more confident in her ability to tolerate uncertainty.
This didn’t mean the intrusive thoughts disappeared entirely. But they lost their grip on her.
A New Chapter, New Fears
After ten months of therapy, Sam felt ready to end our sessions. She had developed effective tools to manage her anxiety and had regained a sense of balance.
Two years later, she reached out again. By then, Sam’s life had changed dramatically. She was pregnant with her first child and planning to move back to Montreal to take a leadership position at a startup. Her partner, a graphic designer, was supportive of the move but faced limited career prospects in Canada.
With these changes, Sam’s obsessive thoughts shifted focus. This time, she was consumed by worry about her mother’s health.
“She’s in good shape for her age,” Sam said during our first session back. “But I can’t shake the feeling that something terrible will happen. I spend hours thinking about what I can do to prevent it.”
The pattern was familiar, but the emotional stakes were higher. Sam’s guilt over her father’s death, coupled with the pressures of pregnancy and the upcoming move, had reignited her anxiety.
Revisiting the Tools
We returned to the strategies that had helped her before:
1. Tolerating Uncertainty: Sam resumed the practice of letting intrusive thoughts come and go without acting on them. She reminded herself that her fears were just thoughts, not facts.
2. Exposure and Response Prevention: Once again, she committed to her worry time, using it as a safe space to confront her fears without seeking solutions.
3. Self-Compassion: We worked on reframing her inner dialogue. Sam learned to treat herself with kindness, recognizing that she didn’t have to carry the weight of her family’s wellbeing alone.
Breaking the Cycle
By the time Sam and I ended our second round of therapy, she had made significant progress. While her obsessive thoughts hadn’t vanished entirely, she no longer felt controlled by them.
“I know I can’t protect everyone I love,” she said. “But I can trust myself to handle whatever comes.”
Sam’s story illustrates the power of therapy—not just as a one-time solution but as a process of ongoing growth and self-discovery. By combining the deep insight of psychodynamic therapy with the practical tools of CBT and ERP, she was able to break free from the cycle of obsessions and compulsions and move forward with her life.
A Note to Readers
Sam’s story is a composite based on real experiences, shared with permission and modified to protect privacy. If you see yourself in her journey, know that you’re not alone. Therapy offers a path forward—one where you can learn to manage your anxiety, build resilience, and reclaim your life.
Our online therapy clinic specializes in evidence-based treatments for OCD and anxiety. Reach out today to take the first step toward lasting change.
By Ari Sotiriou cofounder Online Therapy Clinic
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