I have worked in OCD for 16 years and I still find it one of the most interesting areas of clinical practice.
Not interesting because the disorder is neat or predictable. It is neither. Interesting because OCD forces clinicians to think carefully about fear, uncertainty, meaning, behaviour and the very human urge to get rid of discomfort as quickly as possible.

When I started the OCD Clinic Brisbane, I was literally a one-woman show in a rented GP practice. The referrals came quickly and, fairly soon, there were more people needing specialist OCD treatment than one clinician could reasonably see. That was when I started pulling in trusted colleagues across Australia and New Zealand and building a group practice.

At the time, I thought the problem was mostly access. Sixteen years later, I think the bigger problem is that we still need more clinicians who genuinely know OCD. And by 'know OCD', I do not mean knowing the diagnostic criteria or being able to say that ERP is the gold-standard psychological treatment. I mean recognising OCD when it does not look textbook.

Hearing the function underneath the story. Knowing when a client is asking a reasonable question and when OCD has quietly recruited the therapist into a compulsion.

That is why Daphne Bryan and I created the Obsessive-Compulsive Disorders Training Institute, and why our first major clinician program, DEFINE, exists. We want more good clinicians to become
genuinely competent in this work.

Some presentations are easy to recognise. A person washing repeatedly because of contamination
fears. Someone checking locks, appliances or the route they just drove. A child repeating an action until it feels 'just right'.

But OCD has never been confined to the stereotypical themes.

It can attach itself to sex, harm, morality, religion, relationships, identity, parenting, responsibility, memory and health. In fact, OCD often settles around precisely the things a person most values. That is one of the first clinical lessons I want people learning OCD to understand: the content can be dramatic, confronting and very convincing, but the content is not necessarily where the disorder is being maintained.

Research on clinician recognition of OCD themes has shown how much the content can influence diagnosis. Sexual, aggressive and religious presentations are substantially more likely to be misidentified than classic contamination or symmetry presentations. That matters because once the formulation is wrong, treatment tends to follow it.

I assessed a client recently who had been in therapy for around two years, treated primarily for generalised anxiety with 'provisional obsessive features'. Once the right questions were asked, the OCD was obvious. It was, to use a very technical clinical expression, smack-you-in-the-face OCD.

I do not say that to peacock. I say it because this person had worked hard in therapy for two years without anyone really treating the mechanism keeping them stuck.

Where was it missed? The themes.

This remains a soapbox issue for me because I have seen what happens when sexual or harm-related OCD is misunderstood. People can be referred into services they do not belong in. Families can become frightened. The client can become even more afraid to disclose thoughts. And the clinical response can inadvertently give the obsession more weight.

Nobody intends that harm. Usually the clinician is trying to be thorough. But OCD is one of those disorders where good intentions are not enough; phenomenology and function matter.

OCD is often taught as obsessions plus compulsions. Correct, but clinically incomplete.

The work becomes much more interesting when a clinician starts asking what the person is doing in response to uncertainty. What are they trying to prevent, prove, neutralise, remember or know for certain? What happens immediately after the compulsion? What does relief teach the brain?

Sometimes the compulsion is obvious. Sometimes it looks remarkably like ordinary thinking.

A person may mentally review a conversation for forty minutes, compare today's feelings with yesterday's, check whether they experienced attraction, replay a memory, scan their body, test their intentions, Google for certainty or ask a partner the same question in six slightly different ways.

From the outside, that can look like reflection. In therapy, it can even sound psychologically sophisticated. Functionally, it may be no different from checking a lock twenty times.

Two intelligent people can spend fifty minutes having a very thoughtful conversation — and OCD can have an excellent therapy session.

Most clinicians who specialise in OCD have experienced the moment when they realise the disorder has recruited them too.

The client asks, 'Do you think this means I am dangerous?' The therapist answers. The client asks again, slightly differently. The therapist clarifies. Another piece of evidence appears. Everyone is working hard. Anxiety drops for a moment. Then the doubt returns.

That is not incompetence. Reassurance is seductive. We are trained to help, soothe and reduce distress. OCD asks the clinician to tolerate a different possibility: sometimes the most helpful response is not answering the question but noticing what the question is doing.

Once clinicians learn to see that, cases that previously felt confusing often become much clearer.

Exposure and Response Prevention has a strong evidence base and remains a first-line psychological treatment for OCD. The principle is straightforward: help a person approach what OCD has taught them to fear or avoid, while reducing the responses they use to obtain relief, certainty or a sense of safety.

Good ERP, however, is not simply 'do something scary and do not ritualise'.

The clinician needs a formulation. They need to know what is being targeted, what the person is learning and what subtle safety behaviours might be keeping the cycle intact. An exposure can look impressive and achieve very little if the person is covertly neutralising throughout it. Conversely, a small behavioural change can be clinically powerful if it targets the mechanism properly.

For one person, ERP may mean holding their baby while allowing an intrusive harm thought to be present. For another, it may mean sending an email without reading it fifteen times. For someone with relationship OCD, it may mean staying present with their partner without continuously checking whether they feel 'in love enough'. For another person, it may mean driving home without retracing the route.

The useful question is not, 'How frightening can we make this exposure?' It is, 'What is OCD stopping this person from doing, and what would help them take that part of life back?'

I think our language around recovery matters.

OCD can be episodic. Symptoms move. Stress changes. People become parents, lose people, get sick, change jobs, enter relationships and leave them. A treatment model that promises a future with no intrusive thoughts is not particularly useful.
I am much more interested in functional recovery.

Can the person make a decision without three hours of review afterwards? Can they drive, work, hold their child, be intimate, leave home, take a risk and allow some questions to remain unanswered?

The point is not to teach people to win an intellectual argument with OCD. OCD will almost always have another question.

The point is to help people become less governed by the need to answer it.

This is where I think specialist training is sometimes misunderstood.

Expertise should make a clinician more flexible, not less. Knowing ERP well does not mean mechanically applying the same hierarchy to every person. It means understanding the treatment well enough to know what needs to remain faithful to the evidence and what can be adapted to the individual.

Real clients are complicated. OCD can sit alongside autism, ADHD, depression, eating disorders, body dysmorphic disorder, tic disorders, trauma histories, family accommodation and significant functional impairment.

The question is not simply whether comorbidity is present. The better question is what that comorbidity means for assessment, formulation, pacing, communication and the delivery of ERP.

Sometimes it changes a great deal. Sometimes surprisingly little. Knowing the difference comes from training, supervision, case discussion and experience.

That is the craft of OCD treatment.