Obsessive-Compulsive Disorder (OCD) is a debilitating mental health condition characterized by intrusive thoughts (obsessions) and repetitive behaviors (compulsions) which can take many different forms. Traditionally, the gold standard treatment for OCD has been Exposure and Response Prevention (ERP), a type of Cognitive Behavioral Therapy (CBT). However, emerging research suggests that secure attachment plays a crucial role in both the causation and the cure of OCD. In our own clinical experience, obsessions and compulsions have also proven to show an important relational function. While the history of OCD diagnosis and treatment has largely focused on the cognitive aspects of its presentation, is it possible that there is a relational basis of its cause?

Understanding OCD Through the Lens of Attachment Theory

Attachment theory, pioneered by John Bowlby, Mary Ainsworth, and many others in the 1950s-1980s, posits that early interactions with caregivers shape our sense of self and ability to form secure relationships. Secure attachment results from consistent, responsive caregiving, leading to a felt sense of safety and trust. Conversely, insecure attachment, resulting from inconsistent or neglectful care, leads to feelings of generalized anxiety and distress without apparent cause.

Recent research indicates what many clinicians have suspected for some time; that individuals with OCD often have histories of insecure attachment (Doron et al., 2009). Insecure attachment can manifest as either anxious or avoidant styles, both of which are characterized by heightened anxiety and difficulty managing distress—core features of OCD.

The Role of Attachment in the Development of OCD

It is likely that individuals with insecure attachment develop obsessive thoughts as a way to gain a sense of control over feelings of foundational insecurity. Because attachment insecurity is often experienced by the individual as a problem with themselves, rather than a problem in their attachment relationship, they often seek individual solutions to address it. Perhaps unsurprisingly, OCD usually centers on themes of safety, responsibility, and order—attempts to impose predictability on a world in which others are not a clear source of soothing or support. The compulsions of OCD may initially serve to alleviate this anxiety. For example, compulsively checking traffic reports to see if one has caused an accident in harm OCD may provide temporary relief from anxiety, but reinforces the behavior and creates a vicious cycle. Unfortunately, this cycle only serves to keep the person at a distance from others and trapped within their own overthinking.

The Curative Aspect of Exposure and Response Prevention (ERP): Secure Relating

ERP remains the frontline treatment for OCD. It involves exposing the individual to anxiety-provoking stimuli (exposure) and preventing the compulsive behavior (response prevention). Over time, this helps reduce the anxiety associated with obsessions and the need for compulsions. However, ERP does not explicitly discuss underlying attachment issues. In our clinical work and experience, it is likely that the effectiveness of ERP may lie not solely in the process of learning that the feared stimulus is not dangerous, but in fostering a positive self-concept through secure relating. When individuals with OCD are exposed to distressing thoughts, images, or sensations, the therapeutic process involves more than just reducing anxiety through repeated exposure. It involves learning that one can remain psychologically intact even in the face of the distressing stimulus. This psychological intactness implies maintaining a positive sense of self in the face of others. Therapists serve as secure attachments, providing a stable, supportive presence that allows individuals to confront their fears without feeling overwhelmed. This supportive environment helps clients develop a resilient self-concept, where they learn to see themselves as capable of handling distress without resorting to compulsions. In essence, the curative factor in ERP is the exposure to avoided content and the maintenance of a positive self-concept through secure relating, rather than habituation alone.

While ERP remains an essential treatment for OCD, attachment science appears to offer valuable insights into the disorder's cause and potential cures. Secure attachment may help better explain the underlying anxiety and emotional dysregulation that fuels OCD. Integrating attachment-based approaches with traditional ERP could greatly enhance not only our understanding of OCD, but help streamline treatment to address the most curative aspects of ERP, secure connection with a caring, responsive other.

Note: In writing this blog post, I utilized ChatGPT to gather research and insights on the topic, which helped inform and enhance the content. The ideas and final writing are my own. The image was generated by DALL·E. Both are AI systems developed by OpenAI.