Introduction
Obsessive–Compulsive Disorder (OCD) and Self-Regulation: As a counselling psychologist, I have learned that OCD is far more than a collection of idiosyncratic thoughts and rituals – it is often an attempt to cope with deep internal distress. Clinically, OCD is characterised by recurrent intrusive obsessions (unwanted thoughts, images, or urges) and repetitive compulsions performed to alleviate the anxiety those obsessions cause (APA, 2013). For example, a person might feel driven to wash their hands dozens of times (a compulsion) to neutralise a terrifying feeling of contamination (an obsession). These compulsions typically serve self-regulatory functions – they reduce anxiety or a sense of impending harm in the short term. Therefore, from a therapeutic standpoint, it is unhelpful to conceptualise these symptoms as mere “irrational” behaviors to be eliminated, but as adaptive responses the person’s psyche has developed to manage threat and distress. In this article, I reflect on using Attachment Informed EMDR for OCD within an integrative framework that includes cognitive-behavioral therapy (CBT), attachment-informed therapy, and evolutionary perspectives on self-regulation. My aim is to bridge theory and practice: to discuss current research and models of OCD while sharing insights from clinical experience, in a way that can be helpful to both professionals and clients.
An Integrative, Biopsychosocial-Evolutionary Lens: Modern psychotherapy encourages us to consider the biopsychosocial context of mental health – biology (e.g. genetics, neurophysiology), psychology (thoughts, emotions, behaviors), and social factors (relationships, culture) all shape a person’s struggles. OCD, in this view, is not an isolated quirk of the brain but a phenomenon emerging from a person’s entire life system. Evolutionary psychology further expands this lens: it prompts us to ask, could these “maladaptive” behaviors actually have an adaptive origin? There is a growing call to move away from pathologising labels and consider how a given behaviour or symptom might have been adaptive in the past or under certain conditions (Del Giudice, 2014; Johnstone et al., 2018; Maté & Maté, 2022; van der Kolk, 2014).
In my own practice and research, I try to have this always in mind, looking for the adaptive origin of seemingly “maladaptive behaviours”. In this article I will explore how OCD rituals can be conceptualised as understandable attempts to survive, self-soothe, or maintain stability given that person’s history, and as such, keeping this in mind can encourage clients to adopt a self-compassionate stance that can facilitate alternative ways at self-regulation. Within this framework, Obsessive-Compulsive Disorder (OCD) symptoms can be reframed as self-regulatory responses, where shame and attachment trauma often drive the anxiety experienced in OCD. Shame can arise from fears of being morally flawed or "bad," feelings of responsibility for causing harm or contamination, and experiencing socially unacceptable thoughts or impulses (Abramowitz & Jacoby, 2014; Veale & Roberts, 2014). Therefore, as Joyce Blake (2024) reported in her article, integrating Cognitive Behavioral Therapy (CBT) techniques with Attachment-Focused Eye Movement Desensitisation and Reprocessing (AF-EMDR) can address both surface symptoms and underlying attachment wounds that lead to difficulties in self-regulation, particularly concerning shame. Blake's case studies demonstrated that combining these therapeutic approaches facilitated significant improvements in clients with treatment-resistant OCD, highlighting the importance of addressing early attachment traumas to enhance self-regulation and reduce shame-driven compulsions.
Compulsions as an ‘Adaptive’ Self-Regulatory Strategies
It may seem counterintuitive to describe the compulsions characteristic of OCD "adaptive." After all, these can consume hours of a person’s day and cause significant distress. However, research and evolutionary perspectives suggest that OCD behaviors often develop as creative attempts to cope with perceived threats - essentially, survival strategies that have become maladaptive in modern contexts. For instance, some theorists have proposed that OCD and Post-Traumatic Stress Disorder (PTSD) lie on a continuum, with OCD rituals arising as coping strategies to reduce or avoid traumatic memories and feelings. This perspective is supported by studies highlighting the overlap between OCD and PTSD symptoms, suggesting that compulsive behaviors may function as attempts to manage trauma-related distress (Williams et al., 2011; Fontenelle et al., 2012). In other words, compulsive behaviours (such as checking locks repeatedly or strict ordering of items) may originally emerge to create safety and predictability in a chaotic or dangerous environment. Indeed, there is evidence linking OCD to adverse events in childhood (e.g. trauma, loss, or instability). In one study, Gershuny et al. (2003) found that many individuals with OCD had histories of abuse or traumatic stress, and they theorised that the OCD symptoms were initiated as a way to cope with trauma-related fear. Similarly, Miller and Brock (2017) review data suggesting OCD can develop as a consequence of childhood adversity.
From a life-history or evolutionary psychology standpoint, this makes sense – a young mind facing overwhelming threat (whether emotional or physical) may adapt by becoming hyper-vigilant and controlling of its environment, which in milder forms could be protective, but in extreme forms manifests as OCD (Del Giudice, 2014). This perspective aligns with the notion in my own doctoral research that what we label “symptoms” are often adaptive self-regulatory responses – ingenious if costly solutions the person’s system has constructed to handle earlier challenges (Flores, 2019). Participants in my research often described their problematic behaviors as ways to connect with others or cope with a lack of connection, and as means to maintain a sense of power or self-esteem in the face of threat. For example, one individual saw his checking compulsion (needing to ensure loved ones were safe) as an attempt to prevent the kind of loss he experienced as a child. Another viewed her elaborate cleaning rituals as the only way she knew to feel “worthy” and avoid the rejection she feared. Such narratives underscore that OCD rituals are meaningful when viewed in context – they reflect the person’s lived experience of what it took to survive or stay accepted. This adaptive reframing does not mean OCD should be left untreated; rather, it means our treatment should honour the protective purpose the symptoms serve, even as we work to replace them with healthier strategies.
From an evolutionary perspective, extreme anxiety traits can be seen as one end of a spectrum of survival strategies. A classic example is the “smoke detector principle,” where it is better (from a survival standpoint) to have many false alarms than to miss one real danger. OCD can be imagined as a smoke detector on overdrive – the mind is continually sensing potential threats (germs, mistakes, harm to others, etc.) and forcing the body to respond with rituals that signify safety (washing, checking, mentally reviewing).
In therapy, when we discuss evolutionary ideas such as OCD being an over-learned safety strategy – an automatic self-regulation habit their brain uses to deal with stress – I often see a sense of relief. It reduces shame and stigma when they realise “I’m not bad; my brain was trying to help me survive.” This understanding provides a compassionate foundation on which we can build new, more effective regulatory skills.
The Hidden Role of Shame and Attachment Trauma in OCD
OCD has long been treated as a fear-based condition, but in practice I frequently encounter shame being an unspoken emotion underpinning many clients’ obsessions and compulsions. Brené Brown (2012) defined shame as that “intensely painful feeling…of believing that we are flawed and therefore unworthy of love and belonging,” essentially a primal fear of disconnection and unworthiness of even existing. This toxic shame often germinates in early attachment experiences – how we were cared for (or not cared for) in childhood. Traditional cognitive-behavioral models of OCD emphasise how people attach catastrophic meaning to their intrusive thoughts (“Having a blasphemous thought means I’m an evil person!”) and then try to neutralize or suppress those thoughts with compulsions. What these models historically left out is why certain thoughts strike such a chord in the person’s core self-concept. In my experience, the answer is often shame rooted in attachment trauma. If a child grows up feeling fundamentally unsafe, unlovable, or responsible for others’ chaos, common in neglectful, inconsistent, or abusive caregiving environments, they may internalise beliefs like “There’s something wrong with me” or “I must be bad.” These implicit beliefs linger into adulthood and can attach themselves to intrusive thoughts when they arise. For example, a boy who was emotionally abused for minor mistakes might later develop obsessional doubt about accidentally causing harm, because any hint of wrongdoing triggers his deep fear of being a “bad person.” The compulsions (such as seeking reassurance or excessively checking that nothing bad happened) temporarily soothe that shame-based fear.
Research is increasingly validating these clinical observations, for example,the study by Gershuny et al., 2003) individuals with treatment-resistant OCD observed that reductions in OCD symptoms were associated with increases in PTSD symptoms, and vice versa, suggesting a functional connection between the two disorders. This interplay implies that OCD behaviors may serve as coping mechanisms to manage trauma-related distress. In another study, "Childhood emotional maltreatment, maladaptive coping and obsessive–compulsive symptoms", Visser et al. (2022) and colleagues found that individuals with a history of physical or verbal abuse in early life are more likely to develop ‘maladaptive’ coping mechanisms, which in turn are associated with increased obsessive compulsive symptoms suggesting that these behaviours develop as coping strategies to handle trauma-related memories and distress. Another study found that childhood emotional neglect was linked with adult OCD, likely because neglect impairs the child’s ability to self-regulate or self-soothe—skills normally learned through secure attachment (Boger, Ehring, Berberich, & Werner, 2020).
Developmental neurobiologists such as Allan Schore have described how attuned caregiving shapes an infant’s developing brain, particularly the right hemisphere systems involved in emotion regulation (Schore & Schore, 2007). Secure attachment relationships provide the relational co-regulation that supports the infant’s ability to develop stable self-regulation capacities. Conversely, if attachment is insecure or disrupted, the child may fail to internalise a stable sense of safety and struggle to regulate emotional arousal independently (Schore & Schore, 2007).
Gabor Maté (2012) similarly observed that children who lack responsive parenting often turn to substitute self-soothing behaviours - whether it be rocking, thumb-sucking, or later, more pernicious habits such as compulsive behaviours - to fill the void left by inadequate co-regulation from caregivers. Maté (2012) argues that these compensatory behaviours serve as the child's attempt to regain a sense of control and manage overwhelming emotional states. In this context, obsessive-compulsive rituals can be understood as evolved versions of these early self-soothing attempts. They represent the brain’s way of saying, “I will take control and calm myself, since no one is there to do it with me” (Maté, 2012; Schore & Schore, 2007). The compulsive behaviour offers a predictable means of regulating emotional distress in the absence of secure relational support.
Shame, in particular, thrives in secrecy and self-judgment, and OCD provides both in spades. People with OCD are often deeply ashamed of their obsessions (“What kind of person has thoughts about harming their own baby? I must be horrible!”). They go to great lengths to hide their thoughts and rituals, which unfortunately only fuels the shame cycle. Brown notes that shame needs three things to grow: secrecy, silence, and judgment – conditions often met in OCD sufferers’ lives as they struggle alone with their condition. This is one reason I believe that purely symptom-focused CBT, while crucial, may inadvertently overlook the role of shame.
Beyond Symptom Management: Revisiting CBT for OCD
Cognitive-behavioral therapy has been the gold-standard treatment for OCD for decades, and rightly so – techniques like Exposure and Response Prevention (ERP) have robust evidence behind them (NICE, 2005; Abramowitz, 2006). The flipside of this is that CBT for OCD steered away from anything resembling “psychodynamic” conceptualisations of early trauma or attachment issues. The emphasis was on the here-and-now: identify the distorted belief and correct it, or face the feared situation and realise it’s harmless. These strategies work for many, but in some cases they leave the shame wound untouched. I have had clients who, after textbook-perfect exposure therapy, could touch “contaminants” without panic but still felt “disgusting” or unworthy as a person at a deeper level. Many OCD clients come to see me (looking for a psychologist) after unsuccessful CBT, one client lamented that her previous therapy addressed the mechanics of what she needed to do (e.g. exposure and tolerating uncertainty) but avoiding any exploration on why or how the particular concern developed in the first place. Why does this matter? Because a substantial minority of OCD sufferers do not respond fully to standard CBT. Studies estimate about 40–50% of patients either refuse ERP, drop out, or continue to have significant symptoms after ERP (Foa et al., 2005; Loerinc et al., 2015; Ong et al., 2016). If a client has never learned to calm themselves when anxiety peaks – perhaps their caregivers exacerbated rather than soothed their distress – then ERP can feel like being thrown into the deep end without a life vest. They may white-knuckle through a few exposures but eventually quit, reinforcing a sense of failure.
An attachment-informed view suggests that we must address the relational injuries and shame beneath OCD if we want full healing. Paul Gilbert and colleagues point out that individuals with OCD often experience profound feelings of isolation, ‘abnormality,’ and unworthiness, accompanied by high self-criticism (Gilbert, 2017), all hallmark outcomes of shame and insecure attachment. Moreover, neurocognitive findings show that people with OCD can exhibit heightened sensitivity to expressions of disgust or anger from others – essentially, they expect and fear others’ contempt Mancini et al. (2004). This hypervigilance to social rejection cues again suggests an early template of interpersonal threat. From a compassion-focused therapy (CFT) perspective (Gilbert, 2010), the threat and self-protection systems are overactivated in OCD, while the soothing system (linked to self-compassion) is underdeveloped. Indeed, a recent pilot of CFT for treatment-resistant OCD found that cultivating self-compassion helped reduce OCD symptoms as well as associated fear of guilt and self-criticism (Moulding et al., 2021). The authors noted that giving patients tools to self-reassure and feel part of common humanity countered their tendencies to withdraw in shame and feel “beyond help”. What this all tells us is that shame is not just a byproduct of having OCD; it is often a driver of it. The more a person feels fundamentally defective, the more desperately they may cling to rituals that promise to “cleanse” or check away their feared defects. The therapeutic relationship is essential for providing the empathy, and validation that provides the safe space to explore and process the shame and attachment trauma underlying OCD, and learn to internalise a positive view of the self and experience self-compassion. A client who feels accepted by their therapist can start to internalise a new experience: “I am cared for even with my worst thoughts,” which counteracts the isolating fear of being unlovable (Brown, 2012). In this image, a therapist provides comforting support to a distressed client – illustrating how attunement and compassion in therapy help regulate the client’s nervous system and emotional pain.
In sum, CBT gives us essential tools for treating OCD, but if we rigidly avoid any “depth” conceptualisation, we risk missing the full picture of the person. If we ignore that dimension, we may inadvertently reenact the very dynamics that maintain the OCD (e.g., The client feels that, just as it was in childhood, they are being told to “just stop it” - reinforcing the shame and associated core beliefs). On the other hand, when we integrate CBT with a broader lens – attending to shame, using compassion, bolstering emotion regulation – treatment can become more flexible and humane without losing its effectiveness. This is where EMDR and related approaches come into play, as part of a co-formulated treatment plan between clients and therapists.
Attachment Informed EMDR for OCD - Healing Underlying Wounds
Eye Movement Desensitisation and Reprocessing (EMDR) therapy emerged as a breakthrough in the treatment of trauma (Shapiro, 1989), and over the years its applications have broadened to other conditions, including OCD (Böhm, 2021; Nazari et al., 2011). EMDR is an eight-phase psychotherapy approach that uses bilateral stimulation (often side-to-side eye movements) while the client briefly focuses on distressing memories or thoughts, with the goal of reducing their emotional charge and fostering adaptive reconsolidation of memory (Shapiro, 2001). In essence, EMDR helps the brain reprocess stuck experiences – it’s often described as unlocking the traumatic memory network and allowing the brain to digest it properly, much like it would an everyday experience.
Early results are promising: one randomised controlled trial found EMDR significantly more effective than SSRI medication in reducing OCD symptoms (Nazari et al., 2011), and another study found EMDR equally as effective as Exposure and Response Prevention (ERP), with treatment gains maintained at a 6-month follow-up (Triscari et al., 2015). While research is still emerging, these findings suggest that EMDR can be a powerful augmentation to CBT, or even serve as a standalone treatment for some OCD presentations (Böhm, 2019). What makes EMDR especially suited for an integrative approach is its flexibility in targeting not just surface symptoms, but the past experiences and core beliefs underpinning those symptoms.
In my practice, after we create a shared case formulation (combining the client’s narrative with evidence-based models), we often identify certain key memories or emotional themes feeding the OCD. For example, a client with scrupulosity (religious OCD) might reveal a childhood memory of being harshly shamed by a parent or clergy for a minor misbehavior – a memory that still carries a charge of “I am evil/sinful.” With standard CBT, we might note that as a hypothesis but not have a method to explicitly work through it. With EMDR, that memory can become a target for reprocessing. Flexible use of EMDR within a co-formulated plan means we don’t abandon CBT techniques; rather, we weave them together. For instance, I might begin therapy focusing on stabilisation: teaching the client basic CBT skills (managing cognitive distortions, practicing gradual exposure to very low-level triggers) and teaching EMDR-based resources (in attachment-focused EMDR, as described by Parnell (2013), there is heavy emphasis on resource development and installation before trauma processing). We create a “safe place” imagery, strengthen the client’s internal nurturing and protective figures (imaginary or real), and practice techniques to dial down distress (grounding exercises, breathing linked with bilateral taps, etc.).
Once a foundation of safety is established, EMDR and CBT can work in tandem. The co-formulation with the client might designate certain sessions for EMDR trauma processing and others for behavioral exposure practice, depending on what is needed. For example, in treating a man with contamination OCD rooted in bullying experiences, we alternated between EMDR sessions focused on memories of being humiliated at school (which targeted his core belief “I’m disgusting”) and in vivo exposure homework where he’d deliberately do something “messy” (like get mud on his shoes) and not wash – but now with a different mindset. After EMDR, he reported that confronting dirt no longer provoked the same visceral shame; it was as if we had defused the emotional bomb underlying the dirt fear. Interestingly, addressing those memories also seemed to reduce the frequency and intensity of his intrusive thoughts in general. This aligns with what I’ve seen elsewhere: healing an old wound can have a ripple effect on multiple OCD symptoms, because you are effectively removing a central organising fear. It also aligns with polyvagal theory, which suggests that when we resolve trauma, the nervous system can shift out of chronic threat mode into a more regulated state (Porges, 2011).
Importantly, this integrative approach explicitly addresses the shame and relational trauma we discussed earlier. During EMDR processing, it’s not uncommon for clients to spontaneously connect dots: “I feel this sense of panic in my chest – it’s the same as when I was little and felt completely alone.” As they process, they might cry and release grief or anger tied to those moments. My role is to offer a regulated, compassionate presence through that wave of emotion, effectively providing a corrective relational experience (“You’re not alone now; I’m here with you and you are safe”).
Francine Shapiro distinguished between “big-T Traumas”—criterion-A traumatic events such as abuse, accidents, or natural disasters—and “small-t traumas,” which are the cumulative losses, rejections, and humiliations that can be part of everyday experience for many children and can leave deep psychological wounds (Shapiro, 2001). Clients with Obsessive-Compulsive Disorder (OCD) often have multiple small-t traumas that have neither been validated nor processed within the context of a secure attachment relationship (Shapiro, 2001; Parnell, 2013). EMDR provides a therapeutic framework for targeting and reprocessing these experiences as legitimate contributors to ongoing distress (Shapiro, 2018).
In her model of Attachment Informed EMDR, Laurel Parnell (2013) argues that clients with insecure attachment histories benefit from a more permissive, relationally attuned approach. Within this model, the therapist may interweave nurturing statements or jointly create reparative imagery with the client - for example, imagining going back in time to comfort the child-self during a painful incident (Parnell, 2013, 2019). This adaptation does not violate EMDR protocols but rather modifies the standard approach to ensure that clients are not retraumatised by overwhelming affect (Parnell, 2013). Through this process, therapists can help clients directly address internalised shame, supporting the development of positive self-talk to soothe their wounded parts (Parnell, 2019). This flexible, titrated use of EMDR is far from the rigid, manualised “follow the script” stereotype sometimes associated with structured therapies. It requires therapists to be fully present, creative, and client-centred, constantly attuning to what interventions will best serve the client in each moment (Parnell, 2013, 2019).
Polyvagal Theory and Evolutionary Self-Regulation - Concluding Thoughts.
Underneath successful therapy - whether CBT, EMDR, or otherwise - lies the foundation of a felt sense of safety. Stephen Porges’ polyvagal theory underscores safety as central to therapeutic healing (Porges, 2011). It explains how the autonomic nervous system continuously shifts between states of safety (ventral vagal activation, facilitating social engagement and self-regulation) and defence (sympathetic fight/flight or dorsal vagal shutdown, characterised by dissociation and immobilisation) (Dana, 2018; Porges, 2011).
Polyvagal theory introduces the concept of neuroception – the body’s unconscious detection of safety or danger (Porges, 2011). Through that lens, someone with OCD likely has an overactive neuroception of danger, scanning their inner and outer world for the slightest sign of threat. Maybe as children they lived in an environment where the danger was real (an alcoholic parent’s unpredictable behavior) or where they had to “walk on eggshells” to avoid shame and anger. Their nervous system learned that the world (and other people) are unsafe. This sets the stage for persistent sympathetic arousal (anxiety, panic, compulsive “action” to fight or flee an invisible threat) (Dana, 2018; Maté, 2012).
I believe that shame can be conceptualised as dorsal vagal shutdown, a dissociative state characteristic of profound shame experiences (Dana, 2018; Porges, 2011). In my experience Clients with OCD often present primarily with chronic anxiety, rather than depression, as their obsessive-compulsive behaviours serve to keep shame at bay as these have a self regulatory function protecting them from the unbearable collapse associated with shame (Boger et al., 2020).
From an evolutionary and biopsychosocial perspective, this integrative approach addresses multiple dimensions simultaneously: biologically through neural plasticity and autonomic regulation, psychologically through cognitive restructuring and trauma processing, and socially through repairing attachment wounds in therapy. Ultimately, integrating EMDR within a CBT, attachment, and evolutionary framework is as much an ethical choice as a clinical strategy. It embodies a commitment to understanding the entire person, fostering empowerment and hope, and moving beyond mere symptom relief to genuine healing. In my doctoral research, I proposed that OCD symptoms can be viewed from an adaptationist perspective—as evolved self-regulatory strategies that once served protective functions in response to early life stressors, even if they have become maladaptive in the present (Flores, 2019). This approach can bring freedom from OCD, especially in those “treatment-resistant” cases whose traumatic upbringing is not addressed in therapy because they don’t meet the criteria for PTSD, leaving their small-t traumas untouched. Through this compassionate adaptationist understanding, we accompany clients through their darkest feelings of shame, helping them experience firsthand that healing from deep-seated wounds is not only possible but profoundly transformative.
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