The Unified OCD Model - An Integrated Approach to the Formulation and Treatmentof OCD 

The Unified Model of OCD draws on clinical and academic research conducted over the last 75 years to present an integrated understanding of the different cognitive and behavioural factors that maintain Obsessive Compulsive Disorder. This includes psychological concepts from the original OCD Phobic Model, Exposure and Response Prevention (ERP), Inhibitory Learning, the Cognitive Appraisal Model, Metacognitive Therapy, Acceptance and Commitment Therapy  and more recently, Inference Based Therapy. Whilst the concepts covered in these different approaches are numerous and complex, the Unified Model integrates these distinct contributions into a simple four-part model. This provides a coherent basis for integrating the latest research into Obsessive Compulsive Disorder, whilst providing flexible access to the best treatment options from these different models. 

Note: The following information provides a detailed understanding of the psychological processes behind the OCD cycle. It should however be noted that clients would not normally be expected to read and immediately understand these processes without the support and assistance of a properly qualified professional.

Our specialist OCD treatments are led and supervised by William Phillips, our Principal Psychotherapist. In addition to his work at, William consults with a number of other private clinics and provides clinical supervision to other Psychologists and Cognitive Behavioural Psychotherapists. You can learn more about William here. 

The Unified Model

Whilst a number of different OCD presentations and subtypes have been identified over the years, all forms of OCD follow the same basic psychological pattern. This is presented as a four-part process involving relevant background factors, triggers / intrusions, obsessional doubts and compulsive / avoidance behaviours:

Background Factors

Whilst Obsessive Compulsive Disorder is maintained by a number of faulty thinking patterns and compulsive behaviours, research indicates that early life experiences, family, genetic, trauma-related, cognitive and behavioural factors can act as predisposing factors in the development of OCD. Identifying and where appropriate, addressing some of these background factors may support effective treatment. This is particularly relevant where early formed maladaptive beliefs, irrational assumptions and unresolved traumatic experiences continue to maintain the individual's vulnerability to OCD doubts.

The Trigger / Intrusion

This initial phase is represented in the folded edge “Rectangle” shape at the top of the OCD model. In this phase, hypervigilant scanning and selective attention to internal or external cues, cause normal doubts or hypothetical possibilities to be automatically interpreted as potential threats or dangers. Triggers or OCD cues can include situations, events, images, memories, feelings and body sensations. Over time and through the processes of operant learning, classical conditioning and inferential confusion, these normal triggers become synonymous with a “Primary Doubt”. E.g. leaving the house and being responsible for a break-in or house fire. Touching a door handle and being contaminated by germs or chemicals. Noticing an attractive person and doubting one’s own sexual preferences. Seeing a child and fearing perverse or shameful intentions. 

The problem is, that the primary doubt becomes tacit and automatic, passing from the trigger stage into the obsessional doubting stage, where it is supercharged and weaponized to such an extent that it leads to intolerable levels of distress. Whilst the psychological processes of operant and conditioned learning have long been acknowledged as behavioural factors in the development of OCD, research into a special form of cognitive therapy known as Inference Based Therapy (IBT), has also identified problems with the psychological processes of internal doubting, as a significant aspect in the maintenance of OCD. This process of “Inferential Confusion” which is relatively new in the field of OCD treatment, deserves it’s own brief footnote:

Inferential Confusion

In addition to the behavioural affects of operant learning and classical conditioning, (covered in the second and third phases of our cycle ), the  “Primary Doubt” is established and strengthened through a psychological process known as “Inferential Confusion”. 

This is an automatic  cognitive process taking place at the initial phase of the cycle. It involves an abandonment of the evidence and an over investment in remote or imagined possibilities at the cost of the individual’s own common sense. 

To understand how this works, we need to draw the distinction between external rational doubts and internal irrational doubts. External rational doubts are normal uncertainties based on balanced and observable data. So for example we might pause to consider our forgotten umbrella when dashing for a late meeting and noticing dark clouds in the sky. Do we go back for the umbrella which may cause further delays, or do we take the chance of turning up to our meeting wet through and soggy? 

When we make healthy judgements or gambles about normal external and observable uncertainties, we refer to this as rational doubt. On the flip side, irrational doubts involve automatically abandoning the evidence and established common sense in support of internally imagined possibilities. Drawing on the clouds and umbrella metaphor, not only do we over estimate the chances of getting wet when the forecast is clear and dry, we might “magically” and tacitly associate the absence of our umbrella with the increased likelihood of rain. 

In our OCD model, the “Primary Doubt” is always an irrational, internally synthesized  doubt synonymous with a normal or ordinary trigger. The problem is that this process becomes automatic and pervasive over time. It passes unnoticed or unchallenged from the first trigger phase into the second obsessional phase. It slips under the radar of conscious awareness into the obsessional phase of the OCD cycle, where it is inadvertently validated and reinforced through obsessional thinking and compulsive behaviour. 

Obsessional Doubts

Once the “Primary Doubt” passes into the obsessional doubting circle, (represented by the circle in our model), it is subjected to over-evaluation, fixation, worry, distortion, amplification and misinterpretation. This weaponizes and escalates the doubt and leads to significant emotional distress. 

The metacognitive processes of thinking about thinking, mean that the significance, importance  and impact of thoughts are over-evaluated. OCD involves worry about the meaning of worry itself. 

The process of “Cognitive Fusion”, which is a core psychological process in Acceptance and Commitment  Therapy, is also a key driver of obsessional doubt in the “Circle” stage of our model. Fusion causes thoughts to become sticky and caught up in attention and emotional resistance. . This increases the intensity and perceived seriousness or literal meaning of thoughts. Fusion translates and classifies thoughts as facts or realistic predictions, rather than loaded internal perceptions or judgements. 

Research by the International OCD Research foundation, has also identified a number of OCD-related thinking patterns that validate and supercharge the primary doubt. These include Over-estimation of Threat, Thought Action Fusion, Perfectionistic Thinking, Responsibility Bias, Uncertainty Intolerance and  Catastrophizing. These thinking habits or distortions compound and exaggerate the worry, rumination and self-questioning, leading to high levels of anxiety, shame, guilt, embarrassment and disgust. Obsessions directly activate compulsive and avoidance behaviours in an attempt to gain relief from the obsessional distress. 

OCD Compulsions

Repetitive checking, avoidance, neutralizing, high-control and ritualistic behaviours are commonly referred to as compulsions in OCD. In our model, compulsions are represented in the “Square”. 

Compulsions can be external or “Overt” , such as checking locks and switches, excessive cleaning, repeating  and comparing. Internal or “Covert” compulsions can involve mental acts, rituals or routines such as thought neutralizing, memory checking, the use of “cancelling” or “magic” words, body scanning  and sensory checking. 

Whilst compulsions create a temporary sense of relief, outlined in the following section on Operant and Conditioned learning, they also lead to significant functional impairment. OCD compulsions and avoidance behaviours progressively interfere with the conduct of normal daily life and consume significant amounts of time and energy. The relentlessness of compulsions causes problems at work, at home and in key personal relationships.

Operant and Conditioned Learning

OCD is reinforced by two important psychological processes known as Operant and Conditioned learning. These processes create invisible psychological forces that maintain and validate the OCD cycle. These forces are represented by the return arrows between the “Circle” and the “Square”, and the arrow connecting the “Square” back to the “Rectangle” at the top of the OCD cycle. 

In our model, the relationship between the obsessions and compulsions is represented by the arrows labeled “Distress” and “Relief”. Obsessional doubts may for example, lead to feelings of anxiety and uncertainty about germs or security. This distress is relieved through cleaning and checking behaviours, also providing a temporary proxy for safety and control. Operant learning  leads to engrained and addictive compulsions by providing the elusion of immediate relief from the obsessional doubt in the “Circle”. 

Of course the relief is not real, it is a proxy or temporary form of relief. The problem is that this also inadvertently prevents the disconfirmation of the obsessional doubt and creates an automatic association between the compulsion in the “Square” and the trigger in the “Rectangle”. This association between the compulsion and the trigger is a process known as “Conditioned Learning”, in which the trigger and compulsion become automatically and tacitly associated. 

Examples might include leaving the house and automatically taking pictures of the lock, touching handles and using sanitizer, seeing a vulnerable person and automatically scanning for feelings of arousal. 

This association between the compulsion and the trigger eventually becomes so intertwined, that individuals often report an awareness of the compulsion, without consciously acknowledging the triggering event or situation. 

This process of association also reinforces the primary doubt implied by the compulsion, which in turn maintains the vicious OCD cycle. In this way, OCD can be viewed as a three-part cycle, reinforced through a number of faulty thinking processes and habitual behavioural patterns. The problem is that for every increment of short-term relief or certainty gained through the compulsion, OCD trades an increment of long-term reinforcement. 

This trade-off between relief and reinforcement leads to chronic psychological symptoms. The purpose of cognitive and behavioural Therapy is to learn new thinking and behavioural techniques to break the cycle and establish healthy and adaptive coping strategies. 

These strategies include cognitive reappraisal of faulty thinking, learning how to identify and unhook from obsessions, graded exposure to feared situations and a process known as “Inhibitory Learning”. These strategies are covered under the section on Cognitive and Behavioural treatment. The first step in this process and the purpose of this material, is to understand how OCD is maintained in order to learn how to disrupt, break and replace the OCD cycle.

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