This post was co-authored by Melissa Mose, LMFT.

Obsessive-compulsive disorder (OCD) is a cycle characterized by unwanted, intrusive thoughts, feelings, images, and urges (obsessions) that cause distress, followed by repetitive behaviors or mental acts (compulsions) that aim to relieve distress. Common obsessions involve contamination, harm, morality, or symmetry, while compulsions include excessive checking, washing, ordering, counting, ruminating, and seeking reassurance.

Today we know that OCD arises from brain circuits—particularly those connecting the orbitofrontal cortex, anterior cingulate, and striatum—that have become biased toward detecting threat and generating uncertainty signals while struggling to register safety and completion. This reflects a combination of genetic predisposition and developmental factors; stressors may activate this vulnerability, but are not always necessary or identifiable.

The first-line, evidence-based treatment for OCD is called exposure and response prevention (ERP). When skillfully delivered, it provides roughly 50 percent symptom relief in at least 75 percent of the clients who complete a course of treatment. Unfortunately, far too many individuals with OCD are unable to access trained OCD specialists, or they are unable to fully participate or follow through. Medications are most effective when combined with ERP.

In her new book, OCD expert Melissa Mose (a co-author of this post) looks at the OC cycle through the lens of Internal Family Systems (IFS), a therapy model that views the mind as a community of parts. According to IFS, vulnerable parts in the neurotypical brain develop negative identity beliefs like I am worthless, disposable, unlovable in response to interpersonal or existential insults, and then other parts step in protectively. Proactive protectors (called managers in IFS) keep the injured part (an* exile*) out of sight and mind while working to be good and ward off future injury. When their inhibitory inner shaming becomes oppressive, reactive protectors (firefighters) activate to douse emotional flames with some pleasurable disinhibition like substances, sex, entertainment bingeing, gaming, gambling, and the like; or some extreme big distraction like excessive work hours and overly strenuous exercise routines.

With OCD, differences in brain circuitry create alerts and mental intrusions that can be shockingly violent, sexual, and guilt-inducing in nature. IFS sees obsessional manager parts responding with a slew of alarming what-ifs*?* (What if you’re a monster? What if you killed someone?) They escalate until reactive OC firefighters activate with compulsions (let’s check). But when those unanswerable intrusions continue, the cycle repeats. Along the way, this dynamic often causes vulnerable exiles to wonder if they are the problem: *Was I careless? Am I dangerous? Did I hurt someone? *When this happens, their uncertainty becomes additional fuel for obsessional managers, further intensifying the cycle.

While traditional ERP aims to calm fearful parts by blocking safety-seeking behaviors and promoting new learning, IFS aims for vulnerable exiles to experience secure internal attachment. In turn, this convinces protectors that the Self can discern genuine threats and offer reasonable protection. The exile’s attachment to the Self would typically liberate protective parts from their jobs. In our experience, IFS therapy for OCD may progress along this route if the OC cycle began when interpersonal trauma activated intrusive thoughts or images. But more commonly, OC brain circuitry—whether it is the chicken or the egg—disrupts this typical sequence, and the exile’s emotional recovery seems less relevant to OC protectors. In these cases, the project of therapy shifts to helping healed exiles learn that OC protector activity isn’t about them—it’s circuit noise, not meaningful feedback about their worth or safety; helping OC protectors ignore intrusions; and encouraging all parts to follow the Self’s lead.

Who Could Benefit?

While ERP has been the safest, simplest, and most successful treatment for OCD to date, many people cannot access a well-trained ERP clinician, and others may wish to go beyond symptom management to healing their exiles. In our experience, ERP in combination with IFS (which Mose dubs Self-led ERP or SL-ERP) can fulfill this broader role. While SL-ERP can benefit anyone with obsessive-compulsive patterns, it is particularly well suited for:

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• treatment-resistant clients who haven’t responded fully to standard approaches

• trauma survivors who need inner relationship repair in preparation for taking external risks

• individuals with high nervous system sensitivity whose attunement abilities have been pathologized

• individuals with multiple diagnoses or extra challenging life circumstances

Evidence Supporting the Use of IFS for OCD

Critics might worry that combining IFS with ERP will dilute the effects of the latter. However, research on therapeutic alliance, trauma-informed care, and individualized treatment all support the IFS approach, which develops a strong positive therapeutic alliance; addresses trauma at a tailored pace; provides experience-near, individualized attention; and highlights self-compassion, which is notably beneficial for OCD. Statistics indicate that the therapist’s delivery style and ability to develop a positive therapeutic relationship are both vital to the success of ERP.

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Conclusion

Like other treatments that developed with the advice and consent of traumatized people, IFS used exposure strategies from the beginning. By extension, SL-ERP incorporates all of the active ingredients that make ERP effective:

• Practicing mindful, present-centered attention
• Decentering to differentiate between thoughts and feelings
• Accessing enough of a sense of safety to tolerate distressing feelings
• Approaching rather than avoiding feared experiences
• Challenging safety behaviors and compulsions
• Choosing valued experiences despite uncertainty
• Incorporating new behaviors in real-world contexts

To date, there is no research on SL-ERP. In practice, we find that clients with OCD, particularly those with a co-occurring history of interpersonal trauma, value the way SL-ERP honors their mind’s inherent wisdom and empowers their Self to lead despite anxiety. Finally, not least, when we trust clients and access our Self-energy, we therapists also benefit.

References

Mose, M. (2025). Internal Family Systems Therapy for OCD: A Clinician’s Guide. Routledge Press.

Launes, G., Hagen, K., Sunde, T., Öst, L.-G., Klovning, I., Laukvik, I.-L., Himle, J. A., Solem, S., Hystad, S. W., Hansen, B., & Kvale, G. (2019). A Randomized Controlled Trial of Concentrated ERP, Self-Help and Waiting List for Obsessive-Compulsive Disorder: The Bergen 4-Day Treatment. Frontiers in Psychology, 10, 2500. https://doi.org/10.3389/fpsyg.2019.02500