Surrender, disidentification, and reappraisal: a qualitative comparison of psilocybin responders and non-responders in treatment-resistant OCD.

Introduction: Psilocybin treatment has shown promise for treatment-resistant obsessive-compulsive disorder (OCD), yet clinical response is variable. Little is known about the subjective experiences associated with divergent outcomes or the psychological processes differentiating responders from non-responders. Materials and methods: A qualitative case comparison was conducted using semi-structured interviews from six participants enrolled in a randomized controlled trial of single-dose psilocybin with psychological support for treatment-resistant OCD. Participants were purposively selected to contrast three responders with marked symptom improvement and three non-responders with minimal improvement or worsening symptoms. Interviews were conducted approximately 1-2 months post-dosing and analyzed using reflexive thematic analysis. Results: Four dialectical themes captured key contrasts between responders and non-responders: 1) Surrender vs. Control, 2) Disidentification with OCD and Self-Compassion vs. Overidentification with OCD, 3) Emotional Breakthrough vs. Emotional Containment, and 4) Reappraisal of OCD as Inconsequential vs. Sustained Conviction in OCD. Among responders, surrender during the acute session appeared to enable subsequent psychological shifts. The self was separated from OCD while self-compassion was developed; emotions were experienced directly in the body without the usual cognitive filtering; and OCD-related concerns were spontaneously reappraised as arbitrary and inconsequential. Among non-responders, control was maintained or surrender was experienced as overwhelming; identification with OCD and persistent self-criticism remained; difficult emotions were avoided or accessed without lasting breakthrough; and conviction in OCD's logic and demands was maintained or intensified. Discussion: The distinction between intellectual insight and embodied change emerged as central: responders described viscerally felt insights that spontaneously shaped behavior, whereas non-responders articulated understanding without corresponding change in feeling or action. Across themes, surrender during the acute session appeared to enable subsequent shifts in self-concept, emotional processing, and reappraisal of OCD as inconsequential. Therapeutic benefit may depend on the quality of psychological engagement-particularly the capacity to surrender, tolerate intense emotion, and translate insight into behavioral change-rather than experiential intensity alone. The distinction between intellectual insight and embodied change emerged as central to understanding differential response.