Can Psychotherapy Help with Intrusive Thoughts and OCD?

When understanding yourself helps — and when it becomes part of the cycle

If you experience intrusive thoughts, you may spend a surprising amount of time trying to understand what they mean.

You might find yourself thinking about why a particular thought has appeared, what it says about you, whether you really feel the way you think you should, or why you can't seem to let something go.

You might replay conversations to work out whether you upset someone, question your feelings towards a partner, worry about whether you are a good person, or repeatedly go over something that happened in the past because you aren't sure what it means.

Sometimes this kind of self-reflection can be useful. Understanding yourself, your relationships and the experiences that have shaped you can be an important part of therapy, and can help you recognise patterns that you may not have been aware of before.

But there is a difference between understanding an intrusive thought and trying to solve it. You might begin by asking a reasonable question about an experience, only to find yourself repeatedly analysing it, checking your feelings, seeking reassurance or trying to reach a level of certainty that never quite feels sufficient.

For some people, these patterns form part of OCD. For others, similar cycles of rumination, reassurance seeking and difficulty tolerating uncertainty can occur in the context of anxiety or other difficulties.

When the desire to understand becomes part of the cycle

The difficulty is that the desire to understand can sometimes become another way of trying to achieve certainty.

What begins as an attempt to make sense of yourself can gradually become a search for an answer that feels completely certain. You may keep analysing, checking, comparing or asking yourself the same question in slightly different ways, hoping that eventually you will reach a point where you no longer have any doubt.

This is one of the reasons intrusive thoughts and OCD raise some interesting questions about psychotherapy. When does self-reflection help, and when does it become another way of keeping the cycle going?

There is an important place for approaches such as Exposure and Response Prevention (ERP), which can help people change the patterns of responding that maintain OCD. But that doesn't necessarily mean that psychological understanding has no place in therapy.

The two don't have to be alternatives. They can complement one another, provided we can recognise when exploring yourself is helping you develop greater awareness and freedom, and when it has become another attempt to find an answer that will finally make you certain.

Why understanding yourself can be helpful

There can sometimes be an unnecessary divide between psychological understanding and practical change.

With OCD, there is good reason to focus on the things that keep the cycle going, particularly compulsive behaviours and mental rituals. But that doesn't mean that understanding yourself has no place in therapy.

There is an idea in CBT that you don't need to know how you got into a hole to get out of it. This can be a helpful way of thinking about OCD treatment: you don't necessarily need to understand the origin of every thought before you can learn to respond differently to it.

At the same time, nobody is simply a collection of symptoms. We are all shaped by our experiences. Our relationships, family environments, attachment experiences and the ways we have learned to cope can influence how we see ourselves and other people, as well as how we respond when we feel vulnerable, uncertain or under threat.

For some people, psychotherapy involves exploring these experiences and relationships, making sense of patterns that have developed over time, or understanding why particular difficulties continue to affect the way they see themselves and other people.

There is no reason that someone experiencing OCD or intrusive thoughts should be excluded from this kind of work simply because they also need to address compulsive patterns.

You may have experienced difficult or traumatic relationships, rejection, loss or other experiences that continue to affect you. Exploring these experiences can be valuable in its own right, while also helping you understand why particular fears, themes or ways of responding may have become important to you.

The aim isn't necessarily to find one explanation that will make the intrusive thoughts or OCD disappear. It is about developing a fuller understanding of yourself while recognising when the process of trying to understand has itself become part of the problem.

When self-reflection becomes rumination

The difficulty with intrusive thoughts, anxiety and OCD is that the same capacity for reflection and analysis that can be useful can sometimes become part of the problem.

You might start with a reasonable question such as:

Why does this particular thought bother me so much?

But the question can lead to another, and another:

What does it mean that it bothers me? Where did it come from? Does the way I reacted tell me something about myself? What if I'm misunderstanding it? How can I know that I've understood it properly?

The same thing can happen with relationships or social situations. You might replay a conversation to work out whether you offended someone, analyse your feelings towards your partner to establish whether you really love them, or repeatedly examine your behaviour to determine whether you are actually a good person.

At some point, the process may stop being about gaining useful insight and become an attempt to reach a feeling of certainty.

This can be difficult to recognise because the thinking itself may appear thoughtful or psychologically sophisticated. You may genuinely be interested in understanding yourself, and you may have spent a great deal of time reflecting on your experiences. That doesn't mean that all reflection is rumination.

The question is more about what the thinking is doing.

Is it helping you develop a broader understanding of yourself and giving you more freedom in how you respond? Or are you repeatedly returning to the same question because you feel that you need to find an answer before you can feel okay?

With OCD, those two processes can look very similar.

When therapy itself becomes part of the cycle

The same distinction is important within psychotherapy.

It can be tempting to believe that if you can understand an intrusive thought properly, identify exactly where it came from or work out what it really means, you will eventually feel certain enough to let it go.

A therapist could inadvertently reinforce this by spending session after session analysing the content of an obsession, providing reassurance or trying to establish exactly what a particular thought says about you.

That doesn't mean that exploring the origins or meaning of something is always unhelpful. There are many situations where going deeper can be an important part of therapy.

The issue is whether the exploration is helping you understand yourself or whether it has become another way of trying to resolve uncertainty.

This is why it can be useful to pay attention not just to what we are talking about in therapy, but to what the process of talking is doing. Sometimes going deeper can open up something genuinely useful. At other times, continuing to analyse may simply give the cycle another opportunity to ask the same question in a slightly different form.

These questions are particularly relevant when working with OCD, where the search for certainty can become central to the difficulty. But similar patterns can occur more broadly in people who are highly anxious, prone to overthinking or feel a strong need to make sense of their experiences.

How ERP can help — and what comes afterwards

Exposure and Response Prevention (ERP) is an evidence-based approach for OCD and can be an important way of disrupting the cycle.

The principle is that you gradually face situations, thoughts, sensations or uncertainties that trigger OCD while reducing the compulsive responses that normally follow. Over time, this can help you learn that you don't need to perform the compulsion every time uncertainty or anxiety appears.

Those compulsive responses aren't always obvious from the outside.

OCD can involve visible behaviours such as checking, washing or repeatedly seeking reassurance, but compulsions can also take place almost entirely in the mind. Mental reviewing, analysing, comparing, replaying conversations, checking how you feel, mentally testing yourself and repeatedly trying to reach an answer can all become compulsive responses.

For someone whose OCD is predominantly mental, this can be particularly important. The absence of an obvious physical ritual doesn't necessarily mean that there isn't a compulsive process taking place.

ERP can therefore be an important part of learning to step out of that process. Rather than continually trying to settle the question, you begin to practise allowing uncertainty to be there without responding to it in the way OCD demands.

But disrupting the OCD cycle doesn't necessarily mean there is nothing else to explore.

You can make significant progress with OCD and still find that difficulties in your relationships, self-worth or sense of yourself remain.

None of this means that ERP hasn't worked, or that treating the OCD wasn't important. It is simply a recognition that OCD is something a person experiences; it isn't the entirety of who they are.

Psychological depth and practical change

This is the position I bring to my work with intrusive thoughts and OCD.

I incorporate approaches including ERP and ACT where they are likely to be helpful, and I pay attention to the ways in which rumination, checking and reassurance seeking can maintain difficult cycles. If compulsive patterns are keeping someone trapped, addressing those patterns is important.

At the same time, I don't see the answer as simply stopping at symptom management. I'm interested in understanding the person experiencing the intrusive thoughts or OCD, including the relationships, experiences and patterns that have shaped how they see themselves and respond to the world.

Sometimes that means working directly with the cycle of intrusive thoughts, rumination or compulsions. At other times, particularly once there is more space from these patterns, it can mean exploring other aspects of your life and experience in greater depth.

The two approaches can support one another. ERP can help create freedom from the OCD cycle, while psychotherapy can provide an opportunity to understand what you want to do with that freedom.

You can become more aware of yourself without understanding everything. You can explore your past without finding a definitive explanation for your present. And you can learn to live with uncertainty without giving up on the process of understanding yourself.

Understanding yourself can be valuable, but you don't have to understand everything before you can move forward.

Considering therapy for intrusive thoughts or OCD?

If you're considering therapy for intrusive thoughts, OCD or related patterns of rumination and anxiety, an initial conversation gives us an opportunity to talk about what you're experiencing, what you're looking for and whether my approach might be helpful.

You don't need to have everything worked out before we speak.

Arrange an initial conversation