1. EVERYONE has weird, unwanted intrusive thoughts

People with OCD almost always have a huge sense of guilt or shame about the intrusive thoughts they experience, but a strong evidence base shows just how common unwanted intrusive thoughts (UIT’s) are in the general population. Sharing this research with clients is usually a game changer.

Radomsky et al^[1] give arguably the most impactful data so far. Across 6 continents and 777 non-clinical participants, the study showed that 93.6% of people experienced UITs over the previous 3 months. The themes included thoughts of harm, sexual thoughts, immoral or religious thoughts, thoughts about doubt, and contamination thoughts as well as a range of others – all present in the general population across the world, as part of a normal human experience.

This research remains an important cornerstone of CBT for OCD. It helps clients challenge the idea that having UITs in some way makes them bad, deviant or unworthy of compassion. The idea that these thoughts are universal is often a huge relief to clients who have been holding onto a sense of shame, guilt and secrecy about their thoughts for a long time. It allows clients to begin viewing themselves through a more compassionate, evidence-informed lens, paving the way for effective therapeutic change.

Practical takeaway: bring the data into the room. Sharing concrete research on the universality of intrusive thoughts can powerfully reduce shame and create space for real therapeutic change.

2. EVERYONE has compulsions

A common challenge in the Exposure and Response Prevention (ERP) component of CBT for OCD is that clients frequently have very high expectations of themselves and experience a sense of failure if they have ‘given in’ to a compulsion. This can be compounded by the nature of ERP itself, which explicitly asks clients to resist their compulsions – often as homework. As therapists, it is important to name and challenge this form of ‘recovery perfectionism’ as I like to call it.

It is often useful to remind clients that everyone occasionally goes back to the front door to check whether they have locked it, or pops downstairs because they are worried they may have left the iron on or knocks on wood when a scary thought pops into their mind. From a CBT perspective, it is vital to clarify that occasionally giving in to compulsions is not a problem. It is only when the compulsions become so frequent that they cause distress and interfere with life that that they become clinically significant. Helping clients relinquish the idea of a future “compulsion-free” state is often key to their continued engagement in ERP. Once clients are able to grasp this, their ability to be kinder to themselves and less self-critical in turn benefits their continued recovery.

Practical takeaway: name recovery perfectionism when you see it. This helps clients stay grounded in real-world progress, not imagined perfection.

3. EVERYONE has to deal with uncertainty

A very common problem for people with OCD is “better safe than sorry” thinking. Although clients might know logically that doing a compulsion is unlikely to have any influence on whether a distressing thought comes true, or that no amount of checking will resolve the possibility that something might not be quite right, it’s often a huge leap of faith for clients to feel safe enough not to do the compulsion… “just in case”. What frequently lies beneath this is a notable discomfort with uncertainty itself.

In therapy, it often helps to support clients to become aware of this discomfort. It helps make sense of why certain situations are so anxiety provoking and can often shed light on why a client’s OCD might have started in the first place. The realisation that uncertainty is something we all have to live with – and do so every time we get out of bed in the morning – is often very helpful for OCD sufferers.

I sometimes tell the story of my nine-year-old son who, on realising for the first time that black holes are real and “not just in Marvel films” was shocked at how relaxed we all were, living in a universe where a black hole could swallow us all at any time. In practice, there is some self-talk that clients can start to use, like “this is just my brain not enjoying uncertainty” or “I can’t get total certainty on this no matter what I do”, which supports them to feel more comfortable resisting compulsions.

Practical takeaway: support clients to build a “tolerance toolkit” — combining awareness, compassionate self-talk, and graded exposure — to help them approach uncertainty rather than avoid it.

4. BUBBLES under wallpaper

This is a metaphor you can use to describe how OCD themes can shift fluidly from one topic to another. You smooth out one area, only for another to ‘pop up’ somewhere else. As well as often occurring naturally across the lifespan of a sufferer’s OCD, it also frequently features when clients are in the later stages of CBT for OCD. As clients become more comfortable not engaging in compulsions for one distressing intrusive thought, another takes over.

This usually reflects a well-established habit of using compulsions to avoid anxiety. When therapy helps reduce anxiety around one particular theme, it may resolve that one area of compulsion, but the next time an uncomfortable thought pops in clients will be in the same position. This is why, as part of a successful OCD therapy process, it is essential for clients to gain an understanding of the need to authentically sit with their anxiety, in order to learn that nothing catastrophic will happen if they do so.

Techniques from Acceptance and Commitment Therapy (ACT), such as “expansion” and “diffusion,” can complement CBT here, as can grounding and mindfulness-based interventions. The aim is not to eliminate the experience of anxiety but to cultivate a more flexible, accepting relationship with it.

Practical takeaway: prepare clients for OCD’s shape-shifting nature. Lasting progress happens when clients learn to address the underlying anxiety response, not just the surface theme.

References

[1] Radomsky, A., S., et al. (2013), "Part 1—You can run but you can't hide: Intrusive thoughts on six continents." Journal of Obsessive-Compulsive and Related Disorders, http://dx.doi.org/10.1016/j.jocrd.2013.09.002i