OCD (Obsessive-Compulsive Disorder)

What OCD actually is

OCD has two parts. Obsessions are unwanted thoughts, images, urges, or doubts that push their way in and won’t leave — usually about the thing you would least want to be true. Compulsions are what you do to make the feeling stop: checking, washing, repeating, confessing, asking to be told it’s fine, or running the same argument silently in your head.

The compulsion works. That’s the problem. Relief arrives, and it teaches your brain that the thought was a genuine emergency and the ritual is what averted it. So the thought comes back with more authority, and the ritual has to be bigger. That loop is OCD. It isn’t a character flaw, and it isn’t a sign of what you secretly want.

The forms it takes

OCD attaches itself to whatever you care most about, which is why it can look so different from one person to the next:

• Contamination — dirt, illness, chemicals, or a feeling of being contaminated that washing never quite settles
• Checking — doors, hobs, switches, emails, your own memory of what you just did
• Harm — intrusive images of hurting someone you love, and the horror of having had them
• Sexual or religious intrusions — thoughts that feel blasphemous or perverse and utterly unlike you
• Symmetry and “just right” — arranging, repeating, redoing until something internal clicks
• Relationship OCD — relentless doubt about whether you love your partner, or they love you

Where there’s no visible ritual, it’s sometimes called “Pure O”. The name is misleading — the compulsions are there, they’re just happening in your head.

Why reassurance makes it worse

Almost everyone with OCD has been offered reassurance, and almost everyone has noticed it stops working. Being told “of course you wouldn’t” settles things for an hour, maybe a day. Then the doubt returns, because certainty is not actually available about the future, about other people’s minds, or about your own deepest intentions — and OCD will always find the gap.

This is why the work isn’t about proving the thought false. It’s about changing your relationship to not knowing.

How CBT works with it

The evidence-based treatment for OCD is CBT built around exposure and response prevention (ERP), which is what NICE recommends.

We start by mapping your particular loop — what triggers it, what the thought seems to mean, and every compulsion that follows, including the invisible ones. Most people are surprised by how much of the day turns out to be ritual once it’s written down.

Then, together, we build a hierarchy: situations ranked from mildly uncomfortable to genuinely difficult. You approach them deliberately, starting low, and don’t perform the compulsion. What follows is uncomfortable and finite. The anxiety rises, levels off, and comes down on its own — without the ritual. Do that enough times and the obsession stops carrying the charge.

Alongside it we work on the beliefs underneath: that thinking something makes it likelier, that you’re responsible for preventing every possible harm, that not being certain is the same as being in danger.

I’ll be straight with you — ERP asks something real of you. It is also the thing that works.

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When CAT is the better route

Sometimes OCD sits inside something older: a long pattern of needing to be blameless, or a childhood where you were the one who kept everyone safe and control became the only way to feel alright. When the OCD is one expression of that wider pattern, CAT can reach it in a way symptom-focused work doesn’t. We name the pattern, and early on I write you a reformulation letter setting out how it formed and what keeps it going.

Often it’s both — ERP for the compulsions, CAT for the pattern holding them. We decide together at the first session. More on how I work.

What treatment looks like

Most courses run 12 to 20 sessions, weekly to start. The first two or three are assessment and mapping — no exposure until we both understand the loop and you know exactly why each step is being asked of you. Between-session practice is where the change happens; the hour with me is for planning it and making sense of what came back.

Nothing is sprung on you, and nothing happens that you haven’t agreed to. You set the pace on the hierarchy.

Common questions

Does having these thoughts mean something is wrong with me? No. Intrusive thoughts are close to universal — most people have them. What distinguishes OCD isn’t the thought, it’s the meaning attached to it and the effort spent neutralising it.

Will you make me touch a toilet seat? No. Exposure is agreed between us, graded, and built around what is actually keeping your OCD going. It should be difficult, never humiliating.

I’ve had OCD for years. Is it too late? No. Long-standing OCD responds to ERP. It may take longer, and relapse prevention becomes a larger part of the work.

Can I do this online? Yes. ERP works well remotely, and where the compulsions happen at home there’s a good argument it works better — we can do the exposure where it actually occurs.

What about medication? SSRIs have good evidence in OCD and combine well with ERP. That’s a conversation for your GP, and I’m glad to work alongside it.