Why Traditional CBT Talk Therapy Doesn’t Always Work for OCD
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Often times when people go into therapy for anxiety, they’re first taught the Cognitive Behavioral Therapy approach. It’s basically the first line of defense for therapists to address anxiety. You’re taught to identify irrational thoughts and then challenge and replace them with more balanced thinking. For depression or generalized anxiety, this approach can be powerful, and I certainly use it often.
So why wouldn’t we use this with OCD, an anxiety disorder that causes people to have obsessive thoughts? Well, if you live with Obsessive-Compulsive Disorder (OCD), you may have noticed that “just thinking rationally” about your fears doesn’t make them go away. In fact, trying to reason yourself out of OCD can actually backfire and make symptoms worse.
Because here’s the thing- OCD thoughts don’t respond to logic. OCD is sometimes called the “doubting disorder” for a reason. Even when you know a fear doesn’t make sense (“I know my hands are already clean”), the doubt feels overwhelming. Your brain keeps saying “But what if…” Because there is NO pleasing OCD thoughts. Unlike ordinary worries, OCD thoughts are sticky. You can reason with them all day, and they’ll keep coming back. Why?
Because ultimately there’s no certainty in life. And OCD HATES UNCERTAINTY. There is always a teeny, tiny, infinitesimal chance that the “bad thing” could happen. And that is why it doesn’t help an OCD brain to tell it “Hey, that thing that you’re worried about, that teeny tiny chance that it will happen- it won’t happen!” Because your brain is brilliant. And it can find danger where there is none if it wants to.
And while someone without OCD may be able to challenge and accept their self talk if they tell themselves “That’s really unlikely to happen. No real danger right now. Let’s move on,” an OCD brain will turn that reasoning self talk into a compulsion. A lot of people don’t realize that thinking is the compulsion for many with OCD. In fact, OCD loves arguing back and forth because that’s what keeps the obsession strong.
At first, it feels calming to use rational self-talk and tell ourselves all the reasons why the bad thing won’t happen. But soon the brain demands more and more reassurance. The cycle strengthens OCD rather than weakening it. This is why if you have OCD, you may have noticed that no matter how hard you remind yourself of the logical reasons, it doesn’t help you in the long run because, though you might stop worrying about it for the moment, it returns later.
What Works Better? Exposure and Acceptance
The gold standard treatment for OCD is Exposure and Response Prevention (ERP). It’s a pretty radically different approach from CBT. Instead of arguing with thoughts, ERP helps clients face the feared thought or situation (exposure). What exposure essentially means is accepting that there is a chance the bad thing could happen (though typically highly unlikely). People with OCD have a very difficult time accepting uncertainty. They focus on the one-in-five-million chance that the bad thing could happen and they want to know with 100% certainty that it won’t happen to them. And as you might imagine, they never get it. Because there is no certainty in life about anything (terrifying!). In therapy, I work with clients on working to tolerate this uncertainty and accepting that they don’t have all the answers today, and that’s okay. We also work on resisting the urge to do compulsions or reassurance (response preventions).
Another important part of treating OCD is understanding and “accepting” that intrusive thoughts are normal and will happen. The goal is not to get rid of the intrusive thoughts (which typically makes them worse), but rather to help clients learn they can tolerate the anxiety, and that the feared outcomes typically don’t happen. Adding acceptance means shifting from fighting the thoughts and feelings to allowing them to be present without judgment. Instead of arguing with their OCD, clients practice accepting uncertainty and discomfort, noticing that anxiety rises and falls naturally. Over time, this weakens the cycle of OCD.
When clients shift from “I have to get rid of this thought” to “I can live with this thought without giving it power,” real change happens. Exposure and acceptance works because it changes our relationship with thoughts. The goal isn’t to “think rationally” but to learn to live with uncertainty and stop obeying OCD’s rules.
If you’ve tried traditional CBT or talk therapy for OCD and felt stuck, it’s not your fault. It doesn’t mean you’re “resistant” to treatment. It just means your brain needs a different approach. OCD recovery is possible — but it requires learning skills that go beyond rational disputing, toward uncertainty tolerance, exposure, and freedom from compulsions.
