Obsessive compulsive disorder - OCD treatment and therapy from NOCD

Mental Compulsions: The Unseen Battle

10 min read
Stacy Quick, LPC

In Obsessive-Compulsive Disorder (OCD), obsessions are thoughts, images, and urges that are unwanted, persistent, and cause significant distress. Compulsions can be any behavior with the purpose to neutralize or reduce the distress and anxiety that arises from obsessions. 

Sometimes compulsions are visible, meaning they can be seen by others and are physical in nature. These are the actions or outward behaviors of the person with OCD. Less talked about are the compulsions that cannot be seen by others, often known as mental compulsions. These internal behaviors are typically unnoticeable by others—-in many cases, the person with OCD doesn’t even identify them as compulsions. 

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Seeing the physical and behavioral compulsions

With physical compulsions, it can be pretty difficult to hide from those closest to you. These compulsions could look like so many things—it would be impossible to list them all. We know how creative and cunning OCD can be. Some examples of physical compulsions include, but are not limited to the following:

Washing/cleaning/decontaminating: This is arguably one of the most visible compulsions. Actions like excessive handwashing, showering, or spraying items with disinfectant are some ways in which this compulsion may manifest.  

Checking: This may look like checking to ensure that your stove is off, doors are locked, things are unplugged, or you didn’t run over a pedestrian, to name a few examples.

Tapping/touching movements: With this condition, some people will report an urge to do some form of movement when faced with an intrusive thought, image, or urge. Typically there is no logical explanation or connection between the thought and the behavior, but the person is compelled to perform the action to relieve the distress caused by the obsession. People with tapping or touching compulsions might report tapping household items a certain number of times before being able to continue with their daily activities. Some report having to walk through doorways a certain amount of times, sometimes just until it feels “right.” For others, it can be turning on lights, using remote controls, picking items up, or putting clothing on—the list can go on. There might be an urge to do something repeatedly until it “feels okay” to move on. It is often described as being stuck; one must complete this to either neutralize the obsession or move forward. In some cases, people with OCD may indicate that there is no actual obsession, just an urge to go through these motions. 

Redoing: This can go alongside the previous example, but it can also include things like rewriting things repeatedly, saying things over and over again out loud, and doing almost anything in repetition. 

Symmetry/”Just Right”/Ordering: This group of compulsions involves having a need for things to feel a certain way or to look a particular way. An example is when a person with OCD does not want to leave their home until things are just as they feel they should be; this can take excessive amounts of time and often results in the person becoming exhausted. This is not just a love for things to be aesthetically pleasing, as it is not usually enjoyable to the person doing it. Instead, this person will feel anxiety and do these behaviors to reduce uncomfortable feelings.

In addition to physical actions, there are also behavioral-based compulsions that are still visible, but may not be known to be compulsions at first to the person with OCD or those around them. Examples of these compulsions include, but are not limited to the following:

Reassurance-seeking: People with OCD often doubt their own ability to make decisions, because they may want 100% certainty when it comes to the things that they worry about. They often have a very hard time trusting their own ability to “know” something. This can lead to excessive reassurance-seeking. Although this can take on many facets, some common examples include a person with OCD asking whether they’ve lied, sinned, offended someone, or touched something that they deem unclean. Or they may ask their loved ones things like “Are you upset with me?” or “Do you still love me?” Another common example is repeatedly Googling whether other people have experienced the same thoughts.

Confessing: Some people with OCD may feel obligated to tell another person about things that they believe are taboo, or about things they believe they will do or may have done in the past. They feel the urge to let someone know something, often “just in case.” An example might be someone telling their partner about every romantic relationship they have ever been in, or it might look like telling a loved one that they had a thought about stabbing them. It could be telling everyone around them that they touched peanuts earlier in the day, just in case they have an allergy.

Avoidance: With avoidance, the person with OCD goes out of their way to not come into contact with a person, item, or situation that triggers their obsessions. For some, this may be avoiding knives due to intrusive thoughts about harming loved ones. For another, it may look like not touching cleaning products because of fears related to poisoning. It can be not attending certain events because of various obsessions or fears about getting ill or spreading illness to others. Avoiding driving in heavily populated areas because of hit and run thoughts, not watching the news, and not listening to certain songs can also all be avoidance behaviors. 

Silently engaging in compulsive behaviors through mental compulsions

When people first begin OCD treatment, they are usually quick to identify the physical compulsions they’ve been engaging in. They are typically very aware of them and how they are impacted negatively by them. Many times, what brings them to treatment in the first place is the repercussions of those behaviors. Some people will report being unable to work, attend school, or even complete basic functions such as showering or eating. Since these tend to be noticeable, loved ones will sometimes even initiate the treatment process for them, having seen the person they care about suffering. 

What we don’t see as often is someone who recognizes that their own internal dialogue and activity has also been serving to reinforce the obsessions that they are experiencing. Examples of such mental compulsions include the items below (please note this is not exhaustive):

Thought Replacing: This serves to replace “bad” thoughts, urges, and images with “good” ones. Another way to look at this is that the person with OCD is seeking to neutralize an obsession that they feel is inappropriate. This mental activity is not seen by others, but it serves as an action used by the individual to feel better and to relieve their distress, thus making it a compulsion. This may also look like saying particular phrases, prayers, or mantras in one’s head in an attempt to cancel out the obsessions. 

Rumination: This is not just about trying to solve a real-life problem; think of this as overanalyzing or trying to solve a perceived problem. Most often people with OCD explain that they just need to think about something until they can “figure it out.” They may say things like “I just need to know” or “I need to think on it until I have some peace.” What they are actually saying is that they have dwelled on a topic—often for days, but sometimes even years—all in an effort to “feel” okay. A large part of OCD treatment is learning that you don’t need to always “feel” okay. In fact, it is impossible to always “feel” okay. We must teach ourselves that we can sit in discomfort, and we can tolerate anxiety. As much as we don’t like the emotion of anxiety, it is just another emotion, and it will eventually pass on its own. One of the lies OCD often tells us is that we must “do” something to get rid of unpleasant feelings—the truth is we don’t need to “do” anything. It goes away and we learn we can handle it. 

Mental Reviewing: This can look like playing a conversation one just had over and over again. It can be going over an event that occurred 10 years ago and re-envisioning it in an effort to “solve” an obsessive spiral. 

Self-Reassurance: Similar to the behavioral compulsion of seeking reassurance from outside sources, the mental version involves telling oneself that what are obsessing about is okay or not true, in an attempt to alleviate distress and avoid feeling anxious. 

Distraction: This may be purposefully thinking about one thing in an attempt to not think about another. One that is most common is the tendency for people with OCD to stay busy in an effort to keep their minds on other things so as to not allow their obsessions to sneak in. It should be noted that this stems from anxiety and not a general desire to remain busy and active. 

How to effectively identify and address mental compulsions 

The key difference between a compulsion and an everyday behavior really lies in the intent of that behavior. Whether it is internal or external, what is the purpose of that action? If you have OCD and the purpose is to reduce feelings of anxiety, distress, or discomfort, then it is a compulsion. 

We know that compulsions lead to an increase in OCD symptoms over time. It strengthens the idea that the obsessions were indeed dangerous when they were not. I often reference that when you have OCD, it is like having a faulty alarm system in your brain. The alarm system is supposed to alert you to danger. The problem is that when you have OCD it malfunctions. 

When an individual engages in compulsions, it inadvertently reinforces the idea that there really was danger and that they just protected themselves from it. The problem is that there was never any danger in the first place. Only when you do not perform a compulsion does your brain realizes that. Over time and with repeated exposures and non-engagement in compulsions, your brain sort of rewires itself, and the alarm goes off less frequently. And you learn that even when it does go off, you can tolerate the feelings that it brings alongside it.

Exposure and response prevention (ERP) therapy is considered the gold standard for OCD treatment and teaches you how to sit with the anxiety the faulty alarm system brings. ERP has been found effective for 80% of people with OCD, and the majority of people experience results within 12-25 sessions.

The idea behind ERP therapy is that exposure to feelings of discomfort or anxiety is the most effective way to treat OCD. When you continually perform compulsions, it only strengthens your need to engage them. On the other hand, when you prevent yourself from engaging in your compulsions, you teach yourself a new way to respond and will very likely experience a noticeable reduction in your anxiety. As part of ERP therapy, you will track your obsessions and compulsions and make a list of how distressing each thought is. You’ll work with your therapist to slowly put yourself into situations that bring on your obsessions. 

This has to be carefully planned to ensure it’s effective and so that you’re gradually building toward your goal, rather than moving too quickly and getting completely overwhelmed. That’s why the best way to practice ERP and manage intrusive thoughts and mental compulsions is to work with a therapist trained in ERP.  By working alongside a specialty-trained therapist, you will be able to identify mental compulsions that you may not even know you are doing. 

At NOCD, our therapists specialize in OCD and ERP and receive ERP-specific training and ongoing guidance from our clinical leadership team. Your therapist will provide you with a personalized treatment plan designed to meet your unique needs and will teach you the skills needed to begin your OCD recovery journey, while supporting you every step of the way. They will guide you in taking small steps to reach your goals. 

Our team of therapists at NOCD is passionate about the treatment of this debilitating disorder and is trained by world-renowned experts. I encourage you to learn about NOCD’s accessible, evidence-based approach to treatment.

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Taylor Newendorp

Taylor Newendorp

Network Clinical Training Director

I started as a therapist over 14 years ago, working in different mental health environments. Many people with OCD that weren't being treated for it crossed my path and weren't getting better. I decided that I wanted to help people with OCD, so I became an OCD therapist, and eventually, a clinical supervisor. I treated people using Exposure and Response Prevention (ERP) and saw people get better day in and day out. I continue to use ERP because nothing is more effective in treating OCD.

Gary Vandalfsen

Gary Vandalfsen

Licensed Therapist, Psychologist

I’ve been practicing as a licensed therapist for over twenty five years. My main area of focus is OCD with specialized training in Exposure and Response Prevention therapy. I use ERP to treat people with all types of OCD themes, including aggressive, taboo, and a range of other unique types.

Madina Alam

Madina Alam

Director of Therapist Engagement

When I started treating OCD, I quickly realized how much this type of work means to me because I had to learn how to be okay with discomfort and uncertainty myself. I’ve been practicing as a licensed therapist since 2016. My graduate work is in mental health counseling, and I use Exposure and Response Prevention (ERP) therapy because it’s the gold standard of OCD treatment.

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