Why talk therapy typically isn’t effective for treating OCD

Talk therapy, also called psychotherapy, is a process where someone will work with a therapist to talk through their experiences. In talk therapy, a person seeking help can discuss their issues and concerns with a professional who holds no biases or judgment. Talk therapy is very effective for some conditions and can be especially helpful for people going through major transitions or difficult situations, such as an unexpected divorce or loss, to gain a better understanding of their emotions and help them cope. 

However, talk therapy is typically not effective for treating OCD. In fact, talk therapy can often exacerbate OCD and make symptoms worse by having those with OCD repeatedly analyze their thoughts and attempt to solve them. That’s why for most people with OCD, talk therapy is not only unhelpful, but actually harmful and counterproductive to the OCD recovery journey. 

The focus on analyzing thoughts in talk therapy

Talk therapy consists of active listening that acknowledges the relationship between emotions, behaviors, and thoughts. Sometimes, there’s no specified structure to guide talk therapy sessions. Instead, talk therapy relies on a patient communicating past experiences, traumas, and underlying thoughts that may be causing or affecting various mental health conditions with their therapist.

When a person with OCD goes to a talk therapist to discuss intrusive thoughts, their therapist will likely try to work with them to understand the thoughts or try to make sense of thoughts. They may focus on the content of the thoughts and discuss in-depth why they may have had that thought, even looking into how their past may have contributed to it. 

This type of process can ultimately be debilitating for someone with OCD. For a person to manage OCD effectively, they need to realize that a thought is just a thought. The thought is neither good nor bad, and it doesn’t have to mean anything or make sense. That’s why in OCD treatment, it’s critical to deemphasize the importance or meaning of intrusive thoughts. 

As OCD specialists, we try to teach people that their intrusive thoughts, images, or urges—known as obsessions—are not actually a problem. What’s reducing their quality of life is their interpretation of those obsessions, and the behaviors they engage in as a result of the distress they produce. Obsessions cause people with OCD to engage in compulsions in an attempt to get rid of anxiety, eliminate uncertainty, or solve a perceived problem. Compulsions are things that are done either internally or externally to neutralize an intrusive fear or thought, but they do nothing to address anxiety and stress long-term—in fact, they only make obsessions worse over time.

How does talk therapy make OCD symptoms worse?

While talk therapy can effectively treat many different issues, the high risk of people with OCD engaging in compulsions without addressing their behavior is what can make talk therapy harmful, particularly due to these three reasons:

• You might be receiving reassurance, which can be compulsive. When a person is in distress due to their intrusive thoughts, a talk therapist may naturally try to help them alleviate their distress, and in doing so, may provide them with reassurance in an attempt to remove their doubts, fears, or uncertainty. The person may even repeatedly ask the same thing over and over to relieve the anxiety or fear that comes from their obsessions. For someone who has OCD, reassurance-seeking often becomes a compulsion. Only a therapist who deeply understands OCD will know that while providing reassurance may make someone feel better temporarily, it will only reinforce their fears in the long run. They’ll also be better equipped to identify when someone is seeking reassurance in roundabout ways.
  
• You might be ruminating verbally, which makes things worse overall. Often, when people with OCD go to talk therapy, they will engage in a cyclical process of analyzing a thought and trying to understand it, without necessarily implementing a solution. Talk therapy sessions can become opportunities for people with OCD to ruminate verbally—or continuously think about the same thoughts and feelings, often far more than is useful—which is also a compulsion. As with all compulsive behaviors, verbal rumination may provide temporary relief. However, it’s important to assess how they are feeling not just after each session, but over time: does the rumination lead to long-term relief from distress? Once again, the answer is likely no, because relying on compulsions only makes OCD worse.
  
• It doesn’t focus on changes in behavior, which is crucial for OCD recovery. After a talk therapy session, some people may feel that their session was cathartic or that they experienced an emotional release. That may be true, but likely, their OCD symptoms themselves have not been addressed. Sooner or later, they’ll likely begin to doubt everything they ruminated on and received reassurance for in their session. They’ll realize that little has changed—that’s because there was no behavioral intervention to implement change, which is necessary for OCD recovery.  To effectively manage OCD long-term, it’s crucial to challenge OCD fears, accept uncertainty, sit with the resulting discomfort, and reduce or resist compulsive behaviors, such as avoidance and other mental or physical rituals. 

Let’s consider an example: someone begins having intrusive thoughts that they will hit a person when driving. After some time, they may even start to fear that this did happen in the past but they can’t remember it, and they begin to experience extreme guilt. In talk therapy, they might focus on how this is simply logically untrue: “You didn’t hit anyone. Is there blood on your car?”  “Did you see anyone injured?” “It’s ok. You’re fine; everything’s fine.” That will likely feel good for the moment—they’re able to ruminate on their worries and their therapist provides reassurance—but eventually, OCD creeps back. Eventually, their fear of the possibility that they hit someone or might hit someone has become so great that they no longer feel safe driving, and they begin avoiding it altogether. They may continue to discuss this with their talk therapist, but they make little progress in driving without fear, if they keep driving at all. 

That’s why using logic alone doesn’t work for treating OCD: even if someone logically understands that their rituals are irrational, their fear can be so great that they still engage in their compulsions “just in case” or “just to be sure.” To truly overcome OCD, it’s important to learn to live with uncertainty and implement techniques that are focused on retraining thinking and behavior patterns.

Treatment designed for OCD

The key to treating OCD effectively is by seeing a licensed therapist who specializes in OCD and is specialty-trained in exposure and response prevention (ERP) therapy. ERP is a form of therapy that was specifically developed to treat people with OCD. Studies show that ERP is the most effective form of treatment for OCD and is the best way to recover from OCD. 

This unique therapy is specifically designed to help people face their obsessions and resist compulsions in healthy and productive ways. In ERP, people are exposed to different situations that provoke their obsessions in a controlled and safe environment, creating the opportunity to resist engaging in compulsions. 

The goal of ERP is to free individuals from compulsions by accepting uncertainty so they can live more comfortably. ERP will teach them that while their discomfort is not pleasant, it’s also not dangerous, it won’t last forever, and that they can tolerate it without resorting to compulsions. ERP will also help increase someone’s self-efficacy, or their own perceived ability to do challenging things. 

People with OCD who receive ERP often require between 12 to 25 sessions of ERP to begin seeing improvement in their symptoms. The length of time it takes for someone to see improvement can vary from person to person and depends on the severity of their symptoms.

How can you find a therapist who specializes in ERP? 

The most important thing to look for when you’re seeking a therapist who specializes in ERP is whether or not they have specific training or experience in ERP. They will know what to anticipate when you describe your thoughts and behaviors, and how to build your personalized treatment program. Their expertise is in teaching you how to manage your OCD so you don’t feel stuck trying to “get rid of” the unpleasant feelings caused by disturbing thoughts.

People can search for providers through the International OCD Foundation (IOCDF) or Psychology Today. Both networks allow you to search for therapists in your area who treat people with OCD (we recommend that you ask this list of five questions ahead of your first session with any therapist to ensure they are trained in ERP). 

You can also find therapists who specialize in ERP and provide virtual treatment. NOCD’s network of ERP-trained therapists is available to people inside and outside of the U.S. and is one of the most cost-effective solutions available today—we even accept many insurance plans to help make treatment even more affordable. When you schedule a free 15-minute call with us, our team will help you find a licensed, ERP-trained therapist in your area and to help you begin working with them as soon as possible. 

Remember, talk therapy can be helpful in many ways, but for OCD specifically, specialized treatment is needed to get better. With the right type of therapy, you’ll be on the road to freedom from OCD and will begin gaining more control over your life.