Mental Rituals, OCD, and ERP

Five years ago, Seth Gillihan, PhD, wrote a guest post for my blog. Since that time, we have co-authored Overcoming OCD: A Journey to Recovery , and Seth’s own book, Retrain Your Brain: Cognitive Behavioral Therapy in 7 Weeks: A Workbook for Managing Depression and Anxiety, has been published. Seth continues to work tirelessly in his private practice to help people overcome their OCD. He also has his own blog. His popular guest post resonated with many people, and I think it’s more than worthwhile to publish it once again:

Some of my colleagues and I recently wrote an article about common therapist mistakes in exposure and response prevention (ERP) therapy for OCD. I wanted to highlight one of the sections of that paper that may be helpful to individuals whose compulsions are primarily mental. Mental compulsions typically involve words, phrases, prayers, and so forth that the person says silently in order to prevent a feared outcome, or to reduce the anxiety that the obsession causes (see full article for a list of common mental compulsions). For example, a person might have religious obsessions and may fear that her children will become sick if she has blasphemous thoughts. In response to any blasphemous thoughts or images that come to mind she will repeat to herself a memorized prayer about the greatness of God with requests for protection for her children.

The first step in treating OCD that involves primarily mental rituals is to recognize the familiar cycle of obsessions and compulsions. Just like with observable rituals, mental rituals maintain OCD by providing temporary relief from the OCD-related distress. Some clinicians may fail to identify covert/mental rituals, and people with OCD similarly may have a hard time distinguishing between an obsession and a mental compulsion. When thoughts are coming quickly one after another, some causing distress and some intended to relieve that distress, it can feel like a jumbled mess and the compulsions can be hard to identify. For this reason OCD with mostly or only mental rituals is often mistakenly labeled “Pure Obsessional” (or “Pure-O”) OCD.

The way to tell a mental compulsion from an obsessive thought is to ask what the function of the mental act is: Obsessions increase anxiety whereas mental compulsions are intended to decrease anxiety.

Once a person knows what his or her mental rituals are, it is crucial that the person eliminate them in order to recover from OCD. During ERP the individual must avoid doing mental rituals during exposure—for example, saying ritualized mental prayers to neutralize the fear of harm that comes from doing the exposures.  These kinds of private rituals undermine the exposures and can prevent the person from getting better.

As discussed on an earlier post, ERP for mental rituals requires one to do the opposite of the rituals and allow oneself to have the distressing thoughts like “I’m a devil worshiper,” without any mental rituals to counteract these thoughts. Easier said than done! A lot of the difficulty, of course, comes from the almost automatic nature of the mental rituals; people with OCD often say they do a mental ritual even when they’re trying not to. For this reason the ERP therapist and person with OCD will need to work closely and creatively together to find ways to block the mental rituals.  One solution is for the person with OCD to read out loud material that provokes obsessions (either in vivo or imaginal exposure—see sections 3 and 6 of the article for descriptions of these two techniques) so that the mind is not free to perform mental compulsions. It can also be helpful to say exposure statements to prevent mental compulsions, such as saying “I’m friends with the devil” instead of engaging in a ritualized prayer. Exposure statements should also be used if the person realizes he or she performed a mental ritual—what is often called “spoiling” the ritual.

A final point that we highlight in the article is that it’s usually counterproductive to tell oneself “that’s just my OCD” and similar statements when experiencing an obsession. These kinds of statements play OCD’s game of looking for certainty and trying to find a short-term fix to make obsessions less upsetting. As such, these responses to obsessions often become a ritual, another way to neutralize the anxiety and uncertainty that the obsessions cause. A more effective long-term solution is to answer obsessions with exposure statements that recognize uncertainty: “Maybe I did sell my soul to the devil”; “God might punish me for having that thought.” While I’ve focused here on religious obsessions as an example, these principles apply to any obsessional content.

The bottom line of this discussion is that, contrary to what some people with OCD believe or have heard, ERP can successfully address mental rituals. Armed with knowledge about how to recognize mental compulsions, determination to conquer them, and often with the help of a skilled therapist, individuals with mental compulsions can live more enjoyable and fulfilling lives.


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12 Responses to Mental Rituals, OCD, and ERP

  1. Betty sanders says:

    Would a child with o c d now the difference

    • Hi Betty, If you’re asking if the above information can be applied to a child with OCD, the answer is yes, but you really need a competent OCD therapist. Hope this answers your question!

  2. sethgillihan says:

    It’s a good question, Betty. I don’t work with kids with OCD but knowing kids, I would expect they’d have at least as hard a time telling the difference between mental obsessions and rituals. So as Janet said, working with a knowledgeable OCD therapist who understands ERP would be important. Thanks for your question!

  3. anxiouswriter says:

    Thank you for sharing! As someone who’s been through a lot because people don’t understand Suicidal Obsessions, thanks for breaking the silence around Pure-O.

    • sethgillihan says:

      Thank you, anxiouswriter! Sadly it’s very common to have suicidal obsessions confused for actual suicidality, which can end up being quite traumatizing for the person with the obsessions.

  4. Sebastian Howard says:

    I have a rather weird obsession,
    I mean I get different ones but the way that my ocd is working rn is that I’m afraid of things that I’m watching or reading, whatever that they’re bad or a fear that the characters are lacking because they’re not three dimensional because they don’t have enough backstory. This pretty much happens, this fear no matter what I’m reading or writing, regardless of how logical or how much merit the criticism has on what I’m trying to enjoy. I don’t see a specific form of ocd for this but it’s not very different from some of the going over and checking over and over again stuff (as that’s what I end up doing, checking over and over again to make sure the things I like are good). This has been an on/off again fear for me and has been completely mental, the compulsions (though I will have urges to look things up and such like what makes a character three dimensional and look on the net for hours trying to find some kind of answer). I have a lot of different ocd stuff that’s like that but this is one of my main ones, do you have any other advice for something that’s completely mental compulsions or should I just try to stick it out and try not to go into the mental compulsions (which as you’ve noted is hard to do because when it’s mental it’s almost a automatic response). I guess the thing that bothers me is that there’s a hint of truth in the criticisms so I almost feel like I have to check and defend myself even though that’s almost assuredly the wrong thing to do…. additional comments am 23, started having bad ocd in early high school with a serious fear of contracting aids because I was scared that I might’ve stepped on a needle.

    • Hi Sebastian, Thank you for sharing and hopefully Dr.Gillihan will have some helpful advice for you. As you might know, exposure and response prevention (ERP) therapy with a therapist who specializes in treating OCD would be the best route for you to follow. I wish you all the best!

      • Sebastian Howard says:

        Thank you for quick reply, I have thought about doing ocd therapy but in my area (wpb) it’s a lot more expensive and harder to find than just a normal therapist who I feel is unequipped to deal with my ocd at least in comparison with a ocd specialist.

      • I think you are wise to stick with an OCD specialist. There are good self-help books out there that focus on ERP therapy and some therapists will do virtual therapy as well. Also some websites such as the Peace of Mind Foundation can help you get started on ERP therapy. Good luck!

  5. Thanks for your comments, Sebastian. OCD is so tricky because there’s almost always a kernel of truth, so it’s hard to dismiss completely out of hand. This sounds to me like a variant of relationship OCD, which can attack romantic partnerships or one’s faith (among other things). In this case the fear is of being in the wrong “relationship” with things you like. The best approach—what we do in ERP—is to accept the possibility, “Yes, maybe I like the wrong things” or “maybe the things I like are poor quality” or whatever the fear might be, without trying in any way to know for sure if what you’re afraid of is true. And then, keep doing the things you seem to enjoy, with the awareness that it’s possible the intrusive thoughts are right. That kind of acceptance virtually always makes the obsessions quiet down, and become easier to tolerate.

    And you’re right about the expense and difficulty in finding a qualified OCD therapist. Sometimes you even need a specialized specialist who really knows the ins and out of less common forms of OCD. But it can be less time and expense in the long run to work for a few focused sessions with someone who can really help. I hope you find the relief you need, Sebastian.

    • Sebastian Howard says:

      Thank you a lot dr, I will try to do as you said like try to desentize the obsession. Perhaps I will try doing just a few sessions of erp as
      Well. Thank you for the advice.

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