Why I like working with OCD

When someone comes to therapy, the problem is not always in the room

One of the challenges with therapy in general is that the problem often does not show up in the exact moment someone is sitting in front of the clinician. It happens outside the room. It happens before bed, at work, while driving, while praying, while cooking, while being with a partner or children, or in those quiet moments where the mind has space to start running.

Because of that, people often have to explain their suffering before anything can be done about it. They have to somehow put into words what happens when the anxiety takes over, what they do in response, how exhausting it is, and why it matters. Then, even if the discussion in therapy makes sense, they still have to leave the room and remember how to apply it in real life.

OCD on the other hand is different.

OCD does not hide

OCD is one of those conditions that is not scared of showing itself during the session. As the therapist, I can often see the activation happening in real time. I can see the fear, the uncertainty, the intrusive thoughts or images, and the urge to do something to make it feel safer.

That “something” is what we call a compulsion. Sometimes people think compulsions only mean obvious behaviours like washing hands or checking locks, but compulsions can be much broader than that. They can include reassurance-seeking, mentally replaying something, avoiding a situation, checking your body, asking repeated questions, reviewing memories, repeating prayers, or trying to get the feeling of certainty back.

What I like about working with OCD is that I do not have to guess whether it is there. I do not have to rely only on a description of it. Very often, it appears directly in the room, and that gives us something real to work with.

ERP is one of the bravest things I see people do

The main evidence-based treatment for OCD is Exposure and Response Prevention, or ERP. In simple terms, ERP means helping a person gradually face the thing that triggers the obsessional fear, while also resisting the usual compulsion they would do to feel safer.

That sounds simple when written in one sentence, but in reality it is incredibly difficult.

The person is not just facing a mild discomfort. They are often facing what feels like a completely believable catastrophe. The fear does not feel hypothetical to them. It feels real, immediate, and dangerous. So when they agree to stop checking, stop asking, stop washing, stop neutralising, or stop avoiding, they are not doing something small. They are stepping toward something their nervous system is telling them not to do.

This is what makes ERP so powerful. It brings courage and fear into the same moment.

A person might believe:
My child will choke if I do not cut the grapes properly.
My house will be robbed if I do not check the locks again.
If I do not have the right intention during prayer, it does not count.
If I do not pick up every call, I will miss an opportunity and ruin everything.
If I feel something in my chest and do not check it, something terrible might happen.
If I unknowingly eat non-halal food, I will be punished.
If I do not wash properly, I might make someone sick.

To an outsider, some of these fears might sound irrational. But to the person living with OCD, they do not feel irrational at all. They feel urgent, serious, and morally significant. That is why ERP is not just “facing fears.” It is willingly stepping into uncertainty when every part of you wants relief.

One of the things I have also come to appreciate about ERP is that, if it is done in a cold or overly clinical way, it can feel confronting, invalidating, and at times even a bit inconsiderate of what the person is actually going through. For some people, being told to just face the fear and stop the compulsion can land as if their distress is being minimised. That is part of why I have found it helpful to integrate aspects of Internal Family Systems therapy into the work, while still being very careful not to slip into reassurance or offer certainty about the outcome. I might give a small but important amount of rationale about what we are doing, help them understand that there are intense sensations happening in the body and then a story or prediction being made about what those sensations mean, and that our job is to test whether those predictions are actually true, whether they really say something about them, or whether they are the mind’s attempt to make sense of an overwhelming physiological state. A lot of this is also communicated not just through words, but through my tone, my body language, and the confidence I try to hold that there is a way to approach this, even if the path itself is uncertain.

What I have found is that, once people get on board with that frame, it often helps a lot at the start of ERP. It gives them enough understanding to know why they are doing these experiments without feeding the OCD cycle. And then, once they have done one or two exposures, something often begins to shift quite quickly. They are no longer relying only on my word. They start seeing for themselves that they can notice the urge without automatically obeying it, that they can step back from the story a little, and that sometimes the feared prediction does not come true. Once that starts happening, there is often much more willingness to keep going and take on more.

As a therapist its amazing to see this shift occur.

OCD also changes how I have to be as a therapist

Another reason I like working with OCD is that it requires something different from me as a therapist. It asks me to move away from the more traditionally supportive, warm, reassuring stance that people often expect in therapy, and into something more boundaried, calm, confident, and direct. At the best of times, I already think I can be a bit callous and quite direct in session, but ERP is different. From the beginning of treatment, I have to make sure I do not knowingly or unknowingly align with the compulsions.

In most therapy, it makes sense to reassure people about the formulation, the treatment plan, and the likelihood that things will improve. In OCD, I cannot do that in the same way. I do not know for certain what will happen. The feared prediction may not come true, but I cannot honestly promise that it will not. I cannot tell someone with certainty that their child will definitely be fine if they do not check on them again, or that they definitely will not stab their partner if they are holding a knife in the kitchen. I cannot tell the future, and I do not want to pretend that I can. For someone with OCD, that uncertainty is exactly the problem.

So the therapist becomes a kind of role model for how to be with these intrusions and predictions without trying to neutralise them. I enjoy that part of the work because it brings the OCD directly into the room. When I do not offer reassurance, false certainty, or an escape route, I can often see the anxiety rise. I see the intrusions increase. I see the need to shrink the exposure or soften the experiment. And that is useful, because now we are actually working with the OCD rather than just talking about it.

I think I am also better now at explaining just how hard ERP can be. The difficulty is not linear. It is exponential. After experiment one, experiment one does not disappear. It continues, and then experiment two gets added on top of it, and so on. I am more upfront now about the things I have learnt can make ERP hard to stick to. I tell people to expect that it may affect sleep, work, patience, irritability, and family life. I tell them they may start questioning whether treatment is worth it. They may want to stop. They may want to go back to the compulsion. They may start looking for another way out through procrastination, self-soothing, or avoidance.

I say these things because I want people to make an informed decision about whether this is the right time to do ERP. I tell them plainly that it will be hard, very hard. For me, the closest comparison is weight loss. I can go to the gym and train hard, but then I have to go home and eat properly every day, and that is the harder part. With ERP, coming to therapy is often the easier part. The hard part is going home and doing the exposure again and again, often daily, when no one is there to make you do it and your mind and body not on the same page.

OCD is where neurology and psychology clearly meet

OCD is not just a set of random thoughts. We understand it as being associated with changes in the wiring of the brain. At the same time, the content of OCD is deeply psychological. It attaches itself to the things people care about most: safety, morality, religion, health, responsibility, harm, relationships, success, and identity. Its a real situation where the hardware interacts with the software. There is something useful and relieving for people when they begin separating the neurological pattern of OCD from the actual content of the story it is attaching to. Once they can see, “this is OCD doing what OCD does,” there is often more room to step back from the meaning of the thought itself. And then sometimes, once the OCD is less fused, there is room for deeper work too. We can start looking at whether there are other burdens underneath the themes OCD keeps grabbing onto. I like that this work keeps me curious. It reminds me that people are rarely explained by one thing only. Not just biology. Not just environment. Not just psychology. Usually it is some mix, and you only understand it better by staying close to the actual experience.

The change can be profound

Another thing I have noticed is that, at the start of treatment, patients are often not fully aware of what the actual intrusions and compulsions are. They cannot always tell the difference between the two, and often need a fair bit of help to recognise that something is in fact an intrusion rather than just a rational thought or something anyone would think. But it is amazing to watch what happens once that process begins and they do the first ERP experiment. It is like something opens up. They start to realise, oh wow, this is not the only intrusive thought I have. They begin noticing the same pattern in other parts of their life as well.

For example, someone might come in focused on one specific fear, like being overly worried about losing his tools unless he triple-checks that the car is locked. But once we begin working with that, he starts noticing that the same OCD process is showing up elsewhere too — at home, for example, where everything has to be clean and spotless otherwise he feels like he will not be able to settle or sleep properly. What starts happening is that their awareness generalises. They are no longer just looking at the content of one obsession or one compulsion. They start recognising the broader OCD process itself. As a therapist, that is an amazing thing to witness, because it is like they are seeing their internal world in a completely new light.

Towards the back end of treatment, the impact on a person’s life can be so profound that it is like they have a new lease on life. As a therapist, you could not ask for a greater reward than that. People begin to recognise their thoughts as intrusions, notice the urge to engage in compulsions, and realise that what used to feel constant and consuming now has less pull over them. They still get anxiety spikes and somatic distress, but the need to explain, neutralise, or avoid is no longer running the show. That frees them up to keep going with life, to enjoy things again, and to be more present in what they are doing.

Courage

What I have come to respect most about OCD treatment is the sheer courage it asks of people. I am not talking about abstract courage or motivational-post courage. I mean the real kind. The kind where someone is flooded with fear, convinced the worst-case scenario could happen, aware that treatment may affect their sleep, mood, functioning, relationships, and sense of stability — and still chooses to move toward it.

That is what stays with me. Not just the theory, not just the method, not even just the outcome. It is the moment a person understands what this work is going to demand of them and does not minimise it, does not dress it up, does not pretend it will be easy and still decides they want their life back badly enough to proceed.

Despite all the uncertainty, all the discomfort, all the disruption, and all the fear, they look me in the eyes and say, let’s do it.