Mental compulsions: the OCD nobody can see
Updated: 7 days ago
If you've ever lain awake going over the moment the waiter said "enjoy your meal" and you said "you too", you'll know that everyone replays things sometimes. With OCD, though, the replaying can turn into something that takes hours, feels urgent, and never quite gets you to the answer you're looking for, and that's what I want to talk about today.
I'm Charlotte, an OCD specialist therapist in the UK. When people picture OCD they usually picture hand washing or lining things up, and so many people with OCD never recognise themselves, because most of what they do happens quietly, in their head, where nobody else can see it.
First, what's normal
Going back over an awkward conversation, wondering whether you upset a friend, or saying a little "please let them be okay" when someone you love is travelling are all ordinary, human things to do, and none of it on its own is OCD.
So when might it be OCD?
OCD is a cycle of obsessions (thoughts, images, urges or doubts that keep coming back, feel unwanted and cause real distress) and compulsions (things you do, out loud or in your head, to make the distress settle or to feel sure).
Clinicians usually start thinking about OCD when that cycle causes real distress, takes up a lot of time, often more than an hour a day, or gets in the way of daily life. Only a qualified professional can say whether it's OCD, so if this sounds familiar, it's worth asking rather than guessing.
What mental compulsions can look like
A mental compulsion is anything you do in your head to check, reassure yourself, or neutralise the distress of a thought. A few of the ones I hear about most:
Replaying conversations: did I say the right thing, did I hurt somebody's feelings, how did that person react when I said that?
Reviewing memories: going back over something from years ago, again and again, to work out what it means about you.
Mental checking: checking how you feel about your partner, checking whether a thought brought a feeling with it, or checking your body for a reaction.
Self-reassurance: arguing with the thought, listing the reasons it can't be true, or telling yourself the same thing until it feels settled.
Neutralising: replacing a "bad" thought with a "good" one, or saying a word, a phrase or a prayer in your head to cancel it out.
Analysing: trying to work out why you had the thought, and what kind of person it makes you.
You might hear the term "Pure O" for OCD where the compulsions are mostly mental. It's a helpful label for lots of people, and it's worth knowing that the compulsions are still there, they're just harder to spot.
Why they're so easy to miss
From the outside, someone with mostly mental compulsions can look calm, even distracted. Inside, they may be reviewing, checking and neutralising for hours a day. Mental compulsions can also feel like thinking, or like being responsible, so many people don't realise they're doing anything at all, which is why so many go years without the right help.
In my years in NHS services and now in private practice, if I had to name the thing that gets missed most, it's the mental compulsions.
Why they keep the loop going
A mental compulsion works the same way as a visible one. It brings a moment of relief, the relief fades, and the doubt comes back, often a little louder, so round it goes. In therapy, we treat mental compulsions just like we do physical ones.
One small thing to try
For today, just notice. When you catch yourself replaying, reviewing or checking in your head, see if you can gently name it, "there's a mental compulsion", without judging yourself for it. Noticing the loop is often the hardest step, and the most important one.
If that feels hard, that makes complete sense, and it's one of the reasons working with an OCD therapist helps: the quiet compulsions are easy to slip back into without someone alongside you to spot them.
What helps
OCD is treatable and recovery is possible. The treatment NICE recommends first is CBT with exposure and response prevention (ERP), where we work together, at your pace, to gently face the doubt while you practise not doing the compulsion, including the ones in your head. Other approaches like I-CBT and ACT can help alongside it.
If you'd like some small first steps, my free guide ERP Starter Experiments has gentle first-step ideas across 19 OCD themes.
Quick answers
Tap a question to open it.
What if I can't say my thoughts out loud?
That's very common, and we never start there. You can share as much or as little as you like, in your own time, and you can write things down if that's easier. Whatever you tell me, I won't be shocked.
Does CBT with ERP work for OCD?
CBT that includes Exposure and Response Prevention (ERP) is the treatment recommended for OCD in NICE guidance and by the NHS. Many people find their symptoms reduce with it. Everyone responds differently, so we review how it's going as we work.
Will I be made to do things I'm not ready for?
No. We plan every step together, aiming for something that feels a little stretching but still doable. You're always allowed to say no.
How many sessions will I need?
It varies. Many courses of CBT with ERP run somewhere between 8 and 20 sessions, and some people need fewer or more. We'll agree a plan at the start and review it regularly, so you always know where we are.
When you're ready
I work with adults online across the UK, and I'm a BABCP accredited CBT therapist with 12 years in NHS and community mental health services. You don't need to have it all figured out before you get in touch.
For bite-sized OCD support most days, come and find me on Instagram at @the_floral_therapist.
Charlotte
If you feel unsafe, or worried you might act on a thought, call 999 or go to A&E, call NHS 111 and choose the mental health option, or call Samaritans free, any time, on 116 123.
This post is educational and isn't a replacement for therapy. Please speak to an OCD specialist or contact your GP for further support.
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