Why Talk Therapy Often Makes OCD Worse (And What to Do Instead)
When a client with Obsessive-Compulsive Disorder (OCD) has been in therapy for years without improvement — or has gotten worse — it's worth asking a direct question: what kind of therapy were they actually receiving?
Talk therapy is a broad term. And for most presenting concerns, a warm, insight-oriented, or supportive therapeutic approach can be genuinely helpful. OCD is a meaningful exception. For clients with OCD, certain common therapeutic practices don't just fail to help — they can actively reinforce the symptoms and make them worse.
Understanding why is essential for any clinician working with this population.
The Scale of the Problem
This isn't a niche concern.
In December 2025, the International OCD Foundation (IOCDF) released the largest study of OCD diagnosis and treatment patterns ever conducted. The findings were stark: only 2% of people diagnosed with OCD have any documented evidence of having received Exposure and Response Prevention (ERP) therapy — the gold-standard, first-line treatment for OCD.
Most people with OCD are currently in therapy with a well-meaning clinician who isn't trained to treat what they have.
The consequences aren't abstract. The same report estimates that people with OCD are up to five times more likely to die by suicide than the general population. This is not a quality-of-life gap. It's a safety issue.
The IOCDF report also named what needs to change: expanding clinician training so more providers can accurately diagnose OCD and deliver evidence-based treatment with fidelity.
The full report is available at iocdf.org/ocdcarecrisis.
What Happens in Conventional Talk Therapy
In a typical therapy session for anxiety or depression, it makes clinical sense to:
Explore the meaning behind a distressing thought
Offer perspective or reassurance
Help a client understand the origin of their fears
Encourage them to process what they're feeling
With OCD, each of these interventions can function as a compulsion.
OCD is maintained by the relief that compulsions provide. When a client experiences an obsession and then engages in a behavior — physical or mental — that reduces distress, the brain encodes that behavior as necessary. The cycle then repeats and strengthens.¹
Reassurance is one of the most common compulsions in OCD, and it operates the same way whether it comes from a family member, an internet search, or a clinician. When a therapist says "I really don't think you'd ever do that" or "Let's explore where this thought comes from," the temporary relief the client feels isn't therapeutic. It feels supportive, but it actually reinforces the idea that the thought required a response.¹
This plays out across OCD presentations in ways that can be easy to miss in session. The following examples are illustrative only and are not based on any real client; any resemblance is coincidental.
A client with contamination OCD says "I touched a doorknob and now I can't stop thinking I'm going to get sick and die." The therapist responds: "The risk of getting seriously ill from a doorknob is really very low." The client feels momentarily better. The reassurance worked — which means the client will need it again.
A client with harm OCD says "What if I actually want to hurt my child?" The therapist responds: "Everything I know about you tells me you would never do that." The client exhales. However, the obsession returns within hours, often stronger.
A client with relationship OCD (ROCD) says "I just need to know if I really love my partner." The therapist spends the session exploring the history of the relationship, looking for evidence of genuine attachment. The client leaves with a temporary sense of certainty — and comes back the following week needing to do it again.
A client with scrupulosity says "I said something mean three years ago and I think I'm a bad person." The therapist says "That doesn't make you a bad person at all — you clearly have a conscience." There is some relief, but it’s only temporary, and the obsessive thought returns.
In each case, the therapist is responding reasonably to a distressed person. Therapists want to care for their clients. The problem isn't the intent — it's the function. Every response that provides relief in response to an obsession teaches the brain that the obsession was worth responding to.¹
When Therapeutic Approaches Become Part of the OCD Cycle
McKay, Abramowitz, and Storch (2021) have described specific mechanisms by which non-ERP interventions can worsen OCD symptoms. Their framework identifies several categories of potentially harmful treatments, including cognitive approaches not specifically tailored for OCD, misapplied evidence-based interventions, and insight-oriented work that increases the client's focus on the content of their obsessions.²
Psychodynamic and insight-oriented approaches carry a particular concern here. McKay, Abramowitz, and Storch note that psychodynamic therapy has been associated with symptom worsening in OCD, and that insight-oriented work may increase a client's focus on obsessional content in ways that reinforce rather than interrupt the cycle.⁴
Standard cognitive restructuring — helping a client challenge the accuracy of an obsession — can also backfire. The International OCD Foundation's expert review notes that this approach can inadvertently function as a reassurance ritual: clients learn to recite a corrective thought as a mental compulsion.⁴ The relief is temporary. The checking continues.
What Clinicians Often Miss
The challenge is that these patterns don't always look like a problem in session. The therapeutic relationship may feel strong. The client may appear to be engaging thoughtfully. They may express relief after discussing their fears.
That relief is the signal, not the goal.
OCD is maintained by relief-seeking. Any therapeutic technique that provides relief in response to an obsession — regardless of how clinically sophisticated it sounds — is feeding the cycle.
This is also why accommodation matters. When clinicians modify their approach because a client appears distressed by an obsession (avoiding the topic, offering extra validation, answering the same question in different ways), it parallels the family accommodation patterns that have been shown to predict worse treatment outcomes in both pediatric and adult OCD.¹
For more on how compulsions show up in clinical settings — including mental compulsions and the role ofego-dystonic thoughts in OCD — the ocd.xyz blog covers these presentations in detail.
What Actually Helps: ERP
Exposure and Response Prevention (ERP) is the first-line psychological treatment for OCD, with robust support across numerous clinical trials.¹ ERP works by targeting the obsession-compulsion cycle directly: clients are guided to face obsession-triggering stimuli without performing the compulsion, allowing the anxiety to decrease naturally over time, or helping them learn they can tolerate the discomfort.
ERP is not supportive listening, and it’s not processing. It is a structured, active intervention that requires the clinician to stay out of the relief-providing role, and as a clinician that can feel very counterintuitive at times.
What effective OCD treatment looks like in practice:
Functional assessment of what the compulsions actually are (including mental rituals, reassurance-seeking, and avoidance)
Collaborative hierarchy development with the client
Structured exposure work with response prevention
Active monitoring of therapist accommodation within sessions
ERP requires specific training. Clinicians who have received general CBT training but not OCD-specific ERP training are at genuine risk of unintentionally reinforcing the disorder — not because of any failure of skill or care, but because the clinical intuitions that work elsewhere can work backward with OCD.
The Scope-of-Practice Question
This is also a referral question.
Clinicians who are not trained in ERP may be doing their OCD clients a disservice by continuing general therapy. That's not a judgment — it's a structural reality of how this disorder responds. The most helpful thing a non-specialist clinician can do is accurately identify OCD presentations, avoid inadvertent accommodation in session, get trained to treat ERP if they’re interested, and connect clients with ERP-trained providers.
If you're working with clients who may have OCD and you want to build your clinical knowledge of assessment, differential diagnosis, and ERP fundamentals, OCD.xyz offers continuing education training for mental health professionals — including live cohort-based and home-study formats approved for NBCC CE credit (ACEP No. 8051).
Not ready for full training yet? Start with the free guide: What to Do When Your Clients Have OCD and You're Not an OCD Specialist.
References
McKay, D., Abramowitz, J. S., & Storch, E. A. (2021). Mechanisms of harmful treatments for obsessive–compulsive disorder. Clinical Psychology: Science and Practice, 28(1), 52–59.https://doi.org/10.1111/cpsp.12337
Abramowitz, J. S., Blakey, S. M., Reuman, L., & Buchholz, J. L. (2018). New directions in the cognitive-behavioral treatment of OCD: Theory, research, and practice. Behavior Therapy, 49(3), 311–322.https://doi.org/10.1016/j.beth.2017.09.002
McKay, D., Abramowitz, J. S., & Storch, E. A. (2019). Ineffective and potentially harmful psychological interventions for obsessive-compulsive disorder. OCD Newsletter (Spring 2019). International OCD Foundation.https://iocdf.org/expert-opinions/ineffective-and-potentially-harmful-psychological-interventions-for-obsessive-compulsive-disorder/
