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What Is the Compulsion in Obsessional OCD?

Don Rosenberg

What is the Compulsion in Obsessional OCD? 
When Rumination IS the Compulsion 
Don Rosenberg
February, 2026

I want to tell you about an insight that I had about OCD obsessions [Obsessive Compulsive Disorder].

Leona’s Obsessions

The client, Leona, was very obsessional. She was worried that she had made a decision that was incorrect and she should have made a different decision. It involved choosing between two different colleges, one closer to home, one further away. The former was expressively preferred by her family.  The latter offered a program that she very much wanted.  

After she committed to the more distant school, she worried that her reasons for her choice were inadequate. She thought that the reasons not to make that choice probably were better. What made it OCD was how this choice and her thoughts haunted her. It came into her mind unbidden. At times when she needed to concentrate on something else, then she could not shake it. She would think about it and think about it. She asked herself what she did wrong? Should she have undone her choice? Although her parents accepted her choice, she ruminated over hurting their feelings. Then she obsessed about whether she would make fiends there. She worried about disappointing the closer school by turning them down. 

She suffered from what we call Obsessional Doubt, a hallmark of OCD – questioning one’s own perceptions and thinking, beginning to question if what you saw and heard and thought was actually true, then needing to go over and over the situation to double and triple check.

Undoing is one of the defenses in OCD. She would think about undoing her bold decision to go to the far school.  Ruminative Obsession is another feature of OCD as she amply demonstrated.

She worked herself up into an extreme of anxiety that required more reassurance than anyone could reasonably give her. She wanted support that she had made an okay choice. But no amount of it comforted her thoughts.  Perhaps, she thought, she should retract her choice and do the other choice, and this went on and on.  Obsessions overcame her a couple of times a day accompanied by crying and anxiety to the point of dizziness. We suspect that, if she had changed her decision, she would have ruminated over the missed opportunity at the far school and she would have worried the close school was the wrong choice. When she was calmer, Leona lived with the fear the thoughts would cascade once again.  

This obsession with not overt compulsion was new for me.  I was used to obsessional thoughts that were more extreme, unrealistic, and accompanied by a compulsive behavior. For example, a cab driver was sure that he was going to bring home a disease to his partner, one he contracted from the passengers in his cab.  So, he took a great deal of time to spray it with disinfectant after every fare.  The time needed for this compulsion suppressed his income. One client drove around the block a set number of times before giving up the idea she had hit someone with her SUV – when there was no hit or bump to suggest she had done so.  In these case, the compulsion, disinfecting in the one and driving round and round, were evident. 

Uncovering the Compulsion

But in Leona’ case, where’s the compulsion? After a couple of sessions, I realized the compulsion is to keep thinking the obsession and to keep thinking it and thinking it until it feel neutralized. Except it’s never neutralized.  It may be quiet for a few hours and then recur.  

When I asked her what she does mentally when the doubts emerge, we could see the compulsion was covert, internal.  She worked to reassure herself and to seek other’s reassurance.  She weighed her pros and cons for her decision.  She tried to distract herself.  She tried to assure herself she was a good person and was not a disappointment; but the act of doing this – and it was not entirely convincing to her – reinforced the need for reassurance and, therefore, the obsession. She may have gone over her decision hundreds of times! Every repetition trains the brain to act on high alert as if a serious, dangerous matter is at hand.  The mind becomes overfocused on scanning for threat and problems. 

It’s typical for people who have obsessional, ruminative, intrusive thoughts that the harder they try to answer their thought and the more they think it, the more it returns and with increasing power.  One of my mentors say, “Anxiety spreads.”  So it does.  More and more time goes into these thoughts.

False Starts

Often, therapists try to reason with the thoughts.  “Leona, you made a good choice. It was a difficult one, but you chose the program you most wanted.” Reassurance made no difference.  One could grow impatient with the rumination.    

Therapists might try some analysis.  Behind the thoughts was the fear of disappointing others.  When else had she done that.  Perhaps it was a fear of being further from home and more on her own.  What was her angst about independence?  Perhaps it was a fear of failure. But, analysis of the fear behind the thought did absolutely nothing. No analysis would reduce the vehemence of the obsessive thoughts. Therapists have long understood that analysis of the themes in obsessions may not end them. 

Two of the most common compulsions are washing due to fear of contamination and checking to make sure some feared event has not happened, such as leaving the gas on, the door open, or harming someone with one’s car.  In Exposure with Response Prevention [ERP], an evidence-based treatment for OCD, the therapist has the client overcome the compulsion by not doing it, in fact by doing the opposite.  If the compulsion is to clean, we have the client do something to dirty or contaminate his or her hands, and we prevent washing.  If the compulsion is checking, we may have the client leave the iron on for 30 minutes then 40, etc, without checking.  Or just leave the house and not indulge the urge to go back to check the door.  We ask the person to tolerate the uncertainty of what may have happened. We have the person feel the fear but not indulge the compulsion.  We may have the person write out the fear – “the house will catch fire” – but sit with the fear until it subsides. The fear will subside. 

ERP and Other Therapy for Leona

1. ERP Therapy.  Once I realized that the compulsion was to wade deep into these thoughts, we could then go to a more effective approach.  We had to stop reinforcing the obsessions.  We had to sit with the anxiety without answering the demands of the obsessions. When I sensed the Leona was telling me about an episode of rumination or was launching into one in the session, I said, “You are obsessing. I’m changing the subject. You can update me on your job or your family or something effective you did this week.”  Or, “Let’s not indulge your compulsion to go over that again and it just ends with you feeling badly about yourself.”  Or, “I wrote out the steps in your thought process. Let’s give it a name. [For this article, let’s call it Leigh.]  Then let’s wonder when Leigh came into your life and when you don’t indulge Leigh’s demands.”  Or, “No reassurance. No rethinking what is done. It’s done. Let’s just sit with being anxious about the uncertainty, and Leigh coming into it, and that there are no right answers and count aloud until the anxiety subsides.” Or, “There you go again doing that. Miss Leigh is taking over. Sorry, not going to talk about that.”  “Tell me about when you resisted doing it.”  “When could you tell yourself ‘reinforcing that does not help me’ and move on to something else?” 

We also noted that when she obsesses, she is implying something negative about herself.  The words she came up with were failure, disappointment, rebel, hurtful, waste, fool.  We did not counter those – reassurance – but rather encouraged her to just sit with those words.  After some time, she realized the words were only there when she obsessed; other times, such as in class, her identity included more positive words, such as studious, fast learner, friendly.

2. EMDR Therapy. We used another treatment Eye Movement Desensitization and Reprocessing [EMDR]. In EMDR, we bring up the emotional situation along with those negative self-beliefs and the associated emotions.  Then we use bilateral (left-right-left-right etc) stimulation [BLS]  in the form of eye movements or tapping, back and forth.  After sets of BLS, the situation no longer brings up distress. We used EMDR to desensitize the obsession by bring up the worry she made a wrong decision, the belief “I am a disappointment,” and the associated anxiety.  She reported the obsessive thoughts subsided and seemed less powerful and the negative belief dropped out. 

3. Mindfulness Therapy. We could practice mindfulness regularly. In a mindfulness exercise, we practiced putting thoughts into bubbles that floated away and burst.  The obsessions are not more valuable than other thoughts.  And mental contents are mostly just bubbles that float away and pop. That she could do this exercise reinforced pulling away from obsessing.  

We did not push the thought away. We did not fear it.  We basically were saying this is just not important, not useful, not helpful, not answerable, and not worth the time.  We used the idea of scheduling, that “I don’t have time for this right now. I’ll go over my concerns about it this evening.”  After a while, evening came and she did not come back to it.  

Leona’s Results

Once we did all this, something I have not see in discussions of OCD started to happen.  Leona no longer saw her obsessive thoughts as going along with the tone and fabric of herself and her identity.  We term that Ego-Syntonic.  She began to see the thoughts as unwelcome, not part of herself, something she did not have to answer, something to observe and something to let float away.  We call that Ego-Dystonic – unfavorable and against the grain, fabric, and values of who one is.

Over just a relatively short time, about three months of sessions twice per week, the frequency and intensity of the obsessions began to diminish. Once we had more emotional distance, then we could see other ways in which she was reinforcing rumination. She revealed how much she had sought reassurance from family.  So, we asked her to stop that altogether.  Very soon the frequency of the episodes reduced from as many as 8-10 per week to as little as one a week –and eventually one every couple of weeks. And then the intensity dropped from a SUDS (subjective units of distress on a scale of 0 to 10, where 10 is the most distressing) of 10 to maybe a SUDS of three. After a year, the frequency was even lower and the SUDS remained low.

If you act with neutrality, not pushing the thought away, not solving it, not analyzing it, not fighting it, that teaches the brain the thought is not important, just like most thoughts.  It also retrains the brain not to be on watch for threats, not to worry so much about mistakes or things going wrong.  I think a key moment in the process was when she saw the entire process of ruminating as ego-dystonic. 

When I met her, Leona had seven months before school would start.  So we set the goal of being emotionally ready to start school.  As she would be in another state, the therapist could not meet with her.  She could choose a trial of one of the medications that tend to help with OCD and she could meet with a counselor at the school.  We could meet whenever she returned to see her family.  Because she would be away from our therapy for a few months at a time, we recorded some of the instructions and the mindfulness exercise so she could continue to reinforce more effective thinking patterns. On follow up, she made it through the school year with good grades and made some friends. The reduction in frequency and intensity of her obsessional doubts continued to be minimal.  

OCD can be disabling.  But you see it can be treated effectively. If you need help with OCD, do seek help from a therapist who knows ERP therapy.

Shorehaven Behavioral Health is a major mental health clinic and training center with therapy offices in Brown Deer, Greenfield, and Mt. Pleasant, and also offering telehealth throughout Wisconsin. We specialize in challenging cases and rapid access to services.  In addition to depression, anxiety, behavioral problems, and most other psychological problems, we work extensively with children & families and with substance use problems. We also accept referrals for substance abuse care from clinicians who are not comfortable with that population.  We make starting therapy easy with one call to  414-540-2170.
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Note: My written, instructional case examples are heavily disguised, composites, and/or cases from decades past.  They cannot be associated with or identify an individual.