“Pure O” and Mental Compulsions Treatment in Washington State
When it feels like everything happens inside your head.
From the outside, nothing looks like OCD. You don't wash your hands more than anyone else, you don't line things up. But you haven't had a quiet moment in years. A thought lands, and instead of passing, it turns into a review. You go back over a conversation, word by word, checking whether you said something wrong. You scan your own body for a feeling that would tell you what you actually think or want. You argue with the thought, feel like you've won, and then find yourself starting over ten minutes later because the win didn't stick. None of this shows up on the outside. You can be sitting across from someone, nodding along, while your whole mind is somewhere else entirely.
People call this "Pure O," short for purely obsessional, though the name is a little misleading. There are always compulsions. They just happen to live entirely in your mind, which makes them almost impossible for anyone else to see, and for a long time, hard for you to name as compulsions at all. You've probably just called it "overthinking," or wondered if you're the most anxious person you know, or worried something is wrong with you that nobody else seems to see either.
Maybe this sounds like you
Mentally reviewing a conversation, memory, or decision, sometimes for hours, looking for certainty. Silently repeating a phrase, prayer, or word to neutralize a thought or "cancel it out." Scanning your body or your emotions to check what you're "really" feeling, especially about a relationship, your identity, or your morality. Arguing internally with the thought, building a rebuttal, replaying the rebuttal to make sure it holds. Comparing your current thought or feeling to a past one, looking for a pattern that proves something about you. Seeking reassurance indirectly, by asking a question that sounds casual but is really a compulsion in disguise. Avoiding situations that tend to trigger the spiral, without ever naming to yourself that it's avoidance.
What is “Pure O” OCD?
OCD is built from two parts, an obsession, an unwanted, intrusive thought, image, or urge that causes distress, and a compulsion, something done deliberately to reduce that distress or prevent a feared outcome. Compulsions are usually pictured as visible, washing, checking, counting out loud. But a compulsion is any deliberate mental or physical act aimed at neutralizing an obsession, and mental rituals count exactly the same as physical ones. Reviewing, mental checking, silent praying, thought replacement, and self-reassurance are all compulsions. They're just compulsions nobody can watch you do. That's why "Pure O" isn't actually a different disorder from the OCD most people picture. It's standard OCD where the compulsions largely happen in your head.
Why Pure O gets missed
Two reasons why mental compulsions in OCD are more likely to go undiagnosed for years.
First, without obviously visible compulsions, both the person experiencing it and most clinicians default to a different label, generalized anxiety disorder, or just "overthinking." Generalized anxiety and Pure O can look similar on the surface, but they function differently. GAD worry tends to be about real, if unlikely, future events, without a specific mental ritual attached to neutralize it. Pure O has a repeating, identifiable pattern, a specific trigger thought, followed by a specific mental act done deliberately to relieve it.
Second, people with Pure O are often very good at describing their anxiety and unusually struggle at identifying their own compulsions, because a mental compulsion doesn't feel like a ritual from the inside. It feels like thinking. Reviewing a conversation for the fortieth time feels like being thorough, not like performing a compulsion.
What ERP looks like for Pure O
The hardest part of treating Pure O usually isn't the exposure. It's mapping the compulsions since most do not have a clear idea on what they are in the first place. We spend time on this together, tracking exactly what mental act follows which trigger, until the pattern is visible enough to interrupt.
Next we will deliberately trigger the obsessional thought (reading it, writing it, saying it out loud) and then doing nothing, no review, no rebuttal, no neutralizing phrase. Letting a conversation or decision stay unreviewed even when the anxiety to go back over it is strong. Sitting with an uncertain feeling, about a relationship, a belief, your own character, without mentally scanning for the "true" answer underneath it. Practicing letting an intrusive thought sit unanswered for a set period, then gradually extending that period.
Response prevention here is almost entirely about catching mental acts in real time since they're fast and often automatic. Over time, with practice, catching these mental acts will become easier and more automatic.
What treatment with me involves
I'm Eric Taylor, LMHCA, and OCD treated with ERP is the focus of my practice. Sessions run 50 to 60 minutes weekly to start. An extended intensive format can be especially useful, since some exposures benefit from more room than a standard hour allows. I see clients in person in Spokane, where in-session exposure work is often easiest for this subtype, and by telehealth statewide.
My standard session fee is $150 (90837) per session. If you have out-of-network benefits, I provide a superbill you can submit for reimbursement, and I'm happy to talk through that on a consultation call. Full pricing is on the fees page.
FAQs
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Yes, and it's common. A significant part of early sessions is mapping the pattern together, since mental compulsions often don't feel like rituals from the inside.
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It can feel uncomfortable at first, which is expected. Avoiding the content is what keeps the cycle going. Naming it plainly, without a mental ritual afterward, is what starts to unwind it.
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Yes. It's common for the same mental-compulsion pattern to attach to more than one theme, relationships, morality, health, identity, over time or at once. Treatment addresses the underlying mechanism, which tends to generalize across themes.
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It varies by severity and how entrenched the mental rituals are, but many clients notice meaningful change within 12 to 20 sessions of active ERP work.
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No. Assessment happens in the first sessions, and many clients arrive without a prior OCD diagnosis at all.
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