Pure O unmasked: Overcoming obsessive thoughts with CBT

Obsessive-compulsive disorder (OCD) is a widely misunderstood mental health condition, often trivialised by pop culture references to obsessive cleanliness or orderliness. However, the reality of OCD is far more complex, particularly when it comes to a subtype known as Pure Obsessional OCD, or "Pure O."


As a senior psychotherapist with years of experience, I have seen firsthand the profound impact Pure O can have on individuals' lives. This article aims to shed light on what Pure O is, why it is so challenging to manage, and how individuals can seek effective treatment.

What is Pure Obsessional OCD?

Pure O is a form of OCD characterised primarily by intrusive, unwanted thoughts, images, or impulses. Unlike more commonly recognised forms of OCD that involve visible compulsions, such as repeated hand-washing or checking locks, Pure O's compulsions are internal and mental. These might include excessive rumination, mental checking, reassurance-seeking, or avoidance behaviours that are not immediately apparent to others.

Individuals with Pure O experience obsessions that can be distressing and often revolve around themes such as harm, sexuality, religion, or morality. For example, a person might have intrusive thoughts about causing harm to a loved one, even though they have no desire or intention to do so. These thoughts can be profoundly disturbing, leading to intense guilt, shame, and anxiety.

The challenges of managing Pure O

Invisible compulsions: One of the primary reasons Pure O is difficult to manage is the nature of its compulsions. Because these compulsions are mental rather than physical, they can be harder to identify and address. This invisibility often leads to misdiagnosis or delayed diagnosis, as the distress is not outwardly evident.

Stigma and shame: The intrusive thoughts associated with Pure O are often taboo or socially unacceptable, leading to significant shame and reluctance to seek help. Individuals may fear judgment or misunderstanding from others, including healthcare professionals, which can exacerbate their isolation and distress.

Misunderstanding and misdiagnosis: Even within the mental health community, there can be a lack of understanding about Pure O. Patients may be misdiagnosed with generalised anxiety disorder, depression, or other conditions, which can result in inappropriate treatment strategies that do not address the core OCD symptoms.

Cognitive fusion: People with Pure O tend to fuse their thoughts with their identity, believing that having a disturbing thought means something negative about themselves. This cognitive fusion makes it difficult to detach from the obsession, leading to a vicious cycle of rumination and distress.

Avoidance and safety behaviours: To manage their anxiety, individuals with Pure O often engage in avoidance behaviours or seek reassurance. While these behaviours provide temporary relief, they reinforce the OCD cycle and prevent the person from confronting and overcoming their fears.

How can cognitive behavioural therapy help?

Cognitive behavioral therapy (CBT) is a highly effective treatment for obsessive-compulsive disorder (OCD), including the subtype known as Pure Obsessional OCD, or Pure O. CBT focuses on the interplay between thoughts, emotions, and behaviors, helping individuals identify and modify unhelpful cognitive patterns and behaviours that contribute to their distress. Two key components of CBT, exposure and response prevention (ERP) and cognitive restructuring, are particularly beneficial for those struggling with Pure O.

Exposure and response prevention (ERP)

ERP is the cornerstone of CBT for OCD and involves gradually exposing individuals to their intrusive thoughts or fears without allowing them to engage in compulsive behaviours. For someone with Pure O, this means facing the distressing thoughts head-on and resisting the mental rituals, such as rumination or reassurance-seeking, that typically follow. By doing so, individuals learn that their anxiety will eventually decrease on its own, without the need for compulsions. This process, known as habituation, helps to weaken the association between the intrusive thoughts and the intense anxiety they provoke.

For example, if a person with Pure O experiences intrusive thoughts about harming a loved one, ERP would involve confronting these thoughts in a controlled and safe environment, acknowledging them without attempting to neutralise or avoid them. Over time, this reduces the power and frequency of the thoughts, diminishing their impact on the individual's daily life.

Cognitive restructuring

Cognitive restructuring is another crucial component of CBT that helps individuals challenge and change maladaptive thought patterns. People with Pure O often struggle with cognitive distortions, such as catastrophising (expecting the worst-case scenario) or overestimating the significance of their thoughts (thought-action fusion). Cognitive restructuring involves identifying these distortions and developing more balanced, rational ways of thinking.

Through cognitive restructuring, individuals learn to view their intrusive thoughts as just thoughts—mental events that do not reflect reality or their true intentions. This shift in perspective can significantly reduce the shame, guilt, and anxiety associated with the obsessions. By recognising that having a thought does not equate to acting on it, individuals can start to detach from their obsessions and regain control over their mental processes.

Enhancing self-efficacy and coping skills

CBT also equips individuals with practical coping skills and strategies to manage their symptoms effectively. These might include relaxation techniques, mindfulness practices, and problem-solving skills. By building a toolkit of coping mechanisms, individuals can better handle stress and anxiety, reducing the likelihood of relapse.

Additionally, CBT helps to enhance self-efficacy, or the belief in one's ability to manage and overcome challenges. As individuals successfully navigate their exposure exercises and cognitive restructuring tasks, they build confidence in their capacity to handle intrusive thoughts without resorting to compulsions. This growing sense of mastery and control is empowering and can lead to sustained improvements in mental health and well-being.

Long-term benefits and maintenance

The benefits of CBT for Pure O extend beyond the initial treatment period. By internalising the principles of CBT, individuals can continue to apply these techniques throughout their lives, maintaining their progress and preventing relapse. Ongoing practice of exposure exercises and cognitive restructuring, combined with regular check-ins with a therapist, can help sustain the gains made during therapy.


In conclusion, Pure Obsessional OCD, or Pure O, presents unique challenges due to its invisible compulsions and the distressing nature of its intrusive thoughts. However, effective treatments like cognitive behavioural therapy (CBT), particularly through techniques such as exposure and response prevention (ERP) and cognitive restructuring, offer significant relief. By facing their fears, challenging maladaptive thoughts, and developing robust coping mechanisms, individuals with Pure O can reduce their symptoms and reclaim control over their lives. 

The views expressed in this article are those of the author. All articles published on Counselling Directory are reviewed by our editorial team.

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Birmingham, West Midlands, B15
Written by Michael Swift, Integrative Psychotherapist | BSc(Hon), MSc, MBACP
Birmingham, West Midlands, B15

Michael is an award-winning integrative Psychotherapist specialising in the treatment of Anxiety Disorders, OCD, Long-Term Health, and Acute Mental Health Conditions. He has over 10 years of experience working in private healthcare organisations and holds advanced dual qualifications in both Cognitive Behavioural Therapy and Health Psychology.

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