If you have been in clinical practice for any length of time, you will already know that intrusive thoughts are really common. You may have worked with someone who mentions, almost apologetically, a violent image that flashed into their mind while holding their newborn, or a blasphemous thought that arrived mid prayer, or a fleeting sexual thought about someone entirely inappropriate.

People are often mortified by these thoughts, convinced this means something dark about who they are, and desperate for reassurance that they are not, in fact, a danger to anyone.

For many people these thoughts sit at the centre of OCD, including the subtype often referred to as Pure O (Purely Obsessional, where the compulsions are internal thoughts rather than being acted upon and visible to others). However, intrusive thoughts are not the exclusive territory of OCD. They show up in generalised anxiety, in depression, in trauma related presentations, and in most of the general population from time to time.

The difference between a passing intrusive thought and a clinical problem usually comes down to how much meaning gets attached to it, and how hard the mind then works to suppress, neutralise or make sense of it.

Want to learn more?  Join the upcoming training “Intrusive Thoughts: A Treatment Guide” with Vikki Scott, taking place on Saturday 28th November 2026.

Why these thoughts take hold

There is a useful piece of research folklore that gets mentioned a lot in this area, the “pink elephant phenomenon”, where trying not to think about something makes it more likely to intrude, not less. This is worth holding in mind clinically because so much of what keeps people stuck is the effort they are putting into pushing the thought away, rather than the thought itself.

Underneath this struggle there are usually some recognisable mechanisms at play, for example, early experiences of caregiving where emotional containment was limited, a heightened sense of personal responsibility, and sometimes cultural, religious or superstitious meaning-making that turns a passing thought into evidence of moral failure. Shame tends to be the loudest emotion in the room, closely followed by fear and confusion, and clients often arrive already convinced that naming the thought out loud will confirm the very worst about them.

As therapists, a large part of the therapy work is not really about eliminating the thoughts, it is about helping clients change their relationship to them, and helping them understand that having a thought is not the same as wanting it, believing it, or being close to acting on it.

The ego dystonic distinction

Intrusive thoughts of the kind we are discussing are called ego dystonic, meaning they clash sharply with the person’s values and sense of self, and this is precisely why they cause so much distress. A person who genuinely wanted to act on a harmful impulse would not usually be sitting with us in therapy feeling horrified, and seeking reassurance that they are not a monster.

The distress itself is often the clearest evidence that the thought does not reflect intent. Being able to explain this clearly, calmly and without minimising the client’s fear is one of the more powerful things we can offer.

What tends to help

There is no single gold standard approach here, and most experienced clinicians end up drawing on several frameworks depending on the client in front of them.

Cognitive behavioural therapy, particularly exposure and response prevention, remains the most researched approach for OCD related intrusive thoughts, helping clients face the thought or feared situation without performing the mental or physical rituals that usually follow. Metacognitive approaches take a slightly different angle, focusing less on the content of the thought and more on the beliefs a client holds about thinking itself, for example the belief that a thought must be controlled or that thinking something is as bad as doing it.

Acceptance and commitment therapy offers another route in, encouraging clients to make room for the thought without engaging in a tug of war with it, and to keep moving towards what matters to them regardless of what their mind throws up along the way.

Psychodynamic thinking might focus in understanding why a given thought has taken hold for this client, at this point in their life, and what earlier relational patterns might be feeding the anxiety around control and responsibility. Mindfulness and grounding techniques, compassion focused approaches, and straightforward psychoeducation about how the brain’s alarm system works all tend to earn their place in the toolkit as well.

Most people we work with who have intrusive thoughts will not have a diagnosis of any kind, and they will not fit neatly into any manualised description. Our task is to read what is in front of us, ask the right questions, and be willing to sit with some uncertainty. There’s no tidy framework here.

Workshop on Intrusive Thoughts

If this is an area you would like to feel more confident in, we have a new one-day workshop on Saturday 28th November 2026 called “Intrusive Thoughts: A Treatment Guide” with psychotherapist Vikki Scott, who brings both clinical expertise and lived experience of Pure O to the day.

It covers the main categories of intrusive thought, the psychological mechanisms behind them, the emotional impact on clients, and an integrative look at CBT, ACT, metacognitive therapy, compassion focused work and how to work with clients who share their intrusive thoughts with us.

You can find the full details and book your place here:* Intrusive Thoughts: A Treatment Guide*. It runs online via Zoom with a 28 day catch up option if you can’t make it on the day or want to rewatch after the event.

References and further reading

Duarte, D. (2021) Cognitive behavioural therapy in obsessive compulsive disorder, a review. European Psychiatry, 64 (Suppl. 1). DOI: 10.1192/j.eurpsy.2021.1117.

International OCD Foundation (accessed July 2026) OCD Treatment Guide, evidence based therapies, medications and new advances. iocdf.org/ocd-treatment-guide

Khomami Zadeh, L. and Corso, G. (2024) Advances in paediatric obsessive compulsive disorder treatment, a comprehensive narrative review. Cureus, 16(8). DOI: 10.7759/cureus.68225.

Veloso, P. and Pereira, F. (2025) Third generation cognitive and behavioural therapies for obsessive compulsive disorder, a narrative review. Cureus, 17(10). DOI: 10.7759/cureus.94299.

Ryan, E. (accessed July 2026) CBT for intrusive thoughts. MoodSmith. moodsmith.com/intrusive-thoughts/cbt

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