Therapy for existential OCD

CBT and ERP for unanswerable questions about reality, consciousness and death that you cannot stop trying to solve — online across the UK, in English or Spanish.

Does this sound familiar?

What happens when I die? What if none of this is real? Why is there something rather than nothing? How can the universe just go on forever — and how can it not? What if I am the only conscious thing here and everyone else is scenery? Why am I me, looking out of these eyes, and not somebody else?

A philosophy student can close the book at the end of the chapter. You cannot. The question arrives with dread attached and something in you insists it has to be settled before you can go back to your day — and then the answer you reach dissolves in about ten minutes and you start again.

So the hours go. Rumination that feels like serious thinking rather than a symptom. Physics and consciousness videos at one in the morning. The same forum threads, read again. Checking whether the world feels real right now, which reliably makes it feel less so. Asking people whether they think about this too, and needing them to say the reassuring thing in the reassuring way. Avoiding funerals, documentaries, the night sky, birthdays, any conversation that goes near death.

For a lot of people it comes with a strange, unreal quality — as though you are watching yourself from slightly behind, or the world has gone flat and papery. That is derealisation. It is frightening and it is a known anxiety response. It is not the question being answered, and it is not you losing your mind.

How I treat existential OCD

CBT with Exposure and Response Prevention (ERP) — the NICE-recommended treatment for OCD — applies here in a particular way, because the compulsion is almost entirely mental. There is no light switch to check and no hands to wash. There is rumination, which looks from the outside like a person sitting quietly, and which is why existential OCD often goes years without anyone recognising it as OCD at all.

I will not debate whether reality is real with you. If I did, I would simply be performing your compulsion on your behalf, and you would feel better until you got to the car. Instead we learn to catch rumination in the first few seconds — it has a recognisable feel once you know what you are looking for — and to let the question stand there unanswered while you carry on with what you were doing.

Alongside that we go back to what has been avoided, gradually and by agreement: the documentary, the conversation about death, the night sky. And the derealisation usually loosens on its own once the monitoring stops, because checking whether things feel real is what was producing most of it.

This theme also responds well to inference-based CBT, which works on the reasoning that makes an abstract possibility feel like a live emergency in the first place. I use it alongside ERP where it fits, and I will explain what I am doing and why rather than just doing it.

What to expect

We begin with one or two assessment sessions to map how your version of this works — which questions, which triggers, and what you do afterwards. A typical course runs 12–16 weekly sessions of 50 minutes, with short experiments between them, because that is where most of the change happens.

Early on, a good deal of the work is simply learning to tell rumination apart from thinking. People arrive convinced that the difference is obvious and leave the first few sessions surprised at how much of their day was the former wearing the clothes of the latter.

Sessions are online over secure video, anywhere in the UK or beyond, or in person at Sanctuary Therapy Centre in Prestwich and Hebden Bridge. We review progress openly with a short measure, so change is visible rather than a matter of impression.

Common questions

Isn't this just being a deep thinker? Plenty of people find these questions fascinating and sleep fine. The difference is not the subject matter — it is the dread, the compulsion to resolve it, and the hours it takes. Curiosity can be put down; this cannot.

What if the questions really are important? They are. They have occupied serious people for three thousand years, which is rather the point: they are not the kind of thing that gets settled before Tuesday. Therapy does not make them trivial. It gives you back the ability to hold them the way everyone else does.

Everything feels unreal, like I'm watching myself. Am I losing my mind? No. Derealisation and depersonalisation are common anxiety responses, and they intensify with exactly the kind of self-monitoring this theme produces. They ease as the checking stops.

Will therapy give me an answer? No, and I would be suspicious of anyone offering one. The goal is that the question stops functioning as an emergency — which turns out to be a far more reachable target than certainty, and considerably more useful.

Is existential OCD really OCD? Yes. The obsessions are the questions and the compulsions are mental — reviewing, researching, checking how real things feel, seeking reassurance. Same mechanism as any other theme, same treatment.

Can sessions be in Spanish? Yes — I offer therapy in English and Spanish.