Pure-O is a misnomer that stuck. People use it to describe obsessive compulsive disorder where the compulsions are not obvious. There are no hours of visible handwashing or door checking. Instead, the person compulsively checks in their head. They argue with thoughts, replay moments, seek internal certainty, or mentally neutralize feared outcomes. The suffering is real, and the rituals consume just as much time and energy as the classic behaviors.
Effective OCD therapy accounts for this invisible workload. When treatment targets the mental rituals directly, the symptoms lose their fuel. What follows is a grounded walk through how clinicians assess and treat Pure-O, including the tools that work, the pitfalls that slow progress, and how to tailor care when ADHD, autism, trauma, or health anxiety are part of the picture.
What Pure-O really means
Purely obsessional OCD sounds like it describes obsessions without compulsions. In practice, most people with this presentation have compulsions, just not the ones you can see. The common themes are familiar: harm, sexual orientation and attraction, religion and blasphemy, contamination without visible washing, responsibility for others, relationship doubts, and fears of moral corruption. After a trigger, the person begins a quiet ritual that can run for minutes or hours. The outside world sees a thoughtful pause. Inside, it feels like a courtroom in full session.
The reason the label persists is that it helps people recognize themselves. If you are unsure whether your patterns fit OCD, pay attention to the function of your responses. Compulsions try to get rid of doubt, discomfort, or imagined danger. In Pure-O, the compulsion happens in the mind, and it works the same way as a lock check. It just uses logic, memory, or prayer instead of a doorknob.
Why mental rituals matter more than the content of thoughts
Intrusive thoughts are universal. Most adults report at least a few alarming or bizarre thoughts each week. What distinguishes OCD is not the presence of unwanted thoughts, but the relationship to them. People with OCD overestimate the importance of thoughts, assign them meaning, and then get pulled into rituals aimed at certainty or safety. The content can be anything. The process is the problem.
In therapy, we do not argue with the content. We train a different process. If you stop feeding thoughts with analysis and reassurance, they fade to background noise. The key is to recognize what counts as a ritual, and then practice response prevention in a way that is deliberate, compassionate, and repeatable.
Recognizing mental compulsions
Mental rituals often masquerade as reasonable reflection. A person says they are just trying to be a good partner, a moral person, or a careful driver. The test is whether the behavior is repetitive, driven by anxiety, and aimed at certainty or relief. These are among the most common:
Rumination: prolonged analysis to get certainty, like reviewing conversations for signs of attraction or intent. Mental checking: scanning memory to confirm you did not offend someone, hit a cyclist, or commit a sin. Neutralizing and counter-arguing: silently repeating phrases, prayers, or positive statements to cancel a thought. Reassurance seeking in your head: imagining what a therapist, priest, or friend would say to declare you safe or good. Thought monitoring: constantly testing whether a thought sparks arousal, disgust, or calm to infer what it means.Clients also describe covert avoidance. They steer attention away from reminders, keep their eyes soft to avoid reading a word that might trigger them, or choose routes that minimize uncertainty. These are rituals too, just subtler.
A brief vignette
A 29-year-old teacher, let us call him Marco, drives to work and hits a pothole. His chest tightens. Did I hit a person? He turns off the radio to focus. He replays the last minute, frame by frame. He tries to feel whether the bump was a curb or a body. He searches the rearview mirror. He tells himself he would have heard a scream. The doubt settles for a moment, then returns stronger. What if the person was already on the ground? He circles back to check. This loop costs him thirty minutes and leaves him shaky in the classroom.
Marco is not careless or irrational. He is caught in a set of rules that tell him uncertainty is unacceptable. Therapy targets those rules and the rituals that enforce them.
Assessment that sets up treatment
A good intake does more than label the theme. It maps triggers, rituals, avoidance, and beliefs about responsibility and harm. I ask for a typical day, then a worst day. I time how long rumination lasts and estimate how many reassurance questions happen in a week. I measure severity with the Y-BOCS or DOCS, and I revisit those scores every four to six weeks to track gains.
Differential diagnosis matters in Pure-O because other conditions can mimic parts of the picture. Trauma symptoms can involve intrusive memories that are linked to real events and improve with trauma therapy. Generalized anxiety brings chronic worry that is broader, more future focused, and less tied to ritualized relief. Depression can drive sticky, self-critical rumination that is not compulsive in function. Psychosis involves loss of reality testing, which OCD does not.
Neurodevelopmental traits also shape care. ADHD can make sustained response prevention harder and exposures more chaotic. Autistic clients may report sensory triggers and a strong need for predictability. If attention or social cognition concerns are prominent, consider ADHD Testing or autism testing to inform how you pace sessions, structure homework, and select tools. An accurate map reduces false starts.
I also ask about medication history, sleep, substance use, and physical health. Caffeine and sleep deprivation amplify intrusive thoughts. Stimulants for ADHD can, in a subset of people, spike anxiety in the short term, which we factor into timing and dosing with the prescriber. These details are not side notes. They are levers we can adjust.
How ERP changes for mental rituals
Exposure and response prevention remains the backbone of OCD therapy. With Pure-O, we shift how we do exposures and what we prevent. There is less touching doorknobs and more leaning into thoughts, images, and sensations without doing the mental cleanup.
The basic sequence is straightforward when described well and practiced with coaching:
Identify a clear trigger and the linked urge to perform a mental ritual. Create a provocative cue, such as a sentence, image, or audio, that evokes the obsession on purpose. Approach and stay with the discomfort, and at the same time, withhold rumination, mental checking, and reassurance. Track the urge like a wave, let it rise and fall on its own, while you do something values based or mundane. Repeat often, vary contexts, and allow natural uncertainty to remain after the exercise.The spirit matters. Exposures are not about proving you are safe. They teach your brain that you can coexist with uncertainty without rituals. Over time, your threat system recalibrates.
Designing exposure scripts that actually work
Good exposures fit the person’s life and hook into the right fear. For harm OCD while driving, I might ask a client to listen to a recording that says, There is a small chance I hit someone and will never know. Then we drive past speed bumps without circling back. We keep the statement short and blunt, without neutralizing qualifiers. If the fear is blasphemy, the script might read, I may be a bad believer, or God might punish me. For sexual orientation or attraction obsessions, an exposure could involve looking at a mix of images and noticing any sensation without testing or labeling it.
Imaginal exposures help when the feared outcome is catastrophic and remote, like going to prison for a mistake you missed. We write a one to two page story in the present tense that sits with the worst case, then read it aloud daily. We do not insert a happy ending to soothe. If the client starts to mentally argue with the story during the reading, that becomes the response prevention target.
I ask clients to practice brief, frequent reps. Five minutes, five times a day, usually outperforms one long session. The brain learns from the repetition more than the drama.
Stopping rumination is a skill, not a slogan
Telling someone to stop thinking is useless. Rumination is sticky because it carries the promise of relief. We teach alternatives that keep dignity intact. One approach is attentional anchoring: choose a concrete action, like feeling your feet and naming three sensations while letting the thought sit in the background. Another is the posture of willingness from Acceptance and Commitment Therapy. You say, I am willing to have this thought and feeling while I live my life. That sentence is stronger than any counterargument because it does not take the bait.
I also coach a technique called postponement. When the urge to ruminate hits, you schedule it for later, perhaps a 15 minute window at 6 p.m., and you defer to that time. If it comes back, you defer again. When the window arrives, you sit with the discomfort without analysis. Over a few weeks, the brain stops flagging the subject as urgent.
For clients who benefit from structure, we use brief self-statements that describe the process rather than convince. Examples https://jasperiltq040.yousher.com/neuropsychological-adhd-testing-what-the-results-mean include, This is an obsession. Certainty seeking makes it worse. Allow and move. These are not mantras to cancel thoughts. They are reminders of the plan.
Working with shame and taboo content
Many clients wait years to describe their thoughts because the topics feel unspeakable. In sessions, we name the shame and normalize the mechanics. Then we target the beliefs underneath, like thought action fusion and inflated responsibility. A person might believe that thinking a thought increases the chance it will happen, or that a good person would not have such thoughts at all. We test these beliefs in structured ways. If the client fears arousal means desire, we distinguish reflex from intention and practice allowing sensations without interpretation.
Language matters. When a client with sexual orientation obsessions says, I need to know what I am, we shift from identity labels to tolerance of not knowing for now. When a religious client fears damnation, I collaborate on exposures that honor their faith while practicing uncertainty. This often involves consulting with clergy who understand scrupulosity, so that therapy does not turn into a theological debate.
Medication and combined care
Selective serotonin reuptake inhibitors can reduce the intensity of obsessions and weaken the urge to ritualize. Typical therapeutic doses for OCD are higher than for depression, and response tends to take longer, often 8 to 12 weeks at a steady dose. When medication helps, it creates room to practice ERP more consistently. When it does not, we revisit dose, switch agents, or consider augmentation strategies with a psychiatrist.
Medication does not replace exposure. For Pure-O, pharmacology without behavioral work frequently leaves the mental rituals intact. The combination of SSRIs and ERP is the most evidence based approach.
When ADHD or autism are part of the picture
Coexisting ADHD complicates Pure-O in predictable ways. Impulsivity can lead to quick reassurance texts or sudden checking detours. Inattention makes it harder to spot the first few seconds of a mental ritual, which is the best time to pivot. Therapy adapts by simplifying homework, using timers and visual cues, and breaking exposures into shorter sets. If a client is undergoing ADHD Testing, I align with the evaluator so we time medication changes and ERP stages with care. Sometimes we do a brief skills block on planning and habit building before ramping exposures.
Autistic clients bring strengths that help in ERP, like precision and consistency, alongside challenges like sensory overload during exposures or a literal interpretation of scripts. If autism testing clarifies sensory profiles or social reasoning styles, we can tailor exposures to avoid unnecessary distress. For example, rather than a crowded mall for contamination themes, we might start with a quieter but symbolically potent trigger, and we will script expectations explicitly to reduce ambiguity that is not part of the obsession.
Trauma, anxiety therapy, and sequencing care
People with trauma histories may find imaginal exposures for OCD collide with trauma memories. The rule is simple: treat the target that causes the most impairment first, or the one that blocks other treatment. Sometimes that means a short phase of trauma therapy to stabilize sleep and hyperarousal, then a return to ERP. Sometimes the OCD rituals are maintaining the trauma symptoms, in which case ERP unlocks both. When in doubt, we run small tests and watch function, not just feelings, to guide sequence.
General anxiety therapy tools like paced breathing and cognitive restructuring have a place, but we use them carefully. If a technique becomes a ritual, we retire it. The litmus test remains function. Does this skill help me make room for uncertainty, or does it chase certainty?
What progress looks like, in practice
Early wins often look like time reclaimed. A client who used to spend two hours daily in mental checking now spends forty minutes. They still feel anxious, but they do not turn the car around. By week four to six, most clients report lower intensity and faster recovery after triggers. They describe more mental space. On rating scales, a 25 to 35 percent reduction suggests meaningful change, and we build from there.
Relapses happen. Holidays, illness, or stress can turn up the volume. We plan for this with relapse rehearsals. You write out, on one page, the signs your rituals are creeping back, and the precise actions you will take in the first 72 hours. This turns setbacks into practice reps rather than crises.
Common snags and how to address them
The most frequent stall in Pure-O is covert rumination sneaking into exposures. The client agrees to read a script, then spends the whole time looking for evidence that the feared outcome is not happening. We counter this by naming the behaviors to watch for and setting a clear focus of attention during the exposure, like counting breaths or tracking bodily sensations.
Another snag is reassurance by proxy. The person does not ask directly, but posts online in a way that invites people to declare them safe or good. We treat this like any reassurance behavior and reduce it in planned steps.
A third is overreliance on safety aids. For example, keeping a text from the therapist that says, You are doing ERP correctly, and rereading it whenever doubt hits. We do not yank the aid immediately. We phase it out while boosting willingness to feel wrong for a while.
Practical exposure examples across themes
Harm while driving: create a playlist of bump sounds and headlines about hit and runs. Drive your usual route once without circling back, then park and allow the sensation of uncertainty for five minutes while making a grocery list. If the urge to mentally replay appears, name it and return to the list.
Relationship obsessions: write five brief statements that include uncertainty, like My partner might not be right for me. Read them before dates, and during the date, practice not scanning your feelings for confirmation. Focus on your partner’s words and the environment instead, and let doubts pass like a billboard on a highway.
Sexual orientation or attraction obsessions: view a set of images that include a range of genders, then notice any sensations without labeling them. Drop tests like trying to force arousal or monitoring for disgust. Let the body do what it does while you keep your eyes on an everyday task, like washing dishes or sorting mail.
Scrupulosity: attend your service or prayer time without repeating phrases for reassurance. If the thought arises that you did it wrong, write it on a card and carry it without correcting it. Meet with a clergy member who understands OCD to ensure exposures stay within your faith tradition.
Contamination without washing: touch a doorknob and then read a news story about bacteria on public surfaces. Do not research actual risk. Prepare food afterward, allowing normal handwashing at routine times, not driven by anxiety spikes.
Involving family without recruiting them into rituals
Partners and parents often become part of the OCD cycle. They answer the same questions, offer comfort on demand, or help avoid triggers. Early in therapy, we set a new contract. Loved ones can support exposures and encourage response prevention, but they will not supply certainty. We script a few stock phrases, like, I love you, and I am not going to answer OCD right now. We also acknowledge the discomfort this brings them. Tolerating a loved one’s anxiety is a skill, and we teach it.
Digital supports and self-monitoring
Technology can help if used wisely. Timers keep exposures contained. Notes apps store scripts and track reps. Wearables remind you to pause and feel your feet when you slip into your head. I advise clients to avoid forums that turn into reassurance loops, and to limit symptom tracking to brief, daily check-ins. The goal of tracking is decisions, not data for its own sake.
Choosing a clinician and getting started
Look for someone with specific experience in OCD therapy, ideally with ERP, and with comfort treating mental rituals. Ask how they adapt to Pure-O, how they measure progress, and how they handle reassurance seeking. If your presentation includes attentional or developmental questions, ask whether they can coordinate with autism testing or ADHD Testing providers. For many clients, a clinic that also offers anxiety therapy and trauma therapy streamlines care when comorbidities are present.
In the first week, I usually set two homework items. First, a five minute daily exercise called Notice and Name: you sit, trigger a mild obsession, and label the first urge to ritualize without acting on it. Second, a small behavior that breaks an avoidance pattern, like leaving the radio on while driving through a trigger zone. These are not grand gestures. They are the first bricks in a new path.
What sustains change
Long term, recovery rests on values. ERP teaches your brain not to panic at thoughts. Values give you reasons to keep practicing when motivation dips. A parent keeps reading bedtime stories despite doubts about being a good role model. A teacher keeps grading essays without rechecking every sentence for harm. A person of faith keeps praying in the way their tradition teaches, not in the way OCD demands.
Clients who do well often honor a maintenance routine. Ten to fifteen minutes of exposure a few days a week, a written plan for stress spikes, and brief check-ins with a therapist every few months keep gains solid. They also respect the cost of shortcuts. Quick reassurance feels good, then grows the problem. Letting uncertainty ride feels hard, then shrinks the problem.
Pure-O is treatable. The invisible nature of mental rituals can make it harder to spot and easier to excuse. Once named, the path forward is clear. With targeted ERP, careful response prevention, and attention to the person’s context, intrusive thoughts lose their grip. What remains is ordinary life, with its regular doses of uncertainty, and the confidence to carry on anyway.
Phone: 309-230-7011
Website: https://www.drericaaten.com/
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Dr. Erica Aten, Psychologist provides online therapy and autism/ADHD evaluations for adults in Oregon and Washington.
The practice focuses on neurodivergent adults, especially late-diagnosed and self-diagnosed women, nonbinary, and femme-presenting clients who want affirming care.
Services listed on the site include anxiety therapy, trauma therapy, OCD therapy, LGBTQ+ affirming therapy, autism and ADHD support, and evaluations.
Because the practice works virtually, clients can access care from home without adding commute time or an in-person waiting room to the process.
The site also lists evidence-based approaches such as ERP, inference-based cognitive behavioral therapy, cognitive processing therapy, and prolonged exposure therapy.
Dr. Erica Aten describes the work as supportive, neurodivergent-affirming, and focused on helping clients unmask, build self-trust, and live more authentically.
The official site presents Portland, Oregon and Washington State as the public service-area anchors for this online practice.
To ask about fit or scheduling, call 309-230-7011, email [email protected], or visit https://www.drericaaten.com/.
For public listing reference and map context, see https://www.google.com/maps/place/Dr.+Erica+Aten,+Psychologist/@47.2174931,-120.8825225,7z/data=!3m1!4b1!4m6!3m5!1s0x85dd18267af833d1:0xc46dc79a2debb4e5!8m2!3d47.2174931!4d-120.8825225!16s%2Fg%2F11x_c1z_h0.
Popular Questions About Dr. Erica Aten, Psychologist
What services does Dr. Erica Aten offer?
The official site lists anxiety therapy, trauma therapy, OCD therapy, LGBTQ+ affirming therapy, autism and ADHD support, autism testing, ADHD testing, clinical supervision for mental health professionals, and business development consultations.Is this an in-person or online practice?
The site describes the practice as online and virtual, including online therapy and evaluations for Oregon and Washington residents.Who does the practice work with?
The website says Dr. Erica Aten works with neurodivergent adults, especially late-diagnosed and self-diagnosed women, nonbinary, and femme-presenting clients, along with high-achievers, perfectionists, and burned-out people pleasers.What states are listed on the site?
The contact page and location pages say services are offered to residents of Oregon and Washington.What treatment approaches are mentioned?
The site lists ERP Therapy, Inference-Based Cognitive Behavioral Therapy, Cognitive Processing Therapy, and Prolonged Exposure Therapy among the main modalities.Does the practice offer autism or ADHD evaluations?
Yes. The website includes dedicated autism testing and ADHD testing pages and describes those evaluations as online for Oregon and Washington residents.Is there a public office address listed?
I could not verify a public street address from the official site. The business appears to operate as an online practice, and the public listing pages describe a service area rather than a walk-in office address.How can I contact Dr. Erica Aten, Psychologist?
Call tel:+13092307011, email mailto:[email protected], visit https://www.drericaaten.com/, or follow https://www.instagram.com/drericaaten/.Landmarks Near Portland, OR Service Area
This is a virtual practice, so these Portland references work best as service-area landmarks rather than walk-in directions.Washington Park — One of Portland’s best-known park destinations and home to multiple major attractions. If you are near Washington Park or the west hills, online therapy and evaluations are available through https://www.drericaaten.com/.
Portland Japanese Garden — A major Portland landmark within Washington Park and a strong reference point for west-side Portland service-area copy. If this is part of your regular area, the practice serves Oregon residents online.
Powell’s City of Books — Powell’s on West Burnside is one of the city’s most recognizable downtown landmarks. If you are near the Pearl District or Burnside corridor, online appointments remain available without a commute.
Alberta Arts District — Alberta Street is a familiar Northeast Portland destination for shops, galleries, and neighborhood activity. If you live near Alberta or nearby NE neighborhoods, the practice offers online services across Oregon and Washington.
Mississippi Avenue — North Mississippi is a well-known Portland corridor for restaurants, retail, and local events. If you are based around Mississippi, the practice’s virtual format keeps access simple from home or work.
Laurelhurst Park — Laurelhurst Park is one of Portland’s best-known neighborhood parks and an easy reference point for Southeast Portland. If you are near Laurelhurst, the practice’s online model can help reduce travel and sensory demands.
Tom McCall Waterfront Park — This downtown riverfront park is a common Portland landmark for locals and visitors alike. If you are near the waterfront or central city, the site provides direct access to consultation and scheduling details.
Oregon Convention Center — A major venue in the Lloyd District and a practical East Portland reference point. If you use the convention center area as a local landmark, the practice still serves the wider Portland area through virtual care.