OCD and intolerance of uncertainty

Underneath almost every form of OCD sits the same demand: I need to be sure. Sure the door is locked. Sure I didn't hurt anyone. Sure I really love my partner. Sure that thought doesn't mean anything. The difficulty is that these are things nobody can be completely sure of. In CBT, this is called intolerance of uncertainty, and it is one of the most important ideas for understanding why OCD is so persistent.

What intolerance of uncertainty means

Intolerance of uncertainty is a tendency to find not knowing threatening and unacceptable, and to feel that uncertainty has to be resolved before you can relax. Most people tolerate a great deal of everyday uncertainty without noticing it. We assume the house is fine while we are out, that the people we love are well, and that a passing thought doesn't mean anything. We don't actually know any of these things for certain. We just don't need to.

In OCD, certain areas of life lose that tolerance. A doubt appears, and leaving it unresolved feels dangerous, irresponsible or simply unbearable.

How it shows up across different forms of OCD

The theme varies, but the demand for certainty is the same:

• In checking OCD: Am I certain the door is locked?
• In harm OCD: Am I certain I would never act on this thought?
• In relationship OCD: Am I certain this is the right person?
• In POCD and sexual orientation OCD: Am I certain what this thought or reaction means about me?
• In contamination OCD: Am I certain I won't get ill, or pass something on?
• In "just right" OCD: Does it feel completely right yet? Here, a feeling of rightness stands in for certainty.

Why seeking certainty makes things worse

Compulsions are, at heart, attempts to get certainty: checking, reviewing, analysing, seeking reassurance. They make sense, but they backfire in two ways.

Certainty never sticks. Any reassurance you reach can be questioned. But what if I didn't check properly? What if I'm misremembering? OCD can always find the gap.

Checking erodes confidence. Research on repeated checking has found that the more people check something, the less confident they become in their memory of it, even though their memory is just as accurate. Repeated checking makes memories feel vaguer and less trustworthy, which creates more doubt, which leads to more checking.

So the very strategies used to reduce uncertainty end up increasing it.

What treatment aims for

Treatment doesn't try to give you certainty. It helps you become able to live without it, as most people do in most areas of life. That happens gradually through exposure and response prevention, designed around the particular doubts your OCD targets, alongside work on the beliefs that make uncertainty feel so dangerous, such as "If I'm not sure, something terrible will happen" or "If I stop checking, it will be my fault".

This is one area where working with someone makes a real difference. Trying to "accept uncertainty" on your own often turns into another way of seeking certainty: Have I accepted it properly? Am I sure I'm doing this right? A therapist who understands the mechanism can help you notice when that is happening and keep the work on track.

Mental compulsions are often the hardest place to see this, because the urge to settle the question happens entirely in your head. I write about those in Pure O: when compulsions aren't visible.

In my practice

When people first hear that the goal is to tolerate uncertainty rather than resolve it, it can sound like giving up. In my experience, it turns out to be the opposite. Once the demand for certainty loosens, people get back the time and attention OCD has been taking from them. You can read more about how I treat OCD on my OCD therapy page.

Guy Klein

BABCP-accredited CBT therapist and EMDR Europe accredited practitioner, in clinical practice since 2015. Guy works with adults online and in Queen's Park, North West London, with a particular focus on OCD, anxiety and trauma. More about Guy