Will My Therapist Report Me for Intrusive Thoughts?

This post is part of my Ask a Therapist series, where I take questions I've answered on r/askatherapist and go a little deeper than the comment section allows.

The Question

i'm about to start therapy for the first time in years, and i really want to make sure i tell them everything. EVERYTHING. there's a lot of different things i wanna talk about, my hypersexuality, my issues with family, my struggles with depression. however, i have intense intrusive thoughts i've never told anyone about. i have good reasoning to suspect i have undiagnosed OCD because my father has it and we possess similar traits. the intrusive thoughts are the absolute worst. and i mean like, it's bad stuff. i'd never act on anything and i truly am a goody two shoes like i don't wanna go to jail i don't wanna be in a psych ward, i just need someone to understand that what's in my head, is not who i am as a person. i hate myself for sharing this but, i would never commit incestuous acts or do anything to a child. i would never kill someone let alone get close to something like that. but why do my thoughts convince me that's who i am?? why is it that every time i see a kid, it makes me feel like i should be sexually attracted to them. like genuinely it's so gross living like this because i know damn well this isn't who i am, and there's just disturbing thoughts getting in the way. is it safe to open up in therapy about these thoughts? will it be used against me? i just hate it and hate that i fear for my truth because of some random thoughts i get.

My Answer

Psychologist here who specializes in OCD.

Right off the bat, these thoughts will not land you in trouble. I'd be shocked if your therapist, if they have any experience in OCD or intrusive thoughts, hadn't already had many clients with these exact thoughts. I sure have.

By its nature, the stickiest thoughts are ego-dystonic. The reason why they stick around is because they are so against who you are at your core. Having these thoughts isn't indicative of who you are.

Congrats on taking the first step! I'm sure your therapist will have their own style to ask you about your experience. You'll do great.

Let's Go Deeper

Let me answer the actual question first, because everything else is easier to read once it's out of the way. No, it will not be used against you. A therapist hearing that you have violent or sexual thoughts that horrify you, that you have never acted on and never want to act on, is not hearing a confession. They're hearing a symptom description, and if they've spent any time with OCD it's one of the most familiar symptom descriptions there is.

The reason I can say that so flatly: intrusive thoughts are basically universal. A team led by Adam Radomsky ran the same structured interview at fifteen sites in thirteen countries across six continents, and 93.6% of people with no clinical diagnosis reported at least one intrusive thought in the previous three months. Rachman and de Silva did something even more useful for your specific question, back in the 1970s. They collected obsessions from people with OCD and from people without it, mixed the two lists together, and had experienced clinicians try to sort which was which. The clinicians couldn't do it reliably, because content alone doesn't give it away. And here's the part that actually explains why this feels like something only you carry: the sexual, violent, and blasphemous thoughts showed up least often in Radomsky's data, because those are exactly the ones people are least willing to say out loud, even to a researcher. What you think makes you uniquely broken is mostly just the stuff nobody admits to.

So if content doesn't separate a clinical obsession from a passing weird thought, what does? What happens right after it. Most people get a flash of something ugly, shrug, and move on, the same way you'd shrug off any other stray thought that crosses your mind in a day. In OCD, that same flash gets read as evidence, and that reading is the entire disorder. Rachman had a term for it, a catastrophic misinterpretation of the thought's significance. Mouthful, but it's exactly what's happening to you. The thought shows up and your brain treats its arrival as proof of something, not because the thought is true, but because the part of your brain built to flag real threats has gotten cross-wired to flag this instead. Once it's flagged, you start checking, testing yourself against every kid you see, watching for a feeling that would confirm the worst. The checking is what keeps it lit up.

This is where ego-dystonic comes in, which is the term I'd want you to walk away with. Ego-dystonic thoughts are the ones that go entirely against your actual values and against who you want to spend your mental energy on, and they are stickier than ego-syntonic ones for exactly that reason. Your brain flags what threatens what you care about. If you deeply love kids and would sooner die than harm one, that's a high-stakes value, so your threat detection parks itself right there and won't leave. It's a cruel piece of engineering, and the part people miss is that the horror you feel is a readout of the mismatch between the thought and you. A person who wanted those things wouldn't be on Reddit at 2am hating themselves and asking whether it's safe to tell someone.

Now the reporting question, concretely, because "will it be used against me" deserves a real answer rather than reassurance. What you say in therapy is confidential, and the exceptions are much narrower than most people picture. The standard limits are current or suspected abuse or neglect of a child, an elder, or a dependent adult, meaning an actual identifiable person being harmed rather than a thought about harm. There's also serious, imminent danger to yourself or to a specific person somebody intends to hurt. The exact rules vary by state, and a good therapist will walk you through theirs in the first session before you say anything. But notice what all of those have in common: they turn on intent and on real people in real danger. Intrusive thoughts you find repulsive and have no desire to act on are the opposite of intent, and a clinician assessing risk is asking about urges, plans, and history, not about the contents of your worst mental images.

One thing I'd add, because it's the moment where people in your position tend to panic. Your therapist may well ask you some direct risk questions, about whether you've thought about hurting yourself or anyone else, and if that happens it does not mean a case is being built. Risk assessment is routine. My old supervisor in grad school had all her practicum students run a brief one at the start of every single session just to drill it, and I still do them more often than the average clinician does. I've rarely had anyone push back on being asked, and asking has prevented some genuinely bad situations over the years. So if the questions come, they're the same questions everybody gets, and answering them honestly is how your therapist learns that what you have is a thought problem rather than a danger problem.

I do want to be straight with you about one thing, because you'll trust the rest of this more if I am. Your fear isn't coming from nowhere. When Kimberly Glazier and colleagues sent OCD vignettes to a random sample of psychologists, the overall misidentification rate was 38.9%, and it was worse for the taboo material: 42.9% of clinicians missed obsessions about children, and 77% missed obsessions about sexual orientation. So the thing you're scared of, a professional reading your symptom as your character, is a real phenomenon with a number attached to it. What that number is actually telling you, though, is that this is about fit and training rather than about you. It's an argument for finding someone who knows OCD, not an argument for staying quiet. I don't want to overstate the problem either. It's unlikely that a practitioner is trained to treat anxiety and not OCD, since the two are really closely related, and the same goes for the treatments: ERP, exposure and response prevention, is the gold standard here, and CBT and ACT sit right next to it, so most people trained in one are trained in two of the three. What I'd actually do is ask a prospective therapist directly whether they treat OCD and whether they use ERP. Someone who does this work will not flinch at what you tell them. Someone honest will say when it's outside their wheelhouse and hand you a couple of referrals, because therapists know therapists.

The detail about your father is worth bringing up too. OCD clusters strongly in families, and the big Swedish population study by Mataix-Cols and colleagues, which covered the entire national population and their relatives, found substantially elevated risk in first-degree relatives of people with the diagnosis. That's real diagnostic context, not a footnote, and it's the kind of thing that helps a clinician sort out what they're looking at faster.

Which brings me back to where you started, the "how much info is too much" part. You do not need to deliver everything in session one, and I'd gently point out that the urge to confess all of it, perfectly and completely, so that nothing is left hidden and nothing is misunderstood, can itself be the OCD talking. Confession and reassurance seeking are common compulsions, and a first session built as one exhaustive info dump often runs on the same fuel as the checking. What actually helps is naming the territory. One or two sentences is enough: you have intrusive thoughts that scare you, they're sexual and violent in content, you've never told anyone, and your dad has OCD. That gives a therapist everything they need to start digging in the right place, and the rest of the story can arrive across the next few months at whatever pace it wants to. The reason I'd push you to name it early anyway is that people wait a long time with this one. The Brown Longitudinal Obsessive Compulsive Study found a substantial lag between when OCD starts and when people get treated, often more than a decade, and the silence is usually the expensive part rather than the symptoms themselves. And it doesn't have to come out of your mouth, which is the part I'd most want you to hear. There's no right or wrong way to bring something like this up. Clients have raised things in session, emailed me beforehand, written me notes that I read while they sat there, or typed it into the chat during a telehealth session because saying it was too much. All of that is perfectly acceptable, and if handing over a piece of paper is what makes it possible, hand over the piece of paper. I've written before about the client who wanted to make a PowerPoint for their therapist, and the short version is that we're glad when you come in with something prepared. You've already done the hard version by writing it down for strangers on the internet. Choose whichever method feels least impossible, and let the person you're paying to hear it do their job.

FAQ

Will my therapist report me for intrusive thoughts?

No. Confidentiality has narrow exceptions, mainly current or suspected abuse of a child, elder, or dependent adult, and serious imminent danger to yourself or to a specific identifiable person. Those turn on intent and on real people at risk, not on thought content. Unwanted thoughts you find disturbing and have no desire to act on do not meet the threshold for a report. Exact rules vary by state, and a therapist should explain their limits to confidentiality at the start of treatment.

Can you have intrusive thoughts without having OCD?

Yes, and most people do. In a study across thirteen countries, 93.6% of non-clinical participants reported at least one intrusive thought in the previous three months. Earlier research found that experienced clinicians could not reliably distinguish obsessions reported by people with OCD from those reported by people without it based on content alone. What distinguishes OCD is not the thought but the interpretation of it, and the checking, avoiding, and reassurance seeking that follow.

What does ego-dystonic mean?

Ego-dystonic thoughts are thoughts that run against your values and your sense of who you are. They tend to be stickier than ego-syntonic thoughts precisely because they clash with what you care about most, which is why obsessions so often target the things a person would find most abhorrent. The distress a thought causes is a sign of that mismatch rather than a sign that the thought reflects hidden intent.

How do I bring up intrusive thoughts in a first session?

Name the territory rather than delivering everything at once. A sentence or two works: that you have intrusive thoughts you have never told anyone, roughly what themes they take, and any family history of OCD. The urge to confess every detail perfectly can itself be a compulsion, so a therapist trained in OCD will guide the pacing. It also does not have to be spoken. Clients email ahead, bring written notes, or type it into the chat during a telehealth session, and any of those is a fine way to start. It is fair to ask directly whether they treat OCD and whether they use exposure and response prevention.

References

Glazier, K., Calixte, R. M., Rothschild, R., & Pinto, A. (2013). High rates of OCD symptom misidentification by mental health professionals. Annals of Clinical Psychiatry, 25(3), 201-209. https://doi.org/10.1177/104012371302500306
Mataix-Cols, D., Boman, M., Monzani, B., Rück, C., Serlachius, E., Långström, N., & Lichtenstein, P. (2013). Population-based, multigenerational family clustering study of obsessive-compulsive disorder. JAMA Psychiatry, 70(7), 709-717. https://doi.org/10.1001/jamapsychiatry.2013.3
Pinto, A., Mancebo, M. C., Eisen, J. L., Pagano, M. E., & Rasmussen, S. A. (2006). The Brown Longitudinal Obsessive Compulsive Study: Clinical features and symptoms of the sample at intake. Journal of Clinical Psychiatry, 67(5), 703-711. https://doi.org/10.4088/jcp.v67n0503
Rachman, S. (1997). A cognitive theory of obsessions. Behaviour Research and Therapy, 35(9), 793-802. https://doi.org/10.1016/S0005-7967(97)00040-5
Rachman, S., & de Silva, P. (1978). Abnormal and normal obsessions. Behaviour Research and Therapy, 16(4), 233-248. https://doi.org/10.1016/0005-7967(78)90022-0
Radomsky, A. S., Alcolado, G. M., Abramowitz, J. S., Alonso, P., Belloch, A., Bouvard, M., et al. (2014). Part 1: You can run but you can't hide: Intrusive thoughts on six continents. Journal of Obsessive-Compulsive and Related Disorders, 3(3), 269-279. https://doi.org/10.1016/j.jocrd.2013.09.002

If this resonates, it's the kind of work I do. You can book a free 15-minute intro call, or read more in the Ask a Therapist series.

Olivier van Hauwermeiren, PsyD, is a licensed clinical psychologist serving New York City via telehealth, licensed in New York and Wisconsin and PSYPACT-authorized to practice telepsychology in 40+ states. He specializes in anxiety, OCD, trauma, and performance challenges among high-achieving professionals.

Will My Therapist Report Me for Intrusive Thoughts? What Actually Happens