“What if I picked up that kitchen knife and stabbed my mom?” “What if I want to harm my co-worker?” “Could I poison my child's food and kill them?” “Maybe if I’m sad enough, I’ll kill myself.”
These are just a few examples of the many different intrusive thoughts we hear from clients who experience Harm OCD, a subtype that involves thoughts about harming others or oneself.
Harm OCD is considered to be a taboo subtype of OCD. Taboo subtypes tend to be painful to discuss and as a result often go without disclosure and treatment. The content of these obsessions is generally less well known by the general public relative to other themes. Therefore, people often experience prolonged suffering and distress as a result of these obsessions, which can attack the core of sufferers’ values.
People with Harm OCD often wonder if they are likely to act on these thoughts. One significant difference between someone having Harm OCD and someone who is actually aggressive is how they feel when they have these intrusive thoughts. People who experience Harm OCD are distraught by their thoughts and experience a lot of shame, guilt, anxiety, pain, panic and embarrassment around their presence. Negative self-talk and depression can often accompany this OCD subtype. It is not uncommon to hear things such as, “What type of person would have thoughts about hurting their kid or loved one?” In contrast, people who choose to act on these thoughts are generally not too distressed by the fact that they have them; sometimes they are even pleased or excited by them.
I often ask my clients, “Does the fact that you had these thoughts OR the fact that you were upset by having them say more about you as a person?”
OCD is a mastermind at turning thoughts into threats and making judgments about the content of our thoughts. Practicing non-judgment and using mindfulness and other acceptance and commitment therapy (ACT) techniques can be especially helpful in treatment for harm themes. Normalizing that these thoughts are commonly experienced by individuals with OCD is also vital in the treatment of harm OCD. It is estimated that up to a third of individuals who experience OCD have had some form of harm OCD symptoms.
Exposure and response prevention (ERP) is a frontline treatment for OCD. As with all OCD treatment, we want to take a graduated approach and be careful to not flood people with difficult emotions or utilize extremely challenging exposures too quickly. This facilitates trust and allows for people to experience successes along the way as they engage in treatment. There are several different types of exposures that can be utilized in treating Harm OCD.
At our clinic, we often use in vivo (live) exposures and develop/implement these exposures using an inhibitory learning approach. An inhibitory learning approach to exposure and response prevention includes several key elements to enhance the efficacy of exposures. These include: variety in exposures, using multiple fear cues, integrating an element of surprise, building anxiety tolerance, and disconfirming expectations. This can be contrasted with a more traditional habituation based approach, which posited that strict repetitions of exposures should be used in order to experience fear reductions.
An example of what this might look like for someone with obsessions about stabbing a loved one could include holding a knife during the session, having the therapist walk around the room in different positions/distances from the client, and having the client discuss their loved ones and verbalize their OCD thoughts. This facilitates learning for the person with OCD, as they see that they can do difficult things without the feared consequence happening.
It is important that in vivo exposures like this be thoroughly discussed with the client, that clients express their consent and willingness, and that everyone agrees that they will help clients engage in activities that are meaningful and important to them (such as cooking around a loved one).
In vivo exposures are not always ethical or possible in treatment. Bringing a gun into therapy or deliberately causing harm are clearly not feasible. In instances like this, we have to get a little more creative. Watching movies or reading articles that involve guns or other feared stimuli is one way to do so, especially if these behaviors are in line with the individual’s values (e.g., they used to love reading true crime).
Another way is to introduce imaginal exposures. Imaginal exposures can involve writing about, talking about, recording, and listening to narratives related to obsessions or feared scenarios. Uncertainty scripts are exposure scripts that focus on the fact that we can never find the level of certainty symptoms demand about the obsession or fear. In this case, it may look like a script about having unwanted thoughts and never knowing for sure that you will not act on them. These scripts can help people come to a place of acceptance, and paradoxically help them see that they can be “certain enough” about their fears.
Worry scripts on the other hand involve writing out in detail the worst-case scenario as if it were happening. These are particularly helpful when there’s a high level of mental avoidance in considering one’s theme. Worry scripts can be painful and distressing and are oftentimes met with resistance. In these situations, uncertainty scripts can be a helpful alternative and stepping stone to worst-case scenario scripts where the fear comes true. For those clients who are already rehearsing these scenarios over and over internally as a compulsion, worry scripts are unlikely to be helpful.
The last type of script that we might have clients complete would be an acceptance/motivational script. These are designed to be more motivational and support you in your exposure and response prevention work. They can be used to bolster your motivation and willingness to do hard things without using compulsive reassurance.
In addition to ERP, other treatment modalities that are utilized to treat Harm OCD include ACT, CBT, and mindfulness. There is hope for turning down the volume on Harm OCD symptoms. Finding a trained clinician for individual or group sessions can be helpful as you make your way to recovery.
