Harm OCD, a common taboo subtype

Harm OCD is one of the many subtypes of OCD that is considered taboo. Taboo subtypes tend to be painful to discuss and often go without disclosure and treatment. The content of these obsessions is generally less well known and talked about 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’ identity and values. People with OCD often keep these obsessions to themselves as a result of embarrassment and shame. Additionally, the general public can often misunderstand these obsessions, resulting in secrecy.

“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. 

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 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. 

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.

It is vital that in vivo exposures are delivered ethically, compassionately and always with consent. In vivo exposures are not always ethical or possible in treatment. In instances when in vivo exposures, are not possible.

We have to get a little more creative when in vivo exposures are not possible. In these instances, we often utilize 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.

Another type of imaginal script, are worry scripts. These 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.