A discussion of the treatment of Harm OCD using Cognitive Restructuring. Part three of a series.
In our previous installment of this series, we looked at Mindfulness for the treatment of Harm OCD, and how a change in perspective towards unwanted thoughts and feelings can lead to a change in compulsive behaviors. But as many sufferers well know, one’s response to intrusive harm thoughts is frequently automatic. Those with Harm OCD have conditioned themselves to respond to their harm thoughts in a certain way, and very little thinking may go into it.
Mindfulness encourages us not to waste time and energy attending to thoughts and feelings with urgency when those thoughts and feelings could be simply observed and allowed without response. This is not only difficult to do, but requires practice, training, and education that may not always be immediately practical early in treatment. If we must attend to the content of our thoughts directly, we should attempt to do so with as little mental ritual as possible. So we ask the question, “What is it that I am thinking about my thoughts that appears automatic, yet may be voluntary and may be pointing me in the wrong direction?
Cognitive Distortions Commonly Experienced in Harm OCD
The reason why a harm sufferer feels compelled to compulsively analyze, avoid, or otherwise over-respond to harm thoughts is because they are filtering these meaningless little ones and zeroes through distorted lenses that spit them out as unacceptable indictments. These lenses are called cognitive distortions. Here are some examples of common cognitive distortions experienced in Harm OCD:
All-or-Nothing Thinking (Black and White Thinking)
- Because I had a mental image involving a knife cutting my mother, I am a psychopath and a danger to society.
- If I have one thought of violence, I am a violent person.
- Because I had a thought that involved violence, I will do something horrible and be put away forever.
- If I go to a social event, I will snap and kill everyone there, so I must avoid that event to ensure their safety.
Discounting/Minimizing the Positive
- Though I have yet to even be in a fight, all of this madness has been stewing inside, and I will burst the moment I hold a knife and am near a loved one.
- Though I have had these thoughts for years and not acted on them, I am a ticking time bomb.
- I feel calm while having a violent thought, so I must be a sociopath.
- I feel anxious when I have these thoughts, so that must mean I am about to act on them.
- I feel guilty, so I must be a bad person for having harm thoughts.
- I had a bad thought about my mother dying and unless I complete this ritual, she will actually die.
- My violent thought must be neutralized or my loved one will get in an accident.
Should/Must Thinking (Perfectionism)
- I should only have pure thoughts.
- I must not experience anger.
- I should always feel comfortable around children.
- I can’t watch this movie because it has a fight scene in it.
- There are many different things in this kitchen, but especially knives, which are dangerous.
- I moved my hand in the direction of my child while having a harm thought, so I must have been very close to strangling her.
Cognitive Restructuring in the Treatment of Harm OCD
Understanding your cognitive distortions is an important part of fighting Harm OCD. Cognitive distortions are the language of OCD. By learning to recognize that language, you can learn to identify when you are about to be conned into doing a compulsion. Cognitive restructuring is a Cognitive Behavioral Therapy technique that involves identifying your OCD language, and then imagining what type of rational, objective, evidence-based thinking you could be engaging in without the OCD.
Objective thinking is not “positive thinking”. It is admitting what you don’t know and what magic powers you don’t have. Uncertainty can be habituated to. Nightmares cannot. Repeatedly telling your self that no bad thing will happen is compulsive. Sitting with the following is more effective – “I can’t predict the future, but based on my past experience with these thoughts, they tend not to result in me committing murder.”
Part of what makes Harm OCD so frustrating is the awareness that these unwanted thoughts make no sense, and that you feel helpless to do anything about them. It’s like you’re screaming, “This isn’t the truth!” but your mind is telling you in a low, booming, overpowering voice, “You know it is because you are evil”. But the fact that the rational voice is buried in there somewhere means we should be able to access it and cultivate it, without compulsions, so that its volume can compete on its own with the OCD thoughts.
The primary tool for strengthening this rational voice is called an Automatic Thought Record (ATR). There are different variations in the types of thought records that therapists may use, but they all focus on identifying three basic elements: triggering situations, automatic thoughts, and rational alternative thoughts. In treatment, it is important that you put in the work of writing these things in a disciplined format like a thought record. Acknowledging and admitting the content of these thoughts can be very challenging for some with Harm OCD, and writing some of these thoughts may be an exposure in itself. However, as discussed in the previous article on Mindfulness, the goal is treat them like thoughts, not threats, and writing them is a step in that direction.
We like to call this process “planting seeds” because every time you identify a distorted thought and challenge it with a more viable alternative, you are giving yourself an opportunity to use that thought later and help it grow. Freedom from OCD is not the eradication of unwanted thoughts – it is the equalizing of the volume of distorted thoughts and healthy ones. On equal footing, you can choose between the two, and the freedom to make that choice leads to the freedom from obsessions and compulsions.
Here are some starter examples of alternative thoughts:
- “I have lots of thoughts and these scary ones are just some of them. That doesn’t make them the most important ones.”
- “Just because I feel uncomfortable, doesn’t prove that I have done anything wrong or will do anything wrong. I feel lots of things.”
- “Yes, that is a knife and knives are used for cutting. But just because I am aware of this, doesn’t mean I am going to cut someone. Not everything I am aware of is about my OCD.”
- “Not all my thoughts have to go through some rigorous screening process for perfection. I can have an ugly thought like anyone else and not do anything about it.”
- “In my experience, thinking something does not necessarily result in it coming true. This is why I haven’t won the lottery, and this I why I don’t need to know for sure if these thoughts are going to result in bad things happening.”
- “This serial killer movie may make me very uncomfortable, but discomfort doesn’t have the power to destroy me and maybe there will be parts of the movie I even like. I won’t know until I see it and there’s no point in reviewing something I haven’t seen.”
Given enough time, Cognitive Restructuring can encourage your mind to gravitate toward a direction that allows you to resist compulsions rather than pushing you to ritualize. In other words, your automatic response could become healthy instead of distorted.
It is important to note that cognitive restructuring for OCD is not about proving that your fears are untrue – it is about weighing the evidence for and against the necessity of engaging in a compulsion. Those with Harm OCD should choose behaviors based on evidence, not just thoughts and feelings. If you are genuinely in danger, it makes sense to engage in an avoidant behavior. But you can make this decision based on evidence. If there is no powerful evidence that you or someone else is in danger, you may choose not to engage in avoidant behavior. This doesn’t guarantee that you are safe or that your fears are untrue. It doesn’t have to. Instead it affords you the freedom to tolerate uncertainty and keep your OCD from bullying you into always choosing to ritualize.
Cognitive restructuring is one powerful tool for combating OCD, but for many, relying on it too heavily can quickly become its own compulsion. A more powerful tool is a behavioral therapy technique called “Exposure with Response Prevention” (ERP). Using ERP, one learns to tolerate being exposed to what happens when they don’t try to shut their thoughts down, to the feeling of discomfort that remains, and to the fear of what might happen next while sitting in the present moment with their unwanted thoughts. ERP is probably the last thing you want to do, but it is the thing most likely to result in freedom from Harm OCD. The next installment in this series will aim to demystify ERP, and its role in treating Harm OCD.
To take our free confidential online test for Harm OCD, click here.
To read part one in our series on Harm OCD, click here.
To read part two in our series on Harm OCD, click here.
To read part four in our series on Harm OCD, click here.
•The OCD Center of Los Angeles is a private, outpatient clinic specializing in Cognitive-Behavioral Therapy (CBT) for the treatment of Obsessive-Compulsive Disorder (OCD) and related anxiety based conditions. In addition to individual therapy, the center offers six weekly therapy groups, as well as online therapy, telephone therapy, and intensive outpatient treatment. To contact the OCD Center of Los Angeles, click here.