A discussion of Harm OCD and its treatment using Exposure and Response Prevention (ERP). Part four of a series.
In our three previous articles in this series, we discussed the primary symptoms of Harm OCD, along with how one can use mindfulness and cognitive therapy to address unwanted harming thoughts. In this installment, we focus on directly challenging the behaviors associated with Harm OCD by using Exposure and Response Prevention (ERP).
What is Exposure and Response Prevention
The primary behavioral therapy tool used when dealing with Harm OCD is called Exposure and Response Prevention (ERP). While cognitive therapy challenges the content of our intrusive thoughts, and mindfulness addresses our perspective towards those thoughts, ERP directly confronts the behaviors done in response to those thoughts. While mindfulness and cognitive therapy set the table, ERP is the main course. This is where the real work gets done.
The basic thesis of ERP is that by gradually facing your fears, you will become used to them and hence less afraid of them. In clinical terms this is called habituation or desensitization. In other words, if you face your fears, they will cease to be so scary.
Treating Harm OCD with ERP is quite similar to how one uses exposure therapy to treat a phobia. For example, if a young girl is afraid of the swimming pool, she can usually be helped in overcoming this irrational fear by gradually exposing her to swimming in the pool. At first, you may want to have her merely look at the pool. When she becomes less afraid of being near the pool, you might then have her dip her toes in the pool. Then you would introduce her to wading in the shallow end of the pool, and eventually to the deeper parts of the pool. Gradually, over time, you work up to the point where she feels so comfortable in the pool that she can do back flips off the high dive!
Now, anyone with Harm OCD who is reading this is likely to be thinking “That sounds great for someone with a swimming phobia, but I am afraid of killing people. I don’t do any compulsions and there is no way for me to expose myself to killing people!”
If that sounds like you, it is important to know that you are almost certainly doing compulsions related to your harm thoughts, and that once you identify those compulsions, you can do exposures that will help you to stop doing them.
Compulsions in Harm OCD
Harm OCD is generally considered a type of Pure Obsessional OCD (Pure O). The basic thesis of Pure O is that some people with OCD experience obsessions without doing observable compulsions. But this idea is extraordinarily misleading. I have been treating OCD for nearly 20 years, and have yet to meet anyone with any type of OCD, including Harm OCD, who doesn’t do compulsions. Simply put, people say they aren’t doing compulsions, but they are. This misunderstanding is to a great extent a function of how people define the term “compulsion”. Some people think of compulsions in OCD as being limited to only the most obvious physical behaviors, such as hand washing and door checking. But there are many different ways of doing compulsions, which can be loosely categorized into four types:
- overt compulsions
- avoidant compulsions
- reassurance-seeking compulsions
- mental compulsions
A brief description of each of these will help to clarify how those with Harm OCD perform compulsions.
Overt compulsions are obvious physical behaviors done in an effort to reduce anxiety related to an unwanted thought. In Harm OCD, this might include any of the following common overt behavioral compulsions:
- Compulsively washing hands after exposure to insecticide for fear of accidentally killing your child.
- Throwing away your sharp knives for fear of stabbing your spouse.
- Repeatedly driving around the block to ensure that you haven’t killed a pedestrian.
Avoidant compulsions are behaviors you avoid in an effort to reduce anxiety related to unwanted thoughts. Some common avoidant behaviors seen in Harm OCD include:
- Not driving for fear of running someone over.
- Not eating with your family because you want to avoid thoughts of killing them.
- Not watching certain TV shows or movies with strong violence such as The Sopranos, Dexter, or movies like Saw or Hostel.
Reassurance-seeking compulsions are any attempt to relieve your anxiety by searching for information that will provide you with reassurance that you did not (or will not) cause harm. Some examples of reassurance-seeking compulsions in Harm OCD are:
- Repeatedly asking your parents whether you poisoned the neighbor’s dog.
- Going online to check if any accidents have been reported in the area you where you were driving earlier today.
- Discussing a bloody murder with friends in an effort to see if anyone suggests that you may have had a role in it.
Mental compulsions are the most misunderstood of the four compulsive categories. In fact, clients often ask what the difference is between an obsession and a mental compulsion. An obsession is an unwanted thought that comes into your mind unbidden, while a mental compulsion is any active mental effort put into resolving that thought. Put another way, an obsession is the “what if…” question that your mind produces, while a mental compulsion is a volitional internal attempt to answer or silence that question. It is any attempt to prove or disprove the validity or accuracy of the “what if…” thought. Some examples of mental compulsions seen in Harm OCD include:
- Mentally reviewing your entire drive home from work in an effort to prove to yourself that you didn’t run anyone over.
- Consciously trying to think “good” thoughts, either preemptively or in response to an unwanted thought such as a thought of stabbing your wife.
- Saying prayers in a ritualized manner to make sure that your mother doesn’t die in a plane crash.
All of these various behaviors are compulsions. Simply put, a compulsion is any repetitive behavior (mental or physical) that one does in a conscious effort to reduce, eliminate or control the feeling state of distress they experience when faced with an obsession. Regardless of which type of compulsion one does, the process is the same – an unwanted harming thought leads the sufferer to take action in order to relieve their distress.
ERP For Harm OCD
When clients tell us that there is no possible way for them to do ERP for harm thoughts, it is usually because they have read just enough about Cognitive Behavioral Therapy (CBT) to get the wrong impression of what an “exposure” is. If by “exposure” you mean that you must kill somebody for therapy to be effective, then no, you obviously can’t do ERP for Harm OCD. When clients bring this concern to us, we immediately clarify three basic ground rules of exposure therapy:
- We won’t ask you to do anything we wouldn’t do ourselves.
- We won’t ask you to do anything illegal, immoral, or dangerous.
- We will never force you do anything.
Unfortunately, some people have the idea that ERP involves bizarre exposures to things that nobody in their right mind would do. This is usually because they have seen talk shows and reality TV programs in which ERP has been twisted to the dictates of TV producers who want to make ERP look exotic and over-the-top. That might make for good television, but it makes for terrible therapy.
Conversely, our approach at the OCD Center of Los Angeles is to do exposures based on the client’s actual, real life obsessions and compulsions. With that as a guiding principle, there are plenty of ways to implement ERP without actually doing harm to anyone or anything. In fact, most of the exposures we do with clients who have Harm OCD involve mundane activities that people without OCD do every day. For example:
- If someone can’t drive because of their fear of hitting a pedestrian, we will do therapy sessions in a car with the client driving.
- If a mom must wash her hands compulsively before preparing food for her children for fear of poisoning them, we will have her prepare meals for her kids without compulsively washing.
- If a man can’t hug his children for fear of strangling them, we will assign him to regularly and consistently hug his children.
- If a child repeatedly asks his parents for reassurance that he did not harm any of his peers with his science project, we will help the child to learn how to better tolerate their anxiety without asking for reassurance.
In each of these cases, the individual has harming obsessions and compulsions that can be addressed by Exposure and Response Prevention. The actual process of doing ERP is fairly straightforward. The client and therapist create a list of the client’s compulsive behaviors. That list is then rank-ordered starting with the least anxiety provoking behavior. This list, called a hierarchy, is then used throughout the course of treatment to gradually challenge all of the client’s OCD behaviors.
The key word here is “gradually”. Many times, clients call us because their OCD has gotten so overwhelming that they are incapacitated. They are at the end of their rope, they want relief, and they want it now! While this is understandable, the process takes a certain amount of time, mostly because anxiety doesn’t go away just because we face it once.
Early in treatment, we may have a client do exposures to seemingly simple things such as writing the word “killer” on a piece of paper and carrying it around with them in their wallet. This may seem ridiculously easy to someone without Harm OCD, but to someone who fears that they may secretly be a serial killer, this assignment can be terrifying.
Over time, we gradually have clients with Harm OCD expose themselves to stimuli that are more anxiety-provoking. For example, we may show them crime scene photos or have them read certain news articles about murders or people being killed by hit and run drivers. These sorts of exposures are particularly helpful for those who compulsively avoid exposure to the news media for fear that their harm thoughts will be triggered. We frequently ask clients with with Harm OCD to watch a TV show or movie that has scenes of violence that trigger anxiety for them. When a client identifies a particular scene that significantly exacerbates their anxiety, we will assign them to watch that scene repeatedly, until such time that it becomes tedious to them.
For clients with stabbing obsessions, I may ask that they hold a butcher knife or an open pair of scissors to my throat. At first glance, this may seem insane to clients with Harm OCD (and to readers without it). After all, why would anyone ask a person with thoughts of stabbing people to hold a sharp knife to their throat? And doesn’t this violate the principle of not doing anything dangerous? Well, the simple truth is that I don’t ask clients to do this until we have spent enough time together that I am confident the client is not a genuine risk of stabbing me. I can usually tell within minutes of meeting a new client whether that person has Harm OCD, and thus, whether they pose an actual threat of killing someone. In point of fact, clients with Harm OCD are so horrified by the idea of committing some sort of violent atrocity that I can safely safe they are less likely to purposely harm someone than just about anyone I’ve ever met.
It should be noted that clients with Harm OCD often need to face particularly scary fears repeatedly in order to see a significant reduction in their anxiety levels. Conversely, if an individual with Harm OCD feels that they are being pushed too fast or too hard, they are likely to feel overwhelmed and to abandon treatment. So moving at a pace that doesn’t result in too much anxiety is critical.
It is also important to stress here that there are two parts to ERP – the exposure and the response prevention. If you do exposures, but then follow them with compulsive behaviors, you are unlikely to see much, if any, improvement. In fact, this can actually be worse than doing no exposures at all! When you do exposures, but then respond to the inevitable anxiety they produce by doing compulsions, you reinforce in your mind that you are not up to the challenge of ERP – that your OCD is bigger than you and stronger than you, and that you have no choice but to capitulate ad infinitum. The goal is graduated exposure, in which you allow yourself to develop your capacity to tolerate anxiety by preventing yourself from doing your customary compulsive response. Think of it as exercising you anxiety-tolerance muscle.
Also, keep in mind that obsessions tend to change – to morph. As Phil Jackson said, “problems never cease, they just change.” And as your obsessions and compulsions change, you will need to adapt in kind. Today’s thought about killing a stranger may turn into next month’s thought about killing your newborn child. This is not unusual for Harm OCD – it is the norm. When change happens, your goal is to change with it. Once you have learned to challenge a specific Harm OCD symptom, you can generalize that to all Harm OCD symptoms. So, when you get blindsided by a new, unexpected obsession or compulsion (and you will), use the ERP tools that have worked previously for you to challenge that new symptom.
With Harm OCD, there are times when it is beneficial to do exposures specifically for an obsession (as opposed to a compulsion). For this purpose, we utilize what are known as imaginal exposures. Our next installment of this series will focus on the use of imaginal exposure for the treatment of 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 three in our series on Harm OCD, click here.
•Tom Corboy, MFT is the founder and executive director of the OCD Center of Los Angeles, 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.