As I write this, Time Warner Cable and CBS are in some sort of price war that has resulted in Time Warner’s decision to pull Showtime off the air. What this means for me is no Dexter. It doesn’t mean anything else. Just… no Dexter. So, the thought going through my head on this Sunday afternoon is whether or not my weekly habit of watching my favorite murderer do his thing has somehow been keeping me from killing people in real life. Now, I’m not literally concerned about closeted sociopathic tendencies being kept at bay by watching television. I’m just having a thought process. I think, “Well, maybe I can go to someone’s house who doesn’t have Time Warner Cable and I can watch the show there and stave off my murderous appetite, but then what about the kids? Can’t just leave them in the apartment… And who do I know that will let me come over just to watch tv and won’t bother me with chitchat? Oh well, if I can’t live vicariously through Dexter, guess I’ll just have to ritualistically tranquilize, wrap up, stab, chop and dispose of someone. Anyone, really.” How is it that I can just have these thoughts – like them, even – and not respond to them like they’re dangerous? The answer is my refusal to respond to them in any other way. If you suffer from Harm OCD, you’ve set up roadblocks in your mind that make this thought process terrifying.
Cognitive Behavioral Therapy for OCD: The Cognitive
The central thesis of Harm OCD is that the thoughts going through your head are warning signs of either imminent danger to your loved ones or yourself, or some sort of character indictment. After all, no one but crazy, awful people and Jon Hershfield have horrible thoughts like this! OCD arrogantly assumes that you are more committed to avoiding discomfort than you are to assessing reality. So, you easily fall victim to cognitive distortions pushing you into compulsive behaviors. Here are some examples:
All-or-nothing thinking: If I have one violent thought, then I have a violent mind. If I have a violent mind, then I am a violent person. If I am a violent person, then I should not be around other people. Note how every single one of these ideas assumes that the presence of one thing completely determines the identity of that thing. Reality offers a more complex picture, in which the presence of one violent thought does not necessarily tell us much about the whole person who had that thought.
Emotional Reasoning (assuming something is true because it feels that way): I felt anxiety and tension in my hand when I saw the knife, so this means I’m going to impulsively grab the knife and stab my husband. Notice how the OCD demands that you make the worst assumptions based on a sense or feeling. Yet, when OCD is not running the show, most of the time, you disregard feelings that are inconvenient. After all, the first feeling you have when you wake up is the urge to go back to sleep. Yet somehow, you get out of bed.
Selective abstraction (tying everything in your environment to your obsession): There’s so much violence in the media and this means you need to avoid it because you’re probably prone to murderous acts and watching the news will set you off. Notice how the OCD tells you who you are and what you can handle. It cleverly glosses over the fact that violence is in the news because news is stuff that rarely happens.
Comparing/Contrasting: That guy who killed his family said he did it because he was stressed out at work. I get stressed out at work. I must be a ticking time bomb. Notice how OCD blinds you from the reality that other people are other people and their stories aren’t automatically yours.
The examples above are just a small sample of cognitive distortions found in Harm OCD. Working with an OCD specialist, you will likely work on identifying and challenging distorted thinking. Just be careful not to use this as an attempt to get certainty about your fears. The goal of cognitive therapy for OCD is to lead you away from making compulsive choices, to remind you that the OCD is using trickery, not logic, to compel you to avoid.
Cognitive Behavioral Therapy for OCD: The Behavioral
If you can’t beat ’em, kill ’em. There is no such thing as treatment for obsessive compulsive disorder without exposure with response prevention (ERP), a central technique of cognitive behavioral therapy. But how can you do ERP to the unthinkable? The answer is to make the unthinkable thinkable. Exposure to thoughts is as straight forward as identifying all of the triggering situations you are avoiding and getting in front of them without ritualizing. Ideas for simple exposures:
- Reading and repeating triggering words (i.e. slice, stab, killer, or poison)
- Writing and reading triggering statements such as “I might murder my family.” Or “I may be a sociopath.”
- Writing short triggering flooding scripts, such as “I am going to snap and hurt someone. I will take a knife, cut my girlfriend’s throat, then turn myself in and spend the rest of my life on death row awaiting execution.”
- Writing long form scripts in which you describe your imagined crimes in detail and the consequences that follow.
- Watching triggering movies and shows involving people committing acts of violence.
- Reading news articles about murders (note, reading these articles to prove you weren’t involved or to highlight the difference between you and the killer would be a compulsion, not an exposure)
- Using a knife or some other perceived weapon in gradually increasing exposures while allowing harm thoughts (i.e. being near a knife, holding a knife, pointing a knife with your therapist, keeping a small knife in your bag or pocket, volunteering to slice ingredients in the kitchen)
- Putting yourself in situations where killing is easy, such as a crowded mall where you could push someone over a railing or a subway platform where you could shove someone in front of an oncoming train
- Driving in areas where there are pedestrians and speed bumps and resisting going back to check for signs of hit-and-run or walking in crowded areas without looking back to see if you pushed or stabbed anyone
- Giving a loved one a shoulder massage while thinking about strangling them
- Resisting reassurance seeking about/resisting confessing of harm thoughts
The Infamous Knife Exposure
Clients want to know about the giant bread knife on my desk. I often forget that it’s there; it just sort of blends in with the 2-hole punch and the stapler. Any guided exposure involves striking a balance between pushing the sufferer to confront their fears while standing up to the OCD, but also meeting the client where they are and not completely freaking them out. So usually I go in this order and move up a step each time the sufferer can identify their discomfort level as below a 6 on a scale of 1 to 10.
- Hold knife
- Hold knife with me sitting next to you
- Hold knife pointed in my direction
- Let knife rest against my wrist with the serrated edge up
- Let knife rest on my wrist with sharp end down
- Hold knife tightly
- Hold knife against my wrist tightly while saying “I might cut someone”
- Hold knife against my wrist tightly while saying “I might cut you”
- Hold knife against my wrist tightly while saying “I might cut you, Jon”
- Hold knife against my wrist tightly while saying “I might cut you, Jon, and you will bleed”
- Hold knife to my wrist while saying “I am going to cut you, Jon, and you will bleed out, and…”
- Hold knife pointed at me with my back turned
- Hold knife to my neck with my back turned
- Hold knife to my neck with varying degrees of vocalized threats and predictions
People have asked why I would take such risks with a “mentally ill” person. But the truth is, we take these risks every day in different contexts. We drive metal death cages 60 miles an hour just to go to the grocery store. I’m hardly taking a risk having an OCD sufferer hold a knife to my neck. Trapped on a desert island with no means of defending myself, I’d rather be with a person who has Harm OCD than anyone else (unless it’s someone with a boat; then I’ll go with the boat person).
I’m risking my competency to diagnose. If I’m wrong about my client, I guess I’ll die, but more importantly, I won’t think of myself as very good at my job. It’s the sufferer taking the real risk. The risk that if they just let their thoughts come and go, they may turn out to be a monster. They’re more afraid of killing me than I am of being hurt. So, what am I thinking as a sweating, shaky person holds a giant knife to my neck and tells me they’re going to slit my throat and laugh while I bleed out? I’m thinking about Dexter and how irritated I am with Time Warner for pulling Showtime in the middle of the final season.
Mindfulness and Harm OCD
Though it may seem silly or “crazy” to anyone on the outside looking in, treatment providers and everyone else need to consider what is really going on inside the Harm OCD sufferer’s mind. It’s the automatic pairing of all joy with the sound of a cracking neck at your hands. It’s the smile of a child paired with the image of their bleeding corpse in your arms. It’s the sense of pride in one’s good deeds paired with the feeling that you’ll be remembered only for unspeakable crimes you have yet to commit. And the worst part is there’s a seemingly normal version of yourself constantly commenting on how dreadful it is to have a mind like this. Harm OCD is not anger management issues. It’s not the unexpressed resentment of a cold marriage. It is not the subconscious frustration with inadequate breastfeeding. It is not a powder keg. It is simply the constant collision of unwanted violent thoughts with mental roadblocks. Mindfulness is about putting those roadblocks to the side and allowing the unwanted thoughts to pass through, smoothly and quietly.
The major catalyst for distorted thinking in Harm OCD comes from one simple belief, that decent normal loving people are not supposed to have weird violent thoughts aimed at the destruction of innocence. The truth is, as crazy as the thoughts may look on paper, these are all normal events. You’re supposed to have thoughts about smothering your baby with a pillow, jumping off of freeway overpasses, clawing out people’s eyes in the middle of brunch. The problem isn’t with the thoughts. It’s with the assessment of the thoughts as contaminants, objects on your mind that shouldn’t be there, that must be cleaned off. Mindfulness and exposure therapy serve the same function in Harm OCD, to sit with the discomfort that occurs when you choose not to treat your thoughts and feelings with avoidance, but accept them as they are.
If you have Harm OCD and are using meditation as part of your mindfulness practice, be aware of two things. First, the goal of meditation is not relaxation. That is just a common side effect. The goal of meditation is strengthening your ability to come back to the present moment when the OCD is vying for your attention. If you just let yourself sit and be, the OCD will try to entice you to analyze your harm thoughts. The practice is to acknowledge this without taking the bait. That leads to the second point, which is to not be surprised when the OCD throws some of the worst stuff imaginable at you. One thing OCD does not like, is focused attention on the present moment. So, if you have intrusive thoughts of a violent content, don’t be shocked when the OCD turns your mind into a splatter film. Try to remember, that’s just what the channel is stuck on for now. You don’t need to figure it out (doing so would be a mental ritual).
People Do Horrible Things
Any time you read the news, you will read about a person doing a horrible thing. OCD will ask you to analyze each of these horrible things and find out if you are capable of doing them. It’s a trap. Of course you are capable. If you have arms, you are capable of hitting. Being capable does not provide us with useful information about what you will actually do. Beating Harm OCD is not about proving you are incapable of acting on violent thoughts. It is about demonstrating you are capable of accepting uncertainty about those thoughts.
OCD sufferers have beautiful, open minds. Wide open. Too wide open for their own tastes. The presence of unwanted thoughts is the product of a special kind of brain, capable of considering all possibilities, shining a spotlight on ideas you’d rather have shrouded in darkness. Left untreated, it’s just old-fashioned torture. Nothing fancy. But properly treated with CBT and mindfulness, this awareness of the dark underbelly of human imagination can be a gift, a tool that adds color and dimension to the humdrum. To choose to love others and love oneself in the face of a stream of imagined destruction and death, that’s got to be some kind of profound love. To quiet that stream by doing the hard work of CBT, that takes profound bravery. But you made it this far.
Click here for Harm OCD: Part One
Click here for Harm OCD: Part Three
Jon Hershfield, MFTDirector, The Center for OCD and AnxietySpecialties:Anxiety Disorders, Cognitive Behavioral Therapy, Obsessive-Compulsive Disorder (OCD)