Harm OCD Treatment: Mindfulness Based CBT
The OCD Center of Los Angeles discusses treatment of Harm OCD using Mindfulness Based Cognitive Behavioral Therapy. Part two of an ongoing series.
In our previous installment of this series, we defined the symptoms of a sub-type of Obsessive Compulsive Disorder (OCD) known as Harm OCD. The defining characteristics of Harm OCD are intrusive thoughts of a harming/violent nature (obsessions), and the behavioral response of engaging in physical and mental strategies (compulsions) in an effort to relieve the inherent discomfort one experiences when having these thoughts. In upcoming articles in this series, we will discuss each of the main elements of Cognitive Behavioral Therapy (CBT) used to treat this form of OCD.
Psychoeducation and the Treatment of Harm OCD
The first step in treating Harm OCD is psychoeducation. Unfortunately, sufferers who are not already well-versed in OCD are likely to approach treatment with extreme apprehension and doubt. This is because the pain of being burdened with unwanted thoughts of causing harm has worn them down to a point that they may genuinely believe it’s possible that a therapist will take one look at them, smile, and call the men in white coats. So before any discussion of treatment can begin, a Harm OCD sufferer has to have a better understanding of the nature of the condition, and why some people are hyper-aware of these types of thoughts, while others appear not to be.
To know that something is dark, we must have in my mind some concept of what it means to be bright. To understand peace, we must also have thoughts that are defined by their violent content. Otherwise there would be no frame of reference for understanding its opposite. For most, a thought of happiness is unencumbered by thoughts of sadness. But in OCD, the sufferer’s awareness of this “un-thought” is greater. This awareness is then responded to with fear and disgust, thus making it much more powerful and significant than it need be. This process is described well in Lee Baer’s landmark book on Pure Obsessional OCD, Imp of the Mind.
Violence exists. Therefore having violent thoughts is a normal and essential part of being conscious. For those suffering with Harm OCD, what makes this condition so challenging is the presentation of these normal thoughts at such an intense and intrusive level. If these intrusive, unwanted harm thoughts were simply passing by, we could overlook them. But these violent thoughts often hit hard and stick. For those with Harm OCD, it is not easy to acknowledge and accept the presence of these thoughts as being merely some sort of magnification of a “normal” thought process. For this, we must turn to treatment.
Treatment for Harm OCD
The only form of treatment worth taking seriously for Harm OCD (or any type of OCD) is Cognitive Behavioral Therapy (CBT). This approach to therapy for OCD has been repeatedly researched, and has consistently been found to be the most effective treatment for all forms of the condition, including Harm OCD. Within the overall framework of CBT, one will gain the most benefit from three specific CBT techniques: Mindfulness-Based CBT, Cognitive Restructuring, and a specific behavioral therapy technique known as Exposure with Response Prevention (ERP).
Mindfulness Based CBT For the Treatment of Harm OCD
If you look at the brain as a thought-generator, then you can define the mind as that which receives and processes these thoughts. Few thoughts make it from the brain to the processing center. Most thoughts are out of sight, out of mind. They barely register as blips on the radar screen and no matter how peculiar they may be, they are given little to no attention. When they do make it to the processing center, (i.e., to our full awareness), these thoughts are assumed to be relevant to our experience.
If I have a thought about the sky being blue, that will most likely not be placed front and center for further analysis. It doesn’t matter much what I do with that innocuous bit of information. But if I have a thought about something itching, then that thought will jump to the front of the line so I can assess what behavior it should be met with. Scratching seems appropriate, unless I’m posing for a picture or have peanut butter on my fingers. Then maybe I’ll just acknowledge the itch, but not respond to it.
The problem with OCD is that thoughts sometimes skip to the front of the line as part of a glitch in the system. They slip through a crack in the dam and show up uninvited. So the same part of me asking what I should do about my itch is suddenly appearing to ask what I should do about murdering my family.
You Are Not Crazy and These Are Normal Thoughts
I’ll have to sit with the uncertainty over how many readers have stopped at this point. After all, how can a thought about hurting a loved one or killing myself be called normal? To understand this, one must take a moment to consider what a thought really is. A thought is a mental event. It is a word we use to describe a link between a chemical reaction in the brain and our awareness of it. A chemical event occurs, something happens, and then we become aware of that thing and call it a thought. The judgment of “normal” vs. “abnormal” is used only to describe how we interpret that thought and what behaviors we choose to apply it to. The thought itself is nothing more than ones and zeroes, so how can it be anything but normal?
As I write this and I consider the kinds of thoughts that Harm OCD sufferers find themselves stuck on, the following thought pops into my head: “I will go home and murder my family when this article is finished”. Now, I can try to justify my awareness of this thought by attending to the context of what I was writing previously – that I was considering examples of typical Harm OCD thoughts. But I can’t know for sure if that’s the truth. Perhaps that thought actually represents a genuine, hidden desire to kill my family. How can I know for sure? Well, I can’t know and I don’t particularly care. After work, I will probably go home and have dinner. We’ll have to see what happens after that. In any case, the harm thought itself is not problematic. Its content may disturb you, but its existence is unimpressive at every level. It is, after all, just a thought.
As discussed above, harm thoughts, ugly as their content may appear, are normal, uninteresting events that occur in the brain. The problem is that individuals with Harm OCD judge these thoughts, over-process them, and distort them into threats. But thoughts are just thoughts, not threats. If a harm thought occurs, but there is no awareness of it, it either exists or does not, but in any case it is not a threat. If a harm thought occurs and we are aware of it, the tendency is to go straight into judgment and analysis. This immediately takes the concept of “thought” and changes it to an object of fear.
Treatment with Mindfulness-Based CBT focuses on training yourself to maintain an observational, rather than judgmental, stance towards your thoughts, feelings, urges, and physical sensations. It means letting go of the need to be the actor/director and taking the opportunity to simply be the camera instead.
For mindfulness to be effective at all, one must start from the perspective of accepting the presence of their unwanted harm thoughts. Note that accepting that a harm thought exists is not the same thing as accepting what the harm thought implies after you judge it. The goal of Mindfulness Based CBT is disarmingly simple – to accept the reality of the existence of our intrusive, unwanted thoughts, without attributing any special meaning, value, or judgment to them. For those with Harm OCD, this means accepting that harm thoughts exist, without assuming that they must have some inherently profound meaning about our character and/or intent.
Because many Harm OCD sufferers fear that their thoughts represent a real and imminent danger that must be immediately addressed, the very practice of mindfulness itself often becomes a challenging form of behavioral therapy known as Exposure with Response Prevention (ERP). The following installments in this series will focus on ERP, as well as on a technique known as “Cognitive Restructuring”, and how modifying the way you think about the content of your thoughts can help you choose less compulsive behavioral responses to the unwanted thoughts 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 three 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.
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