Help for HARM OCD
Harm OCD eBook: Tips & Resources to Help Move Past Intrusive Thought OCD
By Debra Kissen Ph.D, Ashley Kendall Ph.D and Michelle Lozano, AMFT
Schedule a session with one of the authors here.
Section 1: Introduction
The origin of this workbook was a Huffington post blog on Harm OCD Dr. Kissen wrote after a session with one of her wonderful patients who she was treating for harm OCD.
While walking to grab lunch, Dr. Kissen was thinking how lovely her patient is and how she is such a pleasure to work with. From here, she started thinking about all of her other Harm OCD patients and started noticing a trend. They were all caring, conscientious, kind, and valued their relationships with loved ones above anything else in life. From this line of thinking Dr. Kissen wrote a brief blog on Harm OCD. The key message of the blog was to highlight how harm OCD goes after what you care most about and how, of the hundreds and hundreds of individuals who we have treated for harm OCD, we have yet to meet someone struggling with harm OCD who we would distrust as a babysitter or teacher or health provider (and we can be quite picky on this front… we only want kind, compassionate, conscientious care givers in our life).
Shortly after posting this blog, Dr. Kissen began receiving messages from readers all over the world, stating how appreciative they were to have finally found information that shined light on their silent suffering. After so many messages came in stating some version of “Thank you so much. You may very well have saved my life”. Dr. Kissen, Dr. Kendall and another therapist at their practice, Michelle Lozano (LINKS) decided there was too much unnecessary suffering experienced by those struggling with harm OCD symptoms and that the time seemed right to offer all of the tools and tips that they currently offer patients experiencing harm OCD in an eBook format, so this information can be accessed by a broader audience.
Section 2: Good News about Harm OCD
The good news— yes, there is good news when it comes to OCD— is that it can be effectively treated. Many research studies have highlighted that OCD symptoms can be reduced non-symptomatic levels by engaging in Exposure and Response Prevention (ERP) based treatment.
OCD was once thought to be one of the most serious and severe of mental health disorders and unresponsive to treatment (Kobak 2004).However ERP has been documented to be effective in treatment for OCD for over five decades(Kobak 2004).Foa and Kozaks 1996 review of 12 outcome studies reported treatment responder rates of 83 among people who completed treatment. In 16 studies reporting long term outcomes, 76 percent were able to maintain there treatment gains over time.In addition to ERP, for harm OCD in particular, it is important to address the cognitive aspects of the disorder, for example thinking errors that lead one to believe a harm thought is equivalent to a harm behavior.
This eBook offers a clinical intervention program based on the principles of ERP for OCD. As you move through this eBook you will learn a good deal more about ERP but for now, the main take away message for you is there is reason to feel hopeful. In other words, your situation is NOT hopeless. You will not always feel this bad. The discomfort you are experiencing is temporary. You are and will be OK!
It is helpful to fill out a pre-intervention assessment so you will be able to quantify the of your symptoms and observe over time, as you put in the work in freeing yourself from , how these symptoms decrease. There day when a of a thought surface you may be tempted to tell yourself, “See, I am still having these horrible thoughts. Nothing ever changes. I will always be stuck.” But then you will be able to do a quick assessment and review where you are at where you startedperspective on just how far you have come.
In the past week, on average:
How many hours a day do you think about your intrusive thoughts?
How much distress do you experience when a harm IT surfaces?
How much impairment does harm OCD cause in your life/how much does impact your ability engage effectively in your life? Please think across all spheres such as:
How hard are you currently trying to avoid or fight or make sense of your Harm related thoughts?
How hard are you currently trying to engage in valued living and putting your attention on the aspects of life that are most important to you?
This eBook is an appropriate first step for those experiencing mild to moderate distress and discomfort. For those experiencing severe impairment, we recommend that the reader seek professional assistance as these symptoms are impacting functioning and creating a high level of distress and one should not have to face that level of suffering alone, without professionally trained assistance. In addition, if the reader is experiencing active suicidal thoughts or abusing substances, etc, then we recommend seeking out professional assistance immediately.
Section 3: Why am I having such horrific thoughts?
If you are reading this eBook book, chances are you have wrestled with thoughts such as “What is wrong with me? What kind of person has such disturbing thoughts? What do these thoughts say about me? Why would I be having these thoughts unless on some level I wanted these disturbing things to happen? Am I safe to be around? Could I harm myself or loved ones?”
The fact that you are struggling with these questions, and that you find your intrusive thoughts distressing— as opposed to enjoyable— lends support that you A) are not a monster, and B) have harm OCD. Not to mention the fact that you are spending precious moments of your life reading and engaging in this workbook seeking relief.
To offer some foreshadowing into the material we will cover in later chapters, we cannot guarantee that you will not engage in some disturbing act in the future, just as we cannot guarantee that we will not engage in a reprehensible behavior in the future.
Another way to assess if you are experiencing disturbing thoughts due to A) being a monster, or B) you have Harm OCD is to assess the behaviors you have engaged in over the course of your life. The old saying “the best predictor of future behavior is past behavior,” is quite accurate. So, look at each of your harm OCD thoughts and ask yourself how many times in your life have you so far engaged in the feared behavior
Example 1. Harm thought: “I am going to lose control and stab my spouse.”
Assessment of prior behaviors in line with obsession: How many times in your life have you stabbed your spouse? ______
Example 2. Harm thought: “I am going to lose control and harm myself”
Assessment of prior behaviors in line with obsession: How many times in your life have you lost control and harmed yourself?” ______
If you have answered 1 or more to any questions above this may not be the right treatment approach. We recommend you review your responses with a trained mental health provider to create the most effective treatment plan.
Note: Some people experiencing harm OCD will answer affirmatively to the questions above because they cannot perfectly prove to themselves that a past behavior was not in some way harm to self or others. If this is the case for you, we recommend you continue reading. When one engages in a true harm-related behavior, it is quite clear and not a murky matter.
Section 4: Common Harm OCD Obsessions
There is always the moment, when treating a client for OCD, when we hand them the checklist of the most common obsessions, a look of relief and release of tension can be immediately seen. They state something like, “I cant believe that others have these same disturbing thoughts and that they are so common that they are on a standard checklist.” We are glad to be able to provide you with this same moment of relief as you realize just how unoriginal and run of the mill, your most shocking intrusive thoughts are 🙂
I’m going to lose control and harm myself
I’m going to lose control and harm my loved ones
I’m going to lose control and cheat on my partner
I’m going to lose control and say (or write) something inappropriate
I am going to lose control and act out sexually in a way not in line with my self identity or values
17: Reading About Harm OCD Makes Me Anxious
If you are finding that reading this eBook is anxiety provoking then congratulate yourself for taking one step closer to freeing yourself of harm OCD. The very act of intentionally bringing on and tolerating feelings of anxiety will be the secret sauce that help you leave harm OCD in the dust, as you proceed forward with your life. We will get to this concept a good deal more as we move forward in this workbook but for now know that it is not at all unusual to feel an increase in anxiety as one begins the work of face Harm OCD head on.
Exercise: review words below and check off any that you find anxiety provoking:
Exercise: What is the scariest word you can think of? On a scale of 0-10, how anxious do you feel at this moment? How anxious do you think you would be if you said that word out loud 100 times?
Section 5: Case examples of individuals experiencing Harm OCD
People with intrusive thought OCD often have deep feelings of shame about their moral character, and struggle to imagine that anyone “normal” could share their thoughts. Here, we introduce you to four wonderful, high-functioning people who have experienced harm OCD, based on client we have worked with. This section will help you come to understand that you don’t have to be a “monster” to experience harm intrusive thoughts.
“Stephanie,” A 33-year-old woman who teaches math and science in a second-grade classroom and volunteers once a week as a math tutor for middle schoolers from low income neighborhoods.
“Greg,” A 47-year-old man who works as a lawyer during the day, and spends much of his free time in the evenings and on weekends with his wife and children.
“Lucas,” A 38-year-old man who has been successfully founding his own start-up in the restaurant industry.
“Chloe,” A 24-year-old woman who recently graduated from college at the top of her class and started her dream job in public relations for an environmental non-profit.
The individuals described above are based on clients who have come to our clinic seeking help for harm OCD. Match the intrusive thoughts below to the client above who you think is most likely to have had the particular concern.
“I’m going to stab my wife and children.”
“I’m going to wake up one night, smothering my wife with a pillow.”
“I’m a pedophile.”
“How can I be sure I’ve never had sex with a child? What if I just don’t remember?”
“I’m going to suddenly start swearing during a board meeting.”
“I’m going to use a racial slur the next time I talk with an African American colleague.”
“I’m going to go crazy on the subway to work, and they’ll have to stop the train to calm me down and everyone will realize I’ve lost my mind.”
Person 1: Thoughts c, d
Person 2: Thoughts a, b
Person 3: Thought g
Person 4: Thoughts e, f
Key take away we hope you are experiencing, experiencing a scary thought is not the same thing as engaging in a scary behavior. Those struggling with Harm OCD are not “monsters”. They are simply regular people who are extremely intolerant of having bad thoughts.
Section 6: The Flip Side of Harm OCD is Strong Values
Exercise: For each of the patients introduced in Section 5, list the values that you think he or she holds most strongly. For example, do you think that Stephanie cares a great deal about children?
Harm OCD will only go after the things that really matter to you. If you don’t care at all about your pets, harm OCD won’t be able to torment you with the thought, “What if I kill my dog?” Our own observation from seeing hundreds of patients with harm OCD is that they tend to be some of the kindest, most conscientious and values-driven people we’ve ever known. This makes a lot of sense when you consider that if a person didn’t have strong values, they won’t be able to react strongly to intrusive thoughts that conflict with those values, and won’t fall into the cycle of shame and avoidance that perpetuates harm OCD.
Section 7: Shame and Suffering associated with OCD
Although the nature of their obsessions differed, one thing that Stephanie, Greg, Lucas, and Chloe all had in common was strong feelings of shame about their own thinking. Each of them had waited several years—and in one case over two decades—to come in for treatment. People with intrusive thoughts often suffer in silence, worried that if they confide in a professional, the clinician will assume the thoughts reflect true urges and diagnose the patient as “crazy,” perhaps even restraining them or reporting them to authorities.
This leads to a nasty cycle for people with harm OCD: the intrusive thoughts create feelings of shame, which lead to avoidance behaviors (for instance, avoiding talking about the thoughts, or being in situations in which the thoughts are likely to come up), in turn strengthening the belief that OCD needs to be avoided—which of course just feeds the OCD. The cycle goes on and on. The good news is that if you’re reading this eBook, you’re one step closer to freeing yourself from the shame of your intrusive thoughts.
All of this hits on a key point that distinguishes harm-related intrusive thoughts from thinking patterns in other types of OCD: Harm-related thoughts are egodystonic rather than egosyntonic. Egodystonic refers to impulses that a person finds repulsive, unacceptable, and inconsistent with their own self-image. Egosyntonic thoughts, feelings, or behaviors, by contrast, are in harmony with a person’s own ideals and self-image.
Activity 1: Identify if the OCD thought or behavior is egodystonic (e.g., a person who loves children but worries he will sexually molest one) or egosyntonic (e.g., a person who values cleanliness and compulsively washes her hands).
Take-away message: Unlike other types of OCD, the thoughts that go along with harm OCD are most often egodystonic. This leads to increased feelings of shame and suffering, but does not mean the person who has these thoughts is “bad” or immoral. In fact, the thoughts are generally very much at odds with the person’s fundamental values.
Section 8: Who is “Better Person” Game
Below we describe different pairs of people. For each pair, identify the person you would be more likely to describe as a “good” person.
Bob, who never gives up his seat on the train for the elderly or pregnant, cuts people off on the road, and gives nothing to charity; or Todd, who has daily thoughts of losing control and stabbing his loved ones, but makes a point to act toward people with kindness, and mentors a “younger brother” in the Big Brothers Big Sisters program.
Jennifer, who reads and thinks regularly about the role of hunger in perpetuating global inequality but never acts on her concerns; or Rita, who does not think nearly as deeply about the global ramifications of hunger as Jennifer, but makes it a priority to volunteer twice a week at a soup kitchen.
Take-away message: Most people would agree that it’s our concrete behaviors, not fleeting thoughts, that most define us as moral beings.
Section 9 : What’s the Flip Side of Your Intrusive Thoughts?
Now that you’ve had practice identifying the values held by other patients with harm OCD, take some time to reflect on your own values, as revealed by your intrusive thoughts.
Exercise: Go back to Section and find the top five intrusive thoughts that you find most upsetting. List them on a piece of paper. Next to each thought, describe the value that goes along with your fear.
Section 10: You Need Not Go Through the Work of Getting Help for Harm OCD Alone
To get the most out of this eBook, it is best to identify a friend or family member or therapist to serve as an OCD coach. Harm OCD grows under the darkness of shame and melts away when confronted with openness and acceptance. Even if your identified OCD coach plays a minimal role in the actual treatment plan, it is still healing to discuss your symptoms with a loved one. It will be a hard but powerful first step forward. It will help to confirm there is nothing wrong with you but some scary thoughts that you are struggling to make sense of.
Exercise – list 2 people who could potential serve as an OCD coach.
Section 11: Harm ITs = Spam mail
For those experiencing OCD symptoms, intrusive thoughts are simply spam mail parading as priority mail. Have you ever received a spam email which described how a loved one is stranded in a foreign country with no money. How alarmed did you feel once realizing this was spam mail? But if your mother or father or child or best friend was in fact stranded in a foreign country with no money and no way to get back home, would you be concerned for them? You can us this same discernment process to distinguish Harm OCD thoughts from true danger.
Section 12: Picking Up a Lab Coat and Setting Down your Judgmental Mind: Viewing Your Own Thoughts like a Dispassionate Scientist
Now we’re going to practice observing the thoughts that come into your mind like a scientist might: objectively, without getting caught up in the thoughts or judging them as “good” or “bad.” This means you simply describe the thoughts, sticking to their objective qualities. It’s the difference between keeping your notepad out and writing down the names of the characters on the screen, and getting so lost in a scene that you forget you’re outside of the film, instead getting emotionally lost in the plot.
Why is this “scientific” approach helpful? A few main reasons. By evaluating your thoughts objectively, you create distance from them. They’re less gripping, and less likely to frighten you. Second, just the mere at of looking directly at your own thoughts is a form of exposure, and will help decrease your anxiety, breaking the harm OCD cycle. Finally, once you get to know thoughts, you’ll be able to better anticipate and work with them when they arise. You’ll recognize when they tend to come and how they feel in your body, and will be positioned to use skills to confront rather than avoid the thoughts.
Exercise: Pick a common stressful thought you have (but don’t go for a harm-related intrusive thought just yet). This should be something that bugs you, but not anything super distressing. Record objective qualities of the thought, just as a scientist might: the words that make up the thought (“There’s going to be a ton of traffic on my commute this morning.”) how your body responds when these words go through your mind (e.g., back muscles become tense), and any other thoughts that they lead to (e.g., “Maybe I should take the train instead.”).
Section 13: Intrusive Thought Tracking Log
The next step in getting to know your own thoughts—and taking away their power—is to understand patterns in when these thoughts come up. Although it might feel like you’re struck out of nowhere by gruesome images of driving your car onto a crowded sidewalk, for most people with harm OCD, the intrusive thoughts come at somewhat predictable times. Just knowing this can make them less scary. For example, our patient “Lucas,” who cared a great deal about the success of his start-up, found that he would worry about saying something inappropriate to a colleague most often around the time of important business decisions. For Chloe, who worked in public relations, she discovered that her intrusive thoughts were tied to shifts in physical health: She was especially “vulnerable” to the thoughts when she hadn’t slept, was hung over from drinking, or was close to her period.
Exercise: Over the next few days, use the following log to record the time and place of your intrusive thoughts, along with where you were, the people you were around, and what you were doing when they came up.
After you’ve collected a few days’ worth of data, note any patterns you see in when your intrusive thoughts tend to come up. Are they more frequent during certain times of day? Around particular people? When you’re doing or thinking particular things?
Section 14: Growing Bored of Your Most Frightening Thoughts
Believe it or not, you can get tired of anything once you’ve had enough exposure to it. The human brain has an amazing ability to grow bo—it’s always looking for something new and exciting. This tendency to get used to and no longer react to stimuli is known as “habituation.” Just think of the movie buff who has seen a horror film so many times she no longer feels frightened (or even interested) during the most suspenseful scenes of the film. Or think of the teenager who nearly panicked whenever he had to parallel park as he was first learning to drive, but now can do so almost without thinking.
Exercise: come up with a list of things that used to be difficult or scary, but that you have habituated to and no longer find frightening. How might this be relevant to your intrusive thoughts?
Section 15: The Doubting Disorder: Doubt and Uncertainty
This section will outline how OCD gets activated at the cross section of (1) what one values the most, (2) what one fears losing the most, (3) the lack of certainty that the feared event will not occur. You might notice from above, doubt is a common thread for all harm obsessions.
Some call OCD the doubting disorder because for all OCD concerns, there cannot be a guarantee that a feared outcome will not occur. OCD is not satisfied with the knowledge that an outcome is extremely unlikely, it wants to know with certainty that the thing that you most fear will not come true.
Freedom from harm OCD does not entail removing all that a feared outcome will occur (although that would be nice if it were true, unfortunately the does not provide any of us with this kind of certainty). Instead freedom from harm OCD entails learning to live with the same smidgen of doubt that the “unthinkable” could happen, in the service of living a life worth living, in line with one’s values and aspirations.
Section 16: Common Thinking Errors
“Thinking errors” don’t refer to flaws in your thinking, so much as common cognitive shortcuts we all take. We use these shortcuts on a daily basis, and they can be adaptive, helping save us time and process information efficiently. At the same time, they reflect a less complex type of thinking—one that often goes along with stress or anxiety. So if you notice that you’re engaging in several of these “thinking errors,” you might regard them as tiny red flags: indicators that you’re under stress. This is important to see, as the thinking errors also often contribute to anxiety, reinforcing the very beliefs that are making you anxious in the first place.
Below is a list of thinking errors common to people with Harm OCD. A particularly important thinking error is thought-action fusion: the belief that by thinking something, it’s more likely to occur.
Exercise: Next to each thinking error, write an example from your own life. For example, our patient “Greg” wrote next to the thought-action fusion thinking error his own common thought, “If I have images of stabbing my wife, it makes it more likely to happen, so I need to suppress those images.”
Section 17: Your Brain on OCD
You may have heard about the fear network in the brain “fight or flight response”. This what gets triggered when experiencing a true emergency such as if you were trapped in a burning building or if your child is about to get hit by a vehicle. The fight or flight response is immediate. If experiencing a true emergency, it is not a time to think and act slowly something. The only goal is to attempt to survive.
The OCD network of the brain is a bit different. It involves the part of the brain that sounds the signal “something is wrong,” but it also involves the part of the brain that says “you must take some kind of action now to fix the current situation.”
The part of the brain signaling you to look for some way to fix the problem at hand interacts with motor planning and increases urge to do something to fix or solve a problem. So the difference between a panic attack, which is an immediate “fight or flight response” and an OCD attack is that when the brain is “on OCD” it believes something dangerous may happen but could potentially be prevented if certain precautions (otherwise known as compulsions) are taken.
Section 18: OCD, AKA The Bully Within
Imagine a bully is in the schoolyard , “You better give me your lunch money or else….”. What are your options? You can give him (or her) your lunch money and he/she may back off for a bit… until the next time the bully is hungry a now knows you have lunch money prime for the taking. Or you can stand up to the bully and say, “I will not give you what is mine so back off.”
Your OCD is similarly a bully, taunting you with threats such as “If you are not careful enough you can lose control and kill your children” And what the OCD bully wants i for you to check and obtain reassurance and to review all of your behaviors to make sure that you will not lose control and engage in a terrifying behavior.
Prior to reading this eBook you may have assumed that the bully means business. You may have been willing to hand over your lunch money (in your case, your life) to the bully in exchange for its protection against YOU. But the good news is that you don’t need protection from YOU. Now is the time to look the OCD bully in the eyes and say, “You can’t mess with me. Just because you are telling me I am unsafe and out of control, does not mean it is true.”
Section 19: Whatever You Do– Don’t Think
If you are reading this eBook, chances are you have already tried many things get rid of your harm OCD. One of the first, and most logical strategies that people try when experiencing harm OCD is distraction. It is common to play video games, watch TV, the eb, or to do just about anything, as long it does not entail thinking about harm obsessions. The challenge is we humans are not very good at “not thinking” about things. The more we try to “not think” about panic, or bananas or flying pigs,or any other topic, the more we find ourselves thinking about . The reason for this phenomena is that the only way to know if we are successfully “not thinking” about a topic is to scan our minds for that content. By scanning our minds to see if we are having a thought, we thereby trigger the unwanted thought.
Exercise: take a moment and conjure up a mental picture of a pink elephant. Picture his pink trunk, his big, pink, floppy ears. Now for the next minute, your job is to think about any topic except for the pink elephant. Remember, whatever you do, don’t think about the pink elephant. So, how did it go?
Clients seeking treatment for harm OCD often come to us stating that they are not engaging in any compulsions and are only experiencing the O (obsession) component of OCD. Upon further investigation and exploration, we are quickly able to come up with several compulsions that they are engaging in on a frequent basis. The challenge in identifying the compulsion component of harm OCD is often it Unlike checking locks or washing hands or organizing objects, mental compulsions can be hard to recognize.
Common compulsions associated with harm OCD:
Trying to “figure it out”
Reassurance seeking from others
Avoidance (parts the kitchen with knives, etc., African-American co-worker)
Checking arousal level around feared people
Section 21: Trying to Make Sense if the Unfathomable
We can all think of countless examples of stories reported in the news were someone who seemed like they were living a normal life all of a sudden “lost it” and committed a heinous atrocity such as killing their themselves or others often ask, what makes a person just “lose it” and o something so awful and out of character?Science has not provided us with a perfect answer to this question but we do have a few clues into :
This section will provide research around behavioral patterns and other things that have been found to be associated individuals who “lose it” and commit crimes.
The goal of this section to educate readers so they understand someone does not just wake up and kill their child or stab their spouse. We want to get across the message that these behaviors do not just happen out of the blue but instead there are behavioral patterns leading up to these events.
Think about how much planning it takes to do something as common as baking a cake. You can think and think and think about baking a cake but if you don’t follow the steps below you will never a cake.
1. Find a recipe
2. Have money to buy ingredients
3. Purchase ingredients
4. Have a space to cook the cake
5. Set aside the time bake the cake
You can think“I am going to bake a cake…any day now I am going to bake a cake…any minute I am going to bake a cake…what if I want to bake a cake…. I am definitely going to bake a cake…” until the cows come home but until you follow steps 1 through 5, you will have . And the same thing is true of a violent crime. It takes a whole lot more than just having then having a violent thought to engage in a violent behavior.
Section 22: When Trying To Solve a Problem Becomes the Problem
For the majority of problems that we humans face, when there is a problem, we strive to fix it. If you have a flat tire, it makes sense to fix the flat in contrast to accepting that you have a flat tire and for the rest of your life resorting to by foot. Unfortunately, the same problem solving/fixing strategies that work so well on the outside do not work when applied to internal problems of thoughts and emotions. .ou are n a tug of war with harm OCD. How is it going as you try to out muscle or out think it? Do you find yourself more locked in to OCD or more free to live the life you choose? If you are finding yourself more stuck on harm OCD thoughts, the more you strive to out power harm OCD, then at the very least drop the rope and walk away from the game. It is ok to be a quitter when it comes to . op wasting energy on a rigged game. There are so many more deserving recipients of your life force.
Section 23: Short-Term Pain versus Long-Term Gain
Say you want to start swimming regularly to get into better shape, but the water feels uncomfortably cold whenever you start to lower your body into the pool. You could retreat from the water, wrapping up in a warm towel and reading a book instead of working out. You’ll probably feel better in the moment, but you won’t get any healthier physically. The other option is to jump in, facing the initial shock of cold water but quickly becoming acclimated as you swim, working toward you goal of getting into shape.
Exposure to your intrusive thoughts works in a similar way. In order to get past these thoughts and feel like you are in better “mental shape,” you have to engage in exposures—directly confronting the thoughts and situations that you fear most. This will be uncomfortable at first, just like jumping into cold water. But similar to how you habituate to the cold temperature, you will stop feeling uncomfortable with these thoughts as you directly exposure yourself to them.
Exercise: Is the short-term pain of exposures worth the long-term gain of getting past harm OCD? List below the reasons you want to break past your intrusive thoughts.
Section 24 : Is All Discomfort Created Equal?
A funny thing we’ve observed in our practice is that people often regard their harm OCD with a particular reverence. Although these clients are generally strong, capable people in many domains of their lives—willing and able to undergo any number of daily pains, from receiving a shot to completing a physically grueling workout to having a deeply challenging conversation—when it comes to intrusive thoughts, they insist they simply can’t handle the discomfort. It’s almost as though when OCD enters the room, our patients forget that they have shown again and again that they are capable of handling distress.
No one enjoys having a sore throat, but few of our patients would say they absolutely couldn’t handle one. We suspect this is because our patients haven’t created elaborate stories about what it means to have a sore throat—concluding it’s a dark, shameful experience that reflects negatively on their character and so must be avoided at all costs.
Exercise: List types of pain or discomfort that you regularly confront and manage.
Take-away: Discomfort doesn’t feel good, but there’s a lot of evidence that you can handle it in many domains of your life. The distress that comes up around OCD isn’t fundamentally any worse or more threatening than any other kind of discomfort.
Section 25: What is OCD taking from you?
As one avoids life activities, to minimize harm OCD thoughts, one’s world gets smaller and smaller. Harm OCD has an insatiable appetite for reassurance and safety seeking behaviors. The more of your life you give over to it, the more it demands to feel future moments of peace. Avoidance will never work as a long term strategy. What does your own experience tell you? What are you currently avoiding in order to not have harm OCD thoughts? Is it working? to 10, how much avoidance are you currently engaging in? 0 to 10, in an average week, how much harm OCD are you currently experiencing? How much does avoidance impact functioning and create impairment in the life spheres below:
Leisure activities: ____
Spiritual endeavors: ____
Academic pursuits: ____
Other spheres: ____
Section 26 : Self-Compassion
There can be something very uncompassionate about how people with harm OCD act towards themselves. They conclude that because they have “bad” thoughts, they are “bad” people, and must punish themselves accordingly—for instance reacting with anger and criticizing themselves after having an intrusive thought.
Instead of indulging feelings of anger or disappointment when you have an intrusive thought, you might practice responding with compassion and reminding yourself, “Wow, if I’m thinking about stabbing my family, it must that they are particularly important to me. Not only is this likely to make you feel better in the moment, but it will help disrupt the OCD cycle, alleviating symptom distress over time.
Exercise: Sometimes, it’s easier to feel kindness toward a friend than toward ourselves. Below, list two of your own intrusive thoughts. For each one, write how you would respond if a friend told you she was struggling with these thoughts. Would you criticize your friend, or help her remember her many strengths and understand why she might be having these thoughts that are incongruent with her values?
Section 27: Excessive Reassurance Seeking and the Effects of Harm OCD on Relationships
Another unfortunate cycle that sometimes comes up for people with Harm OCD is that they excessively seek comfort from others, in doing so pushing away the people they most value and making their anxiety worse.
For example, consider a woman who obsesses that she might say something inappropriate. To try and reassure herself nothing has gone wrong, she constantly asks her friends if she has recently said anything that upset them. Although they might initially comfort her, with time they grow tired of her insatiable need for reassurance, and begin pulling away. The woman feels this distance and becomes all the more worried, asking more often for reassurance she hasn’t said anything “terrible.” Each time, she feels briefly better after her friends confirm she has not made a “terrible” comment. But over time she needs more and more reassurance to feel soothed, and her relationships become more and more strained—effectively bringing about the outcome she feared most.
Exercise: List any ways in which you seek reassurance from others in an effort to feel better about your obsessions. Have these methods of reassurance seeking ultimately helped you?
Section 28: Create an Exposure Hierarchy
Go back to the list you created if your current obsessions.
List out all you checked off as current
Rate each of these from 0 to 10 (0 does not bother me at all, 10 extreme distress)
Go back to the list you created of your current obsessions.
List out all you checked off as current
Rate each of these from 0 to 10 how much distress you would experience if prevented from engaging in this behaviors ( 0 does not bother me at all, 10 extreme distress)
Section 29: Pace Yourself
As you work through your exposures, remember that you’re running a marathon, not a race. It’s much better to have a small victory than to set yourself up for failure, taking on something too challenging at the very start and then getting discouraged.
Another benefit of the “slow and steady” approach is that it helps with battling perfectionism—a tendency that many people with harm OCD have. You might be inclined to be the “perfect” patient, quickly completing each exposure without ever having a setback. By forcing yourself to slow down a bit—and allowing for a natural process of sometimes feeling good and sometimes feeling uneasy as you work with your own mind—you’ll not only experience the greatest success in battling intrusive thoughts, but also work past your own limiting tendencies related to perfectionism.
Section 30: Create your mantra
It can help to have some affirming mantras and other tools at your disposal, to life you up when you are feeling the most down.
Sample exercise – come up with a motivational mantra. What songs inspire you? Make a harm OCD fighting play list. This section will include suggestions/links to inspiring songs and other tools our clients have used.
Section 31: When in Doubt, do the Opposite of the Compulsion
When you were a kid, did you ever talk about Opposite Day? On Opposite Day, down is up and up is down. Dealing with intrusive thoughts is like a never-ending Opposite Day in the sense that the best treatment is the to do the opposite of what the OCD is demanding. If you have intrusive thoughts about having sex with children, your OCD probably tells you that you need to avoid being around kids—in other words, avoiding children becomes a compulsion. OCD might even encourage you to compulsively go through all of your e-mails to see if you ever sent inappropriate sexual messages to a child. But as we talked about before with the OCD cycle, compulsions feed OCD. To overcome OCD and regain power in your life, you have to pause and do the opposite of what your compulsive mind is telling you.
Clients sometimes get confused when we talk about all this and say, “but if OCD is telling me to I might sleep with a child, then isn’t the opposite activity to avoid all children?” Nice try, but that would be indulging a compulsion. In general, the Opposite Day rule applies to compulsions (the things you do to try to alleviate your anxiety) and not to the intrusive thoughts themselves.
Exercise: Find three opportunities to apply the Opposite Day rule today. At the end of the day, record what you did in the space below. For example, “Lucas,” our patient who feared saying something inappropriate, might practice singing inappropriate words—which his OCD tells him to avoid—out loud in his shower.
Section 32: Reward Yourself
Treating your OCD is probably some of the hardest work you have ever done in your life (if it were easy, you wouldn’t need this book!). One very clear finding from psychology research is that behaviors that get reinforced get repeated. Another way of putting this is: if you reward yourself for completing exposures, you’re more likely to have success in overcoming OCD. It’s not self-indulgent to set up rewards; it’s essential to re-training your brain.
Exercise: Create a list of rewards you will get for reaching different milestones in this treatment workbook.
Section 33: Two Lies about Progress
There are two fallacies that we find clients often fall for as they move through treatment for harm OCD.
First, people imagine they will have to complete every exposure on their hierarchy, one after the other. This would make anyone feel overwhelmed, and probably want to give up. The good news is that when it comes to completing exposures, progress is more like a snowball. You’ll find that once you complete one exposure, you’ll no longer feel anxious at all about some of the others on your list, and can let them drop off the hierarchy as they’re no longer issues. The hierarchy is a living document—nothing set in stone—and you’ll be surprised by how quickly you move through it.
The second fallacy is that people imagine their progress should be totally linear, with no setbacks. Basically, they think progress should look like this:
In reality, progress will look more like this:
You’ll notice that in the second figure, the overall trend is downward: symptoms are indeed improving! On any given day, however the symptoms might actually have gotten worse compared to the day before. This is totally normal. In fact, if it weren’t happening, we would question if you were really engaging in the treatment. The trick is not to get lost in despair on the “up” days, when things feel harder than they did before.
Exercise: Using the chart below, log your OCD symptoms on a scale of 0 (no symptoms at all) to 100 (worst symptoms you can imagine) at the end of each day for the next month. What do you notice from looking at this chart at the end of the month?
Section 34 : Warning: Feeling Better May Feel Uncomfortable
Something strange happens as you begin feeling less anxious about your most anxiety-producing intrusive thoughts… you start feeling anxious about what it means not to be anxious!
For example, our patient “Stephanie,” the elementary school math and science teacher, became very uncomfortable when she stopped worrying that she might be attracted to or sleep with a student. “Why aren’t I freaking out?” She asked one day in session. “Anyone should be appalled by the idea of having sex with a kid! I don’t want to get to a point where that doesn’t bug me.”
To unpack this thinking, let’s pause to do a thought exercise: Visualize Katie, a woman who is terrified of flying. Every time Katie flies, she packs a crystal that she believes has protective properties that keep the airplane from crashing. So far, Katie has gone on 32 flights with that crystal and has never crashed. Can she ever know for sure if it’s the crystal keeping her safe, or if perhaps it isn’t necessary?
How might this same idea apply to the compulsions we engage in around intrusive thoughts? Reacting to a thought—getting upset by it—is a type of compulsion. People often believe this compulsion is necessary to ensure that they “stay in line” and don’t act on the thought or otherwise get “too comfortable” with it. But might it be that even if you let go of your reactions to these thoughts—if you leave your “protective crystal” at home—you might still behavior in ways that are OK?
Section 35: Mindfulness
Harm OCD takes you out of the present moment. Now that you have substantial experience with overcoming your intrusive thoughts, it could be a powerful time to begin practicing mindfulness exercises. Doing so both helps with further distancing yourself from the unwanted thoughts, and allows you to bring you attention back to the aspects of your life you value most.
Exercise: The unwanted party guest
Picture that you have spent the last month planning a huge birthday bash. All of your favorite people will be coming, your favorite music will be playing, and your favorite food and drinks will be served. It has all the makings of a perfect evening, except you just learned that your friend will be bringing her boyfriend, Tom, who you can’t stand. What do to now? You could cancel the party entirely. You could throw the party, but spend the whole time fixated on Tom, getting more and more worked up about all his qualities that bug you and effectively ruining the experience for yourself. Or you could throw the party, accepting that Tom is there, and directing your attention to the parts of the evening you value most: the people you love, the music you enjoy, all that. You aren’t denying Tom is there or avoiding him. You’re accepting his presence, but making decisions about where to place your focus. In the same way, you can accept when an intrusive thought has entered your mind, without letting it ruin the party. You don’t attempt to block the thought or shut down all your thinking, but rather notice the thought, maybe even greet it, then go back to focusing on whatever you were doing in the present moment.
Exercise: 2: 3-3-3
Sometimes, intrusive thoughts can make you feel very ungrounded. In these moments, it helps to come back mindfully to the present physical world. First, sit up with your feet flat on the ground, spine straight, rest of your body relaxed. Then look around and say 3 things that you see. For example, right now I can see my computer, my hands, and the picture behind my desk. Then say 3 things that you feel. I can feel the keys under my fingers, the carpet under my feet, and the fabric of my shirt brushing my arm. Finally, say 3 things you hear. I hear the clicking of my keys, the traffic outside my window, and air moving through the vents in my office. It’s good to use this activity any time you’re feeling physically ungrounded, to pull yourself back into the present moment.
Section 36: Diaphragmatic Breathing
You might find you still experience physical anxiety when intrusive thoughts first arrive, even though you largely have skills for managing the thoughts. This is normal. If you spent many years terrified of dogs, you might still find that your heart initially pounds when you see a dog, even after you’ve exposed yourself to dogs and largely gotten over your dog phobia.
A powerful tool for overcoming physical anxiety is diaphragmatic breathing. When we are confronted with something frightening, our breathing often becomes shallow and quick. We take in more oxygen than we need, causing a drop in carbon dioxide in the blood. As a result, certain blood vessels constrict and hemoglobin increases its affinity for oxygen. Less blood reaches areas of the body, and oxygen in the blood is less likely to be released into tissues—all of which produces physical symptoms of anxiety, including dizziness, breathlessness, higher heart rate, tingling sensations, and fatigue. Shallow breathing isn’t dangerous, but it is uncomfortable. Diaphragmatic breathing, by contrast, involves slow breaths into your diaphragm. This type of breathing will restore your oxygen and carbon dioxide levels, and signal to your brain that everything is OK, bringing you back to a state of physical calm.
Exercise: Practice guided diaphragmatic breathing.
Section 37: Exposure a day keeps the OCD away
This section will discuss relapse prevention
Live an exposure fused life, like going to the gym on a consistent basis or life long healthy eating crash diet
Remember triggers and try to be proactive caught off guard
Exercise – write out your ongoing harm OCD “work out plan.”
Section 38: Making Contact with Future arm OCD
At some point in the future you will feel OCD again. How will you handle it? Let’s create a OCD tool box to remind you of all the things you can do to manage your future OCD episodes.
Section 39: Post eBook Harm OCD assessment
In the past week, on average:
How many hours a day do you think about your intrusive thoughts?
How much distress do you experience when a harm IT surfaces?
How much impairment does harm OCD cause in your life/how much does impact your ability engage effectively in your life? (please think across all spheres such as family life, friendships, career, leisure, spirituality, self care, etc)
How hard are you currently trying to avoid or fight or make sense of your Harm related thoughts?
How hard are you currently trying to engage in valued living and putting your attention on the aspects of life that are most important to you?
Overall, How much is OCD now getting in the way of you living your life to the fullest?
Section 40: Growing Bored of Harm OCD
Can you imagine growing bored of one of your harm obsessions? No, you did not misread that sentence. It is not only possible, but in fact pretty easy for your mind to grow bored of any and all thoughts. Before we get into how to get bored of harm OCD, let’s take a step back and discuss the concept of boredom. Boredom is often associated with tasks or stimuli which are too easily understood and therefore, not challenging enough to capture one’s attention. Predictability is also associated with boredom. When we need not exert effort to manage a task, this will often lead to a self reported state of boredom.
Situation 1: Think of the last time you were bored. Where were you? What were you doing? What did it feel like to be bored? Where did you feel the boredom in your body?
Situation 2: Now, think of the last time you felt excited. Where were you? What were you doing? What did it feel like to be excited? What did you feel like to be excited?
List three key differences between Situation 1 and Situation 2:
More To Do:
Over the course of the next week, your job is to grow bored of one thing. Be creative in picking something to grow bored of. It can be a favorite food. It can be a song or a movie a video game. The one critical selection criteria for picking the “thing” you are going to grow bored of is that you should start out having strong feelings for it. It would be way to easy to assign you to grow bored of a cotton ball, for example. There is not much work to be done there. It is more interesting to notice the transition in your feelings from strong to weak.
What are you going to grow bored of?
What is your initial emotional reaction to this item (O absent, to 10 off the charts)?
After the week of growing bored with this item, what is your final emotional reaction (O absent, to 10 off the charts )?
What did you do during the week, to grow bored of this item? What was the behavior you engaged in, to grow bored of it?
Do you have any advice you can offer others? What keeps you going? What has helped for you? What has not helped you? Send us a quote and we will include your words of wisdom on our website.