Acceptance in HOCD and POCD

One of the more terrifying and slippery versions of Obsessive-Compulsive Disorder (OCD) involves experiencing thoughts of harming a loved one or having sex with an inappropriate partner. Typically, people think of OCD as involving fear of germs and doing repeated checking, but in my experience many people with OCD also struggle with these kinds of thoughts. The person who experiences these thoughts interprets the mere presence of the thoughts as meaning that they want to act on them and may be at risk of "snapping" and actually harm their loved one or do something inappropriate sexually. These two types of OCD have been called Harm OCD (HOCD) and Pedophilia OCD (POCD) and the two versions have much in common. In my last blog post I reviewed the book "The Mindfulness Workbook for OCD" and this book has two very useful chapters for dealing with both of these types of OCD. There are a variety of techniques available for managing these kinds of thoughts, but two of the more useful tools, in my experience, are to mindfully accept the presence of the thoughts and to commit to not doing any compulsions in response to these thoughts. "Acceptance" of these thoughts is different from accepting the meaning that one attaches to these thoughts. Having the thought of harming a loved one is not the same as having the "intention" of harming a loved one, but OCD confuses these two. Clearly making this distinction is an important part of the treatment process.  

When I encourage clients to mindfully accept the presence of these thoughts and as clients make progress with this acceptance process, they often begin to feel guilty because they think they "should" be paying closer attention to these thoughts because they are so dangerous. They feel quite irresponsible for not doing all they possibly can to either eliminate the thoughts altogether or to prevent acting on the thoughts and are under the mistaken assumption that they need to understand, figure out, analyze, or in some other way engage these thoughts to become absolutely certain that they will not act on them. It is this feeling of responsibility/guilt that I believe needs to be acknowledged and addressed. I find it helpful to predict for clients, as they seek to mindfully accept their thoughts, that they are likely to feel quite guilty for not reacting "appropriately" (i.e., being horrified/repulsed) to their thoughts. This feeling of responsibility/guilt can be dealt with in the same way that the thoughts themselves are addressed, in that, they can be mindfully recognized and tolerated. To do otherwise, and to in some way engage with these thoughts, is to fall prey once again to compulsions and the OCD cycle starts anew. Frequent questions/issues that clients have raised with me is "What does it mean about me if I don't feel repulsed by these thoughts? I should be repulsed by these thoughts. What if I actually get to like these thoughts?". Clients can come to resist the acceptance process fearing that this "acceptance" brings them even closer to being the kind of person who would act on their thoughts. Predicting that these questions may arise as part of the treatment process and applying the same acceptance/tolerance approach to these thoughts often works well. As the thoughts are recognized and tolerated, their ability to trigger anxiety begins to fade and they become just part of the more normal thought stream.