I avoid bathing my child because of my intrusive harming thoughts. I’m afraid to cuddle up on the bed and read him a bedtime story. At meal times I hide sharp objects. I pray. I seek reassurance. I run and hide. Nothing will make my thoughts go away and I’m terrified that my harming thoughts will come true. What can I do?

First, the behaviours you are doing are known as compulsions. These provide short-term anxiety relief because by doing them you escape your fears; however, in the long-term these “safety” behaviours are negatively reinforcing; and so they keep the problem going in a circle.

I see, so why can’t I just stop the thoughts?

One way to look at this is to recognise that trying to block OCD thoughts is like trying to stop pouring rain, just by thinking about it. It doesn’t work. Similarly, intrusive thoughts are biologically driven into your consciousness without your will and so they will pour into your mind regardless of any attempts to stop them.

Hmm, I get what you’re saying. How about I try to analyse my intrusive thoughts, and search for the answers to my questions that way, could that finally stop them?

No, because OCD cannot be reasoned with by analysis.

Why?

Because intrusive thoughts are not based on valid content. You’ll simply become further entrenched into the confines of the disorder the more you try to analyse or interpret the thoughts because they cannot be logically argued. In other words the conclusion of your analysis could never be verified without contradiction.

Sorry, can you explain that another way?

Well, put simply, OCD is contrary to or disregardful of the rules of logic, hence the saying “OCD is a paradoxical disorder”. So factually, whatever your intrusive thoughts are these are not your true desires, they are quite the opposite.

But how?

It’s a biological process that involves the parts of the brain that are responsible for OCD, which is why it’s important to recognise that you’re dealing with a disorder that involves seeking meaning when there is none.

Yes, but it doesn’t feel like that, the thoughts and urges feel very real… So what can I do?

Well, we’ve discovered that you cannot defeat OCD by emotional reasoning, analysis or by giving into compulsions. However, what you can do is defeat OCD with cognitive behavioural therapy (CBT).

What is CBT?

CBT is concerned with identifying and reframing thinking errors linked to certain belief domains. In a harming example, the cognitive error is viewed as catastrophisng since the probability of harm is exaggerated. Catastrophising in this sense links with the belief domains overimportance of thoughts and responsibility.

Is that it?

No, there’s more. In a nutshell, CBT considers thoughts, feelings and behaviours – these all interact with each other. So once thinking errors are corrected, your emotions change for the better. And when emotions improve so do behaviours. This is the good thing about the cognitive side of therapy, because it prepares you for facing your obsessions and changing your usual responses (resisting compulsions). By changing your responses you build distress tolerance. As a consequence, the intensity of your obsessional fear gradually diminishes.

How would I face my obsessions?

This would be with exposure response prevention (ERP), the crucial part to CBT. A new response following cognitive restructuring of thoughts is the resisting of all compulsions, noted above. Bearing with the anxiety until it reduces naturally is one of the goals in ERP as it is that builds distress tolerance, leading ultimately to habituation.

So habituation is the main goal when doing ERP?

Yes, the main goal is to gradually sever the link between your obsessional fear and your associated anxious response. As an example, when you take your child to bed and the intrusive harming thoughts are entering your mind, you would acknowledge they are there, accept them, and allow them to come and go all the while you continue to put your child to bed. This is a mindful technique which is often integrated into therapy.  At the same time you would resist any urge to give into a compulsion, all compulsions.

And what will the outcome be following habituation?

Well, by doing ERP regularly your brain learns to dismiss the irrational fear. As a result, alert signals become much weaker. As a further example of doing ERP in graduated steps, the next stage (after putting your child to bed with less distress), you would be encouraged to read a story sitting on a chair by your child’s bed. When this becomes less anxiety-provoking, you would agree to sit on the end of his bed and read a story; next you would move closer to him and until you are able to cuddle up and read him a story.  Basically, by breaking the connection between your intrusive thoughts and your fear-related response your tolerance to anxiety increases. Intrusive harming thoughts may still come and go, but at a much weaker volume. This is when you start to grasp that there is and never was any need for “safety” behaviours (compulsions), and this is the way to manage remission.

To summarise, harm OCD has two essential characteristics – obsessions to harm and compulsions to “prevent” harm. The way out of this spiral is to engage in CBT with ERP with mindfulness (also sometimes with medication, particularly if symptoms are severe). The cognitive side of therapy helps to correct thinking errors linked to faulty beliefs; and by facing your obsessions (exposure) and resisting compulsions (response prevention) the long-term gain is remission, or at least much reduced symptoms. Therapy actively changes your brain’s chemistry back to a non-OCD state, meaning intrusive thoughts may still come in, but where you no longer respond to them as you once did.

You might also like to read Afraid of Acting on Your Intrusive Harming Thoughts? Read This…

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