I first hosted Jon Hershfield in a Tuesday Q&A in 2015 and he’s done so much since then it’s time to have him back! With four books under his belt, he puts authors like me to shame, so I don’t know why I’m continuing to promote him. But, really, he has a wealth of practical advice to offer and always does so with humor and compassion. We’re lucky to have him in the OCD community.
A lot has happened since we last chatted! You may be the most ambitious person I know: You just published your fourth book, Overcoming Harm OCD. One of the most common questions I hear about harm-related intrusive thoughts is “How will ERP work for me? It’s not like I can walk around with a sharp knife.” How would you answer that question as a therapist?
Well, you can literally walk around with a sharp knife. Normally we do this when we’re on our way to divide a sandwich. But the question has to do with concern about causing actual harm in the course of doing exposure to a fear of causing harm. In ERP we do a lot of scary things, but what we don’t do is actually hurt people. In OCD there’s been some problematic training of the brain to assign “danger” to uncertainty about harm thoughts. So if I see a knife and I have an intrusive thought of causing harm with it, my brain may believe we are in danger. ERP works by getting in the ring with that uncertainty, resisting compulsions and other safety behaviors, and retraining the brain to have a different association with the uncertainty. So actually, yeah, handling a sharp knife in the presence of unwanted thoughts and other triggers can be really good ERP. I think it’s easy to get confused here because one might think we don’t have people stab strangers as exposure simply because it’s wrong. It is wrong, but that’s not really why we don’t do it. We don’t do it because that would fail to actually teach the brain how to handle uncertainty. For exposures where handling a knife may be complicated (e.g., you can’t bring one on an airplane), we have imaginal exposure where we use writing as a strategy to trick the brain into thinking we could be in danger. In this state, we practice resisting compulsions and we create new learning about being uncertain. People with harm OCD are not the ticking time bombs they think they are, but no amount of me telling them this will actually touch the OCD. They have to experience the exposure without the compulsions to truly understand this.
We know that getting the right diagnosis and proper treatment can take years, and I’ve always wondered if it takes longer for folks with harm obsessions. When I was worried I’d hurt a child, I was afraid to tell anyone, even a therapist, because I thought they’d deem me a risk to society and call the police. In your experience, are individuals with harm obsessions less likely to seek help than those with, say, a germ phobia? Or is their fear that they’ll hurt somebody so strong they feel they must be stopped before it’s too late?
Both of these things are very common in unwanted violent obsessions. A person with harm OCD may avoid treatment because of the concern that the treatment provider will have them hospitalized or arrested, or that disclosure of these thoughts will bring shame and scorn to them and their families. In more severe cases, anxiety can be so high and insight so low that a belief develops in the mind of the person with OCD that they must be defective at the core. Essentially, they imagine that going to treatment will reveal this defect and the borrowed time they’re living with before hurting someone will come to a sudden end. We can largely blame external stigma about mental health issues, especially as it relates to intrusive thoughts, for inhibiting people from seeking help. But self-stigma is even more powerful and the belief that having these thoughts makes us immoral or bad keeps a lot of people from asking for help.
We know reassurance seeking is a compulsion, and giving reassurance only adds roadblocks to the recovery process, so what is the best way to help a loved one with these upsetting intrusive thoughts?
Loved ones can educate themselves about the disorder. Knowing your loved one without OCD understands that you have OCD is reassuring in the best possible way. If the sufferer and the family member (or partner, etc.) can work together with compassion and an educated understanding of the disorder, navigating reassurance becomes easier. Collaborating on non-reassuring, but compassionate, responses makes a huge difference. So rather than constantly telling a person with harm OCD that they’ll never hurt anyone, they can find appropriate ways of telling them that they understand OCD is really painful, that they are proud of and support the work that’s being done to overcome it, and that there are several shows on Netflix right now that demand more attention than the question on the table at the moment. Of course, none of this type of interaction is possible without empathy and kindness. Helping them access treatment when possible, supporting that treatment, and never confusing the symptoms with who the person really is are all instrumental.
Speaking of not giving in to compulsions, let’s talk about your book When a Family Member Has OCD. It must be hard for parents to resist the urge to act as a therapist themselves, and to instead support their child through the recovery process. What would you tell a parent who is at his wit’s end and just wants to make life easier for his child, even if that means doing the “wrong” thing?
In writing When a Family Member Has OCD, I really kept in mind two audiences: one is the family member who wants to better understand a loved one with OCD and the other is the OCD sufferer who wants to be understood. Families operate as systems. There is no such thing as a child with OCD that exists in a vacuum where the child just gets fixed by the therapist and life goes back to normal. A child with OCD does hard work with CBT/ERP to master the disorder. The parent of that child must also be willing to do exposure to their own fear that they aren’t doing enough to relieve their child’s suffering. It’s excruciating, but when parents sabotage the treatment by providing reassurance and accommodating rituals, they just set the stage for more pain for everyone later. Reassurance actually doesn’t make life easier for the child because it sends the message to the child’s brain that there was something dangerous to reassure about and that they could not have coped without your intervention. Confronting the discomfort over withholding reassurance means sitting with uncertainty about how much pain you and your child can withstand in the face of OCD. It’s not easy. But parents who overcome this fear get a better understanding of what it’s like for their child to overcome fear and when the child improves, the parent’s relationship to anxiety changes too, and the whole system improves.
You co-authored Everyday Mindfulness for OCD with Shala Nicely, an inspiring read about how to enhance ERP with mindfulness techniques. I’ll admit that I always thought sitting in silence with my horrific thoughts felt a little like torture—and many people can’t believe we’re supposed to accept those thoughts.
It’s an interesting way we often put it—“to sit in silence with horrific thoughts.” There are some inherent problems in framing it this way. First, it implies that in the absence of distraction, it’s just the self and the thoughts alone in space. But this isn’t true. In the absence of distraction, we see things as they really are, which includes input from all five senses and, yes, thoughts. So it’s really being in the company of six streams of information and treating them all as such. Sound, touch, thoughts, and so on are all just objects of attention being projected onto the screen of the mind, so if we learn how to pay attention, there’s a lot more to look at than just sitting with obsessions. This highlights the other problem, that word “horrific.” We get so used to categorizing thoughts like movie genres that we easily forget how thoughts are just words and pictures. They don’t really have positive or negative qualities unless we decide that they do. Yes, the thought of harming my children abhors me. But if I write “harming my children” in red marker on a piece of paper, the only thing that’s changed about the paper is that it has red ink on it. The same is true of us. When we think a thought, the thought is just words scribbled on the mind. It doesn’t change who we are.
Tell us how mindfulness can help, and explain why it’s a myth that meditation means completely clearing our minds of all thoughts.
Two problems occur in the way the OCD mind operates that can both be addressed with mindfulness, which simply means watching the mind objectively. First, the mind wanders from the present, as it should, no different than a puppy sniffing things on a walk around the block. But we often fail to notice that it’s wandered and then, in a way, we find the puppy pooping on the neighbor’s porch. In other words, we get lost in our obsessive thoughts because we have trouble paying attention to where the mind is in any given moment. Then, when we discover that we’ve been pulled away by an obsession, the disorder sets a precondition for returning to the present. We feel obliged to neutralize the obsession (i.e., get certainty that it isn’t true), to do a compulsion, and then we get permission to return to wherever we were before we got distracted. If, on the other hand, we had the capacity to notice early on when the mind has been pulled away by an obsession and could simply start over in that moment as if it never happened, without permission from the OCD, we’d be much more in command. Meditation is an exercise that targets these two strengths, of recognizing where the mind is in each moment, and starting over when we see the mind distracted. By definition, this requires the mind to not be clear, but to see it clearly. Have all the thoughts, but know that they are thoughts and don’t try to fix them.
What’s next for you?
It’s been brought to my attention that I’ve written four books in the past five years or so. I’m hoping that Overcoming Harm OCD helps more than just the kind, gentle, and creative people I’ve encountered in my clinical work, but harm OCD sufferers everywhere. I also hope it serves as an excuse for me to slow down before I find myself writing something about sexual obsessions. So what’s really “next” for me is just continuing to build my practice and doing the best I can to help empower the most people in their OCD recovery.
Alison Dotson 