Harm OCD 4: Harm in Space

There are countless people walking amongst us believing that they are living a double-life.  On the outside they seem like regular people, if not a little overly conscientious.  On the inside, they believe themselves to be some kind of sleeper cell, narrowly escaping detection, perpetually and inescapably driven to do evil, despite never actually doing said evil.  “Oh if you only knew” is the mantra of the Harm OCD sufferer.

Not all Harm OCD focuses directly on a fear of violent action.  After all, there are any number of ways you can cause harm and ruin someone’s life and OCD is quite happy to point them out.  The OCD mind moves very quickly.  It jumps from a trigger to a consequence at light speed.  It jumps straight from something like recognizing a potential parenting misstep (letting your 10 year old watch a pg-13 movie) to an immediate terrible consequence (imagining your 10-year old shooting innocent people from a rooftop while shouting “This is because of my parents!”).  It jumps from the mundane (driving by a broken bottle on the side of the road) to the tragic (an image of an innocent person being stabbed with the broken glass, the murderer thinking, “Good thing someone left this here!” and the victim thinking, “I blame whoever drove by and allowed this weapon to be found!”)

The fear of harming others pervades several different manifestations of OCD.  We (clinicians and sufferers) come up with terms like “Harm OCD” to define a focus on a particular thought content, but quite often OCD jumps around and uses the uncertainty inherent in all obsessions to make a kind of cocktail of fears.  Some examples:

Contamination Harm:

  • Fear of causing harm by spreading germs, blood, feces, other bodily fluids as a function of not washing thoroughly or not avoiding vigilantly
  • Fear of allowing others to be harmed by leaving contaminated items accessible (i.e. being responsible for someone getting ill because they came in contact with a used tissue that was on the floor near a trash bin)
  • Fear of poisoning others with expired food, “unsafe” food, improperly cooked food, or by allowing contaminants to have touched food

Sexually-themed Harm:

  • Fear of being in denial of a latent other-sexuality (gay if you identify as straight, straight if you identify as gay, anything if you identify as anything else) resulting in severe emotional harm to a significant other
  • Fear of “snapping” sexually and acting on an unwanted sexual impulse against a loved one or child

Hyper-responsibility/checking Harm:

  • Fear of causing harm to others by negligence (e.g. causing a fire by not checking if the stove is off, causing a burglary by not checking if the doors are locked)
  • Fear of allowing harm to occur by leaving “dangerous” objects around (e.g. seeing a potentially distracting object in the street that could cause a traffic accident or seeing a loose nail that could be used as a weapon or cause a structure to collapse)

Relationship Harm:

  • Fear of causing partner such distress that they might harm themselves or have an unhappy or “wasted” life
  • Fear of acting on unwanted impulses to cheat or otherwise dishonor a significant other, again potentially resulting in emotional harm or suicide
  • Fear of harming loved ones by not perfectly meeting their needs (e.g. harming a child by not playing enough with them and making them feel “abandoned”)

Scrupulosity Harm:

  • Fear of condemning someone to hell by not adequately doing rituals (e.g. not praying enough for others, praying incorrectly for others, or allowing sinful thoughts to harm others)
  • Fear of bringing evil into the world with blasphemous thoughts

Moral Scrupulosity Harm:

  • Fear of causing a loved one to commit murder or suicide as a function of teaching them poor values or being dishonest with them
  • Fear of harming loved ones by exposing them to “inappropriate” material (e.g. violent movies, age-inappropriate music)
  • Fear of harming someone by saying the wrong thing or getting someone in trouble inadvertently (e.g. getting your co-worker fired, causing your therapist to have his/her license revoked)
  • Fear of contributing to global problems that cause harm to innocent people (e.g. buying an article of clothing that might have been manufactured in poor conditions where children are harmed)

And so it goes that the OCD mind traps you in an impossible quandary.  Do no harm.  Sure.  But how much effort should be placed in the not doing of harm?  In our minds we draw a line.  We are good and we sit on one side of that line.  On the other side of that line is evil, the desire to cause pain and suffering to other human beings.  The closer we are to that line, the more uncomfortable we feel.  Without OCD, we tend to tread pretty closely to the line on a regular basis.  We even step over it from time to time, say, “Oops” and then get on with our lives because without OCD we can tolerate the uncertainty and imperfection.

This morning I made oatmeal for my daughter’s breakfast.  When I grabbed the bowl, my thumb pressed against the inside of it.  If I recall now, I know my thumb had previously touched the cupboard door, the oatmeal container, and the microwave.  It may have touched my shirt, my pants… my nose even?  The memory is foggy because I wasn’t paying close attention.  Maybe I got a germ in there somehow.  Maybe she’ll get sick and maybe it’s my fault.  If this behavior was mired in an OCD fear of harm, all of this would seem dangerously too close to the line.  I’d want protection, a kind of buffer separating me from the potential to do harm.  I’d have to be careful to make sure no unclean thing touched me or the bowl.  I’d have to track my moves.  Maybe wear gloves.  Maybe track everything the gloves touch.  Maybe it would be better to have my wife make the food.  But I better watch her, make sure she doesn’t touch anything.  Still too close to the line.  She might make a mistake and if I see it and allow it, it’s like I did it.  Maybe I should stay away from the kitchen altogether just to be certain I don’t contaminate it and inadvertently hurt my family.  Maybe I just can’t be there when food is being made so I don’t see anything.  But is that moral?  Is ignorance an excuse?  Maybe I can’t be a father.  Maybe I should leave.

That got dark pretty quickly, didn’t it?

How far away from the line do we have to be?  At what point do we say, “Well, if that’s what harms my daughter, so be it, but I’m not putting in more effort to keep it from happening”?  This is the challenge a Harm OCD sufferer is up against.  The person without OCD has the same challenge, to accept that they may be doing something that may be harming someone.  The difference is the OCD sufferer has to acknowledge the presence of the challenge.  The OCD sufferer has to take the extra step of acknowledging that they are having a thought about something truly awful.  This is because the OCD sufferer has a mental radar that picks up this extra noise and broadcasts it, shoves it in your face.

The severity of a person’s OCD is best measured by how much of his/her life he/she is willing to sacrifice for certainty.  The implication inherent in an OCD mind is that there is no point at which a person should be willing to accept the possibility that they may harm another person.  This sets the stage for sacrificing everything because no individual thing can be considered too much to sacrifice.  This is how Harm OCD debilitates people rather than just makes them anxious.  And while many with Harm OCD are focused on a fear of snapping and causing overt harm, many simply view harm as a house of cards, wherein one failure of vigilance seems as if it could cause an entire world to collapse.

Interestingly, people need harm to be done to them in some ways.  You may obsess about damaging your children with “bad” food, but then they also need to associate food with pleasure at times in order to develop a healthy relationship to eating.  In other words, in moderation, it’s actually important that they eat liquefied chicken, deep fried, and shaped like dinosaurs… in moderation.  You may obsess about harming an employer by not being hyper-vigilant in how you check your work, risking a mistake destroying the company.  But they actually need you to make the occasional mistake so they don’t get lackadaisical in how they review your work, so that they continue to train their employees and keep the company strong.  This is not a call for cruelty.  It is a call for respect.  Respect for others in their ability to look out for themselves (yes, even kids have immune systems).  And respect for yourself separating your identity from your OCD and its demands for certainty.

Owning your experience

One common approach to OCD treatment within the CBT world is the approach of “It’s not me, it’s my OCD.”  As a concept, it helps many separate themselves from the disorder and treat the OCD instead of inaccurately treating some perceived character flaw.  This is a good thing.  However, this approach presumes that some thoughts should be disowned, implying that any thoughts have some intrinsic value just by the words they may contain.  In mindfulness, a thought about pushing someone in front of a bus is not more or less meaningful than a thought about the indestructability of tardigrades (look it up, people).  It’s possible that an OCD sufferer is more likely to be aware of certain kinds of thoughts than a non-sufferer and so “It’s not me, it’s my OCD” really addresses the awareness, not the content of the thought.  So despite it being a helpful strategy for some, many with harm OCD may end up using the “it’s not me” technique as a covert ritual, just another in a series of mental compulsions aimed at denying the presence of harm thoughts and the feelings of uncertainty they bring.  A more complete strategy would be “It is me, that’s how I think, and so be it.”  At the end of the day, this is the truth.  We cannot complain about a fear of being in denial if we don’t acknowledge certain truths.  These are the thoughts going through your head.  Why are you hyper-aware of it?  OCD.  What does it mean?  Unknowable.  What should you do?  Allow it, accept it, let it pass through you.

But how?

The answer is cognitive behavioral therapy (CBT) with an emphasis on mindfulness and exposure with response prevention (ERP).  These thoughts are going through you.  By exposing to them, sitting with them, and resisting compulsive strategies to neutralize or disown them, they are given free passage.  This may not seem like what you want when your OCD is chipping away at your sense of self, contaminating your relationship to each thing you care about.  But free passage for the thoughts and feelings is exactly what you want.  They are going through you, like it or not, and you are aware of it, like it or not.  If you don’t want them to stay, you can’t keep stopping them on their way through.

“You only lose what you cling to.”

That’s a quote attributed to Buddha.  There may be many ways to interpret such a thing, but mostly we can’t help but hold on tightly to the people we love and of course we “cling” to an un-harmful identity because it just feels right.  But then OCD steps in and tries to pry it away, so we cling harder and harder and our relationship to the things we care about become about the fear of losing them.  All of that attention gone toward a fear of loss and we forget that we have already lost in so many ways.  Parents afraid to touch their kids, spouses afraid to sleep under the same roof, law-abiding members of society afraid to drive or walk down the street; and all because of unwanted, intrusive thoughts about losing something precious.  What a waste of our finite time here.  If you have Harm OCD, you have a treatable mental health condition.  So I say cling to your identity as a positive force in the universe and cling to the people you love.  Just do it differently.  Do CBT, do ERP, learn about and practice mindfulness.  Cling to life, but do it on your own terms, not on the barked orders of your OCD.

Click here for Harm OCD: Part One

Click here for Harm OCD: Part Two

Click here for Harm OCD: Part Three

Jon Hershfield, MFT is a psychotherapist in private practice licensed in Maryland and California, specializing in the treatment of OCD.  Follow him on Twitter and Facebook