Jon Hershfield's Blog, page 4

How to Respond to Unwanted Thoughts

One of the questions that often comes up both in my clinical practice and in the online support groups I contribute to is, “How do I respond to my thoughts?” Or more specifically, “What is the right way to respond to my thoughts?” There is a hidden OCD trap here in the search for the exact right way to respond to thoughts. If we can be certain about the one true or “best” response to thoughts, it means that thoughts themselves have one true nature. If we can fail in our response to thoughts, the implication is that thoughts have an intrinsic power, a quality that must be carefully examined. Yet this idea actually flies in the face of the central thesis of OCD mastery, which is that thoughts are thoughts, not threats. The significance of their content is attributed to them, not hidden in them, and whether they are “worth” incorporating into some behavior or better left alone is not the sort of thing that fits into a concrete equation.

Ultimately, I don’t believe there is a best practice for responding to thoughts (OCD or otherwise).  There are practices that I see working better for some people and for others not so much.  There are practices that have a higher success rate (if we are associating the reduction of suffering with success) and practices that only work every once in a while in specific situations. Any practice done by rote, or done every single time, especially if done in a sense of urgency, can quickly turn compulsive.  Here are some options for responding to thoughts along with their potential pros and cons for OCD mastery:

Doing nothing

One of my favorite things to do in general, or at least it would be if I ever did it for very long. Nothing. In terms of thoughts and the responses we give them, doing nothing means completely ignoring thoughts as meaningless chatter, no different than the ambient noise of traffic from a distance. How can we do nothing in response to thoughts? Well, first, we have to believe that nothing is happening. Easier said than done. Doing nothing in response to a thought means not even taking a moment to acknowledge that the thought (or feeling or sensation) has occurred and simply plowing through your chosen activity as if unaware of any competition for your attention. It’s the “Keep Calm and Carry On” of navigating OCD.

Pros of doing nothing:

It treats the thought like the non-event that it is.
It stays out of the content of the thought altogether.
It wastes as little attention as possible.
It may enable the completion of tasks otherwise disrupted by OCD.

Cons of doing nothing:

It requires one to be in a state of mindful acceptance from the start, which is a major challenge for most people.
It can easily become a form of compulsive avoidance, a refusal to acknowledge that the thought occurred in the first place and a refusal to experience feelings as they are.
Active “ignoring” can trigger an additional sense of being in denial (and thus more anxiety).
It can quickly devolve into a habit of “white-knuckling” through life, which is unsustainable.

Mental noting

In a basic mindfulness meditation practice, mental noting means labeling the internal activity that is occurring in the moment one becomes distracted from their anchor (usually the breath). So, for example, if I am meditating and I notice how bored I am, I might gently say to myself, “boredom,” and then return to watching my breath. If I notice that I’ve wandered off into a train of thought, I may say, “thinking” and gently hop off the train as best I can. Similarly, when just going about my business in life, I may become distracted by an obsessive thought. I might respond to this as well by saying “thinking.” Or I could be more specific and acknowledge when the thought applies to a particular OCD concern, as in “murder thought” or “disease thought.” Once acknowledged, I then return to whatever I was doing before I became distracted (as in, going back to a specific activity) or I incorporate feeling distracted into that activity (do what I was doing but with somewhat divided attention). The point is I release myself from acting on the thought in any way past noting its existence.

Some may find it useful to mentally note “OCD thought” but I generally do not recommend this. By drawing distinctions between OCD thoughts and other kinds of thoughts, we are already playing into the distorted belief that the content of the thoughts has intrinsic value. If we must disown thoughts by calling them “OCD”, then we are saying we would be bad for having them without OCD. But they are thoughts, not threats. So even the worst thoughts are better off being understood as ours. This doesn’t mean that we like them or that they represent us, but simply that we have minds and minds have thoughts.

Pros of mental noting:

It’s honest about the experience of having the thought but without getting too deep into content and without acting directly on the thought.
It often lightens the sense of doom by positioning the thinker as an observer of thoughts instead of a victim.
It renders the debate over whether a thought is “good” or “bad” completely pointless.

Cons of mental noting:

It does give the thought some attention and for some this could lead to too much attention.
It opens up a window to covert mental rituals and can become a compulsion itself (e.g. having to accurately label the thought every time or checking to make sure you’ve noted everything).

Agreeing with the uncertain potential

Most obsessive thoughts come in the form of “what-if” questions like “What if I hurt someone?” or “What if I get a disease from having touched this?” Those that don’t present this way often still involve concerns like “what if I can’t tolerate this?” Given that certainty is a myth, it is reasonable to say that if we can think it, the likelihood of it also being a true about reality is something greater than 0%. It may not be much greater (as in, the ceiling above me may collapse at any moment but probably won’t), but it is nonetheless something other than an impossibility.

So if we were to respond to an unwanted thought with a statement like “That may or may not occur” or “I don’t know” or “Anything’s possible, but I have other things to attend to at the moment”, we are noting that the thought is present, owning that it is ours, and accepting that it has some amount of potential to be connected to reality. Other responses in this vein could include commenting directly to the OCD as in, “Duly noted” or “Mysterious” or “Well, that’s an interesting idea.” To be clear, this is not agreeing that the feared thought is true, that the feelings mean some specific thing, or that we can make predictions about the future. Indeed, it is the opposite of taking the bait. It is defeating the debater by refusing to go on the defensive.

Pros of agreeing with the uncertain potential

It provides a functional exposure (well, maybe that could occur, I don’t know) while interfering in ability to complete rituals (it leaves the verdict on thoughts intentionally incomplete).
It is honest (any statement that starts with “maybe” is technically true however improbable, as in “maybe I will be abducted by aliens tonight” vs. “it is proven fact that I will not be abducted by aliens tonight”)
It can develop into a healthy habit of openness to uncertainty and mindful awareness.

Cons of agreeing with the uncertain potential:

It can increase anxiety because of the absence of reassurance and the assessment that fears can come true.
It does get involved in the content of the thought, which can be a slippery slope to mental rituals
It requires significant effort to resist following it up with compulsions and can be exhausting

Agreeing affirmatively

You may find all sorts of books and blogs alike that recommend simply agreeing with the thought. Done effectively, this can be a way of basically pulling a thought through the mind that would otherwise be stuck. It says, “Alright, fine, it’s all true, let’s get on with it already.” Or you might agree more emphatically, thus allowing yourself to become so affected that you experience strong urges to do compulsions, which you can then practice resisting. Every ERP is a learning opportunity.

Note however that in this discussion I am primarily talking about how to respond to thoughts moment to moment. This is different from how to respond to thoughts in the course of a specific exposure exercise that you may be working on in your treatment. Some forms of imaginal exposure, for example, may promote the use of saying that an unwanted thought is “true” and really hanging on to this as a strategy for increasing anxiety to a level that can produce therapeutic benefits. But in the day-to-day, the habit of affirming the content of thoughts can also be problematic because, quite frankly, there’s more to life than ERP.

Pros of agreeing with thoughts:

It provides an immediate exposure to the feelings associated with the content (as in, when I say the words “I will kill my baby”, I feel disgust and I can then do exposure to that feeling, which is the feeling I most often have trouble resisting compulsions around).
It is a way to outdo the OCD and beat it at its own game, which can be confidence-building and even humorous.
It eliminates the need for debate over the meaning of the thoughts by assigning it a blunt meaning without analysis.

Cons of agreeing with thoughts:

It isn’t technically honest (you could kill your baby, but you can’t know that you will).
It can become a form of compulsive checking (did I like it when I said it?) which can easily spin out of control.
It can be used as a form of compulsive self-punishment.
It gets involved in the thought content and it may cause panic or trauma responses in some susceptible people

Hey, over here! A word about distraction

Many readers may have heard that distraction is a good thing because it takes your mind off of the OCD. Or you may have a heard that it’s a bad thing because it functions as compulsive avoidance of your obsessions, ultimately making them worse. Both of these things can be true or untrue depending on intention. Distraction is just anything that interferes in your ability to give full attention to anything else. To use distraction as an intervention with unwanted thoughts in OCD, the benefits and drawbacks are rooted in whatever message the brain is likely to receive from the shift in attention. Is the brain being informed that thoughts are unimportant such that attention can be lifted from them with ease and dropped on something else? Or is the brain going to get the message that thoughts are so terribly important, we can’t bare to be in their presence for even a moment without distraction?

Bad distraction

In the course of exposure, you become very uncomfortable. To get away from the uncomfortable feeling, you might distract yourself with a video game you’ve played a thousand times that helps you shut off your thoughts. This is what I would call “bad distraction” because it sabotages the exposure therapy (by not allowing you to feel the discomfort and learn from it) and because the attention is being placed in a dead zone and not on something that promotes growth or represents a meaningful value. It is escape. Now let me be clear, escape is not the enemy all the time. We all have a right to check out from time to time. But in the midst of an exposure is not a helpful time for this.

Better distraction

Imagine you’ve just been triggered and the way you are accustomed to responding to triggers is to engage in an elaborate mental ritual that involves reviewing all of your memories associated with the trigger, imagining fictional scenarios where you respond a specific way to your trigger, chanting thoughts that neutralize your fears, or any or all of the above. In other words, the train of your mind is headed to Compulsion Station and you need to get off. Though it is widely agreed that “thought stopping” or trying not to have or not have certain thoughts, is ineffective, derailing a mental ritual is fair game. Ritual-stopping is not thought-stopping.

I sometimes refer to this as running interference. If you can’t think, you can’t complete a mental ritual, and if you abandon a mental ritual before it produces any satisfaction, you’re doing ERP. You’ll know it’s ERP because it will feel flippant or irresponsible to suddenly stop devoting your attention to the ritual and devote it to something else. To effectively drive a wedge between you and the ritual, you can push the mind to attend to something that requires focus and is incompatible with ritualizing. A good example is to try to remember the sound of a 56k modem connecting to the internet (a what? said the reader born in the 1990s). Or, feel free to recollect the lyrics to Peter Cetera’s The Glory of Love, which is infinitely worse than Rickrolling yourself (look it up). The point is, you can’t focus on these things and complete your rituals at the same time, and, once disengaged from the ritual, you can work on resting your attention more mindfully on the present moment. I call this “better” distraction, rather than “best” because this kind of distraction has no real value of its own and is just a tool for disengaging from rituals. Used excessively, it opens a susceptible thinker up to potentially using this tool as a compulsion itself.

Good distraction

If we understand distraction as something that is interfering in focus, “good” distraction is probably not even a kind of distraction so much as a kind of self-direction. In other words, running to something of value instead of running from something scary. One of the greatest challenges obsessive thinkers have is coping with unstructured time. Without a specific present to return to, mindfully stepping back from obsessions doesn’t make much sense. A highly trained and skilled meditator may be able to rest his attention on the feeling of his feet on the ground, but most people find this uninspiring.

So good distraction is filling your life (not to the brim) with things that you value already or have the potential to add value. Good examples are hobbies that leave products behind, such as writing music, painting, or building something. Non-compulsive cleaning or exercising can be good, but they may lack the mental invitation to truly latch the attention securely. Watching movies and television can be a great distraction if the thing being watched is something that will feed your artistic heart, teach you something, or at least give you the opportunity to float a fan theory by your friends. Mindless reruns of shows that provide you nothing but noise and leave you feeling empty inside will not serve this function. So best distraction is when we are mindful of our OCD enough to know that it could use some competition and then to self-compassionately provide ourselves with something worth attending to.

Don’t be perfect

Be beautifully imperfect. It’s harder but it pays better. There is no one right way to respond to thoughts. And if there were, to use it every time would quickly turn it into another “wrong” way, a compulsion. The endgame here is being able to see thoughts as thoughts, not threats. You can entertain them, but only if you wish to entertain. You can expose to them, but only if you want to do the work in that moment. You don’t always have to. You can allow and accept them exactly as they are, but only if you can do so without bullying yourself (“Accept! Accept!!”). If you carry with you a big toolbox for OCD, you can develop the self-confidence needed to reach in there with eyes closed, pull out whatever you connect with in that moment, and use it to navigate OCD in that moment alone. Mastery over OCD is not about being right all the time. It’s about versatility.

Jon Hershfield, MFT is a psychotherapist in private practice licensed in Maryland and California, and director of The OCD and Anxiety Center of Greater Baltimore.  Follow him on Twitter and Facebook. 

Introducing Brenda Kijesky, LGMFT

In 2015 I moved back to my hometown in northern Maryland. It’s been an incredible journey. Naturally, there was some uncertainty to contend with, such as how or when new local clients would come my way. But it’s been less than a year since I went from left to right coast and the Jon Hershfield, MFT project has become The OCD and Anxiety Center of Greater Baltimore. I am so pleased to announce the addition of Brenda Kijesky, LGMFT, to what is now a team of OCD treatment providers using mindfulness and cognitive behavioral therapy to help OCD sufferers master their disorder.

Who?

Brenda is a Licensed Graduate Marriage and Family Therapist in the state of Maryland with experience using cognitive-behavioral therapy and mindfulness in conjunction with family systems therapeutic models in treating anxiety disorders, mood disorders, and trauma in children and adults, as well as treating general family dysfunction. Brenda believes that a relationship built on mutual respect and trust is the foundation for successful therapy. She approaches therapy with warmth and compassion, tempered with tough-love. Brenda believes that asking for help shows bravery and resilience and that just walking through the door to therapy indicates that a client has the capacity for change.

Before joining The OCD and Anxiety Center of Greater Baltimore, Brenda provided therapy to children in residential treatment who experienced acute and chronic mental, emotional, and behavioral issues, which frequently were accompanied by histories of trauma, abuse, and neglect. She also has experience providing therapy in community mental health clinics in both inner city and suburban settings. Prior to her career in mental health, Brenda worked for 13 years in the marketing field. When she no longer found her marketing career fulfilling, Brenda returned to school to pursue a career in therapy. Brenda holds an MS in Clinical and Counseling Psychology from Chestnut Hill College in Philadelphia, PA. She also holds an MBA in Marketing from LaSalle University’s School of Business and a BA in Journalism/Public Relations from Temple University, both in Philadelphia, PA. Originally from the Philadelphia area, Brenda relocated to Baltimore in 2009.

Training Brenda to use her CBT background in anxiety and trauma as a platform upon which to build a specialty in obsessive compulsive disorder has been really easy. Brenda has an intelligence and wit that will make new clients at our center immediately feel supported and motivated to stand up to OCD. She will be providing reduced-fee services and spearheading our forthcoming Saturday OCD group. So welcome, Brenda, and welcome everyone to The OCD and Anxiety Center of Greater Baltimore – mindfulness and cognitive behavioral therapy for individuals and families affected by OCD.

Relationship-themed OCD (ROCD)

OCD is a walking paradox. Those who live with it often miss the forest for the trees. And they see trees everywhere. OCD sufferers notice details and nuances in the realm of human experience that most people overlook. This results in experiences of profound pain and disgust, but also a kind of deep and textured appreciation for the condition of love.   However, this experience of love can be so intense that it becomes a target of the OCD itself. Loving someone, or even considering loving someone, becomes characterized by a hyperawareness of so many things that could be wrong with that person; so much so that experiencing love can hurt as much as it inspires. Love becomes a thing to analyze, to decontaminate, to justify and reconcile with all of its inconsistencies, each made more severe when looked at through an OCD lens.

Relationship-themed obsessions (sometimes referred to by sufferers as ROCD) are not unusual in obsessive-compulsive disorder, and share intellectual space with Harm OCD, Sexual Orientation obsessions, and religious scrupulosity. These obsessions involve a struggle to accept uncertainty about the people we bring close and a sense of urgency to eliminate this uncertainty for fear of causing harm, wasting life, or drowning in perpetual disappointment.

Common obsessive concerns:

What if I don’t really love my partner?
What if I am not really attracted to my partner?
What if there is an aspect of my partner’s past that causes disgust or cannot be understood?
What if this or that behavior is an indicator that my partner’s personality is a poor fit for mine?
What if my confused feelings for my partner are evidence of a problem with my sexual orientation?
What if I am leading this person on and thus committing an immoral or sinful act?
What if thoughts about other people being interesting or attractive indicate that I am cheating on my partner, sinning, that I don’t really love them, that I would hurt them if I stayed, etc.?
What if being with my partner is settling for second best and resigning to a life of unhappiness?

Common compulsive responses:

Seeking reassurance, either directly with partner, with others, or through “research” of relationship books, blogs and articles
Avoiding behaviors that suggest commitment to the relationship (e.g. meeting the parents, romantic getaways, co-signing a lease, etc)
Analyzing/scrutinizing your partner’s behavior for evidence that the relationship is healthy or not
Checking for feelings or thoughts that indicate love or the lack thereof
Mentally testing out scenarios about the future of the relationship
Asking partner to behave or not behave in specific ways to avoid being triggered (e.g. trying to control how they wear their hair, clothes, words they use, etc.)

ROCD, like any other presentation of OCD is partly fueled by distorted beliefs. In this case, it would be distorted beliefs about relationships, reasonable expectations thereof, and what level of urgency is appropriate for addressing concerns. Two core distorted beliefs seem to drive the bulk of relationship obsessions: the fear of “settling” for second best and the fear of not being able to accept unwanted traits in a partner, both imagined to lead to permanent and inescapable unhappiness for everyone.

Fear of settling

The word “settling” is charged with a lot of negative imagery. It has become synonymous with giving up. Even though many people traditionally fantasize over one day “settling down” with a partner, we also seem to resist “settling” for anything less than perfection (whatever that is). Quite often I hear from ROCD clients that they are concerned about how others might view them if they knew there was a chance they could have bagged a better partner. It’s as if they envision an obituary saying “wasn’t patient enough for Mr. Right, took what was available, survived by average children.” I am not suggesting that a person should ever settle for abuse, contempt, hostility, or the absence of any affection. Rather, I am suggesting that what the OCD calls “settling” may just be allowing yourself to be happy in this moment with this person without striving for certainty over the potential of a better moment or a better person.  Bad “settling” is giving more of yourself over to a person than you receive in return. Good settling is not letting OCD decide who you love and for long.

Unwanted traits

For two people to get along and create a systemic flow of information that is a relationship, there needs to be some common ground. The old adage “opposites attract” may apply well to electrons, but they don’t marry for life. That being said, differences are not opposites and differences between two people can foster growth. The truth is that if you found someone exactly like you, then your worst traits would quickly become more severe. So if we are partnering up, it should be with someone who challenges us to be better, not just better in the sense of being motivated to achieve more, but better in the sense of being healthier, more well rounded. If he likes to wax intellectual over politics and she likes to watch romantic comedies, this doesn’t mean that he’s a nerd and she’s a ditz. Rather, it means that he might benefit from learning to relax and be more flexible and easy with the given moment and she may benefit by taking an interest in different ways to think about things and not be too avoidant of serious subjects that may be challenging.

Physical attraction

Quite often OCD sufferers gets stuck attending to a detail and the details of one’s appearance is no exception. The detail may not even be what it appears to be. For example, a person may notice a physical attribute about someone they are in a relationship with and have a thought about the attribute being unattractive. This doesn’t actually mean, from the thinker’s standpoint, that they always believe that attribute to be unattractive. The issue is simply that they had a thought called “that’s unattractive” and it led to some kind of storyline like, “I can’t be happy if I’m stuck with a person who has an unattractive feature.” We get nowhere trying to prove that the feature is indeed attractive (just as we get nowhere trying to prove our hands are clean or whatever else the OCD might throw our way). Instead we have to challenge the notion that any one detail warrants much attention in the context of our values and simultaneously engage in exposure to the fear of being stuck, settling, or whatever other storyline the OCD might be spinning.

The problem with checking your feelings

If you really want to know how you feel about something (or someone), you have to be willing to not-know first. This is an important general lesson for all forms of OCD. To know and have confidence in knowing is to have knowledge itself be optional. If knowledge is mandatory, the insistence on finding the answer will always result in biases and distortions – not the truth. To find the truth, if there is one, you have to let go of the belief that there is one certain answer and allow for the fact that there may not be or that there may be an answer you don’t like. If you truly embrace uncertainty, you start to get clarity, and it is clarity that helps us make decisions, especially about relationships. One of the most common compulsions in ROCD is the checking of feelings. Your partner walks by, you attempt to mentally record the walk in slow motion, add your favorite romantic music, and then ask yourself – is he/she attractive to me? Or, do I love this person? From there you generate a synthetic and artificial holographic interpretation of a feeling. In its worst form, it is numb, dead, the absence of feeling and proof that your fears are true. At its best, it is almost, sort of, but not quite as good as the butterflies you were hoping for… and to your OCD, it becomes proof that your worst fears are true. It is the king of all OCD traps. If you want to know what your real feelings are, you can only do it in the present moment without judgment. That takes mindfulness, which means rejecting any information you may have collected from compulsively checking your feelings. Some people check locks, some people check love.

Being a sociopath in love

One of the biggest concerns I hear from ROCD sufferers is the idea that without perfect knowledge of the value of the relationship, any continuation of that relationship in denial is an act of cruelty knows as “leading someone on.” The interesting thing about this form of moral scrupulosity is that it is, in and of itself, rather cold-hearted. On the surface it looks like you really care about not hurting this person. But at the same time it implies that your partner is not an independent, sentient being, capable of coping with adversity. Rather, the fear of leading someone on suggests that the other person is little more than a function of the relationship. It posits that they have no responsibility for accepting your advances and that if things don’t work out, they won’t be able to cope with the devastating disappointment that you don’t love them enough. You’re probably not that interesting for this to be true. Sorry. To love someone in real life (as opposed to OCD life) is to be willing to ruin another’s life, willing to devastate them, willing to leave them to their own coping mechanisms if things don’t work out. To love someone is to respect them and their ability to persevere.

Doubling down

There are plenty of traditional exposures that can be done to treat this form of OCD, including scripting about being with the wrong person, exposing to pictures of your partner in an unflattering light (or having you partner intentionally do triggering things and resisting compulsions in response), and telling yourself that you may be doomed forever in a loveless, sexless sham of a relationship. But the most effective ERP is what I call doubling down on the relationship gamble. The last thing the OCD wants is for you to accept uncertainty and to continue willingly into an unknown universe of a more and more serious relationship. ROCD sufferers may confuse avoidance of the relationship triggers with a fear of commitment. But more commonly the fear of commitment is an avoidance compulsion connected to the fear of being with the wrong person. So putting up those pictures of the two of you in happier times, writing a love poem, planning romantic getaways, meeting everyone’s parents, getting that pet, and doing other things that make it more likely to be together forever – all fair game in exposure.

Now, it’s probably worth pointing out that not all relationships being obsessed over are healthy relationships. Obvious deal breakers for most, such as physical abuse, may identify clear-cut problems in a relationship. Further, some people just don’t have enough shared values and just can’t seem to make each other happy. And OCD can drive compulsively staying to avoid uncertainty as much as leaving to avoid uncertainty. Still, whether a relationship is perfectly fine and just a victim of OCD’s meddling or truly irreconcilable, but still obsessed over, clarity on the relationship can only come in the absence of compulsions. In the end it is clarity, not more thinking, that reveals the quality of a relationship.

Three’s a crowd. Take a hike, OCD.

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. 

 

 

POCD Part Three: The Groin and Other Junk

It’s getting uncomfortable in here

So keep on all your clothes

I am

Getting

So uncomfortable

I’m gonna keep my clothes on

-not Nelly

 

Get ready to be uncomfortable.

Welcome to the world of POCD (pedophile-themed obsessive compulsive disorder) and bodily sensations around children. Unwanted intrusive thoughts of a sexual nature are relatively common in OCD, and the subject matter can range anywhere from sexual orientation, incest, bestiality, rape, or pedophilia to whatever you just thought of just now that you think no one has ever thought of. As discussed in Part One and Part Two of this blog series on POCD, this manifestation of the disorder is brutally painful, but no less treatable with cognitive behavioral therapy and mindfulness than any other form of OCD. Cognitive approaches look at the way thinking may be pressuring the sufferer to make compulsive and avoidant choices, Exposure with Response Prevention (ERP) looks at ways in which fear can be confronted behaviorally and systematically, and mindfulness strategies promote present-mindedness and acceptance of the presence of difficult thoughts and emotions. But one element of pedophile-themed OCD often appears to elude these offensives, breaking the rules of OCD warfare, dragging the mind and the self into chaos. Yes, it is the ISIS of your OCD, the terrorist network known in clinical circles as your genitals and in colloquial terms, as your junk.

Distorted beliefs about groinal sensations that make it easy for OCD to bully you:

You can control when there will be sensations and what kind of sensations there will be.

Nope. There are several thousand nerve endings in the genitals and they fire off pretty much no matter what is going on. They could fire off with wanted contact. They also fire off with unwanted contact. They could fire off because you saw something you liked. They could also fire off because you saw something you didn’t like. They fire off because of shifts in blood flow, which have numerous sources. And of course, they fire off in response to attention. Spend any amount of time really concentrating on your left elbow and inquiring whether or not it feels free of sensation and, guess what? Your elbow feels weird. Compulsive checking for groinal sensations causes groinal sensations, which perpetuate urges to check. Identifying the checking as the problem (not the sensations) is the only way to undo the obsessive compulsive cycle.




Groinal responses are indicators of sexual attraction.

Actually, they are indicators of activation, which is not the same thing as attraction. Activation is a body state characterized by hyper-alertness and can just as easily be caused by fear, happiness, anger, or any other intense emotion. For the POCD sufferer, the hardest truth to accept is that love, genuine non-sexual compassionate, empathic, affectionate love can also trigger sensations in the groin. That’s right. People sometimes feel sensations in their junk while thinking lovingly about their children and this has nothing to do with sex, orientation, or attraction. It has to do with love being activating and activation shifting blood flow around the body. For the POCD sufferer, this fact is so very difficult to accept. People experience joy in the body and that means that the most sensitive parts of the body are going to respond first. The POCD sufferer is likely to interpret this through one lens when in fact it requires no interpretation, no lens. The more attention you spend on groinal responses (the least meaningful of all responses because the most easily triggered of bodily responses), the more significant they will appear. It’s also worth noting that if you are used to responding to an image or thought one way, you are also going to respond to similar images or thoughts in similar ways even if that is undesirable. Consider that a person may spend a sizable amount of time associating the word “beautiful” or “handsome” with “sexually stimulating.” What might the most sensitive part of the body do in response to those words traversing the mind? How often do we look at children and think of them as beautiful or handsome? Again, it is the OCD driving an interpretation of this automatic body activation with sinister intentions.




Knowing exactly how to have contact with or look at your kids is important.

Actually, it’s impossible. At some point in their development we back away from repeatedly kissing our kids on the lips and slapping them affectionately on the behind. We just find ourselves not doing it, because at some unclear point it just feels uncomfortable. This is not OCD, but standard behavior, to suddenly start feeling icky being “too close” to a little person shaped more like an adult. This suggests that intrusive unwanted sexual thoughts about kids are actually normal events that are simply misinterpreted, over-interpreted, and over-responded to by OCD sufferers. Not only this, but being around children at various degrees of undress is inherently uncomfortable. POCD sufferers cling to a myth that the “normal” way to feel around a 12 year-old in a bikini or a 2-year old flashing his genitals at you while you try to get his jammies on is the same feeling one gets when they look at a brown paper bag or a tree. This is no less irrational than the obsessive thoughts about closet-pedophilia. The normal way to feel is weird, a bit off, and slightly avoidant. Those free of POCD will wince, grimace, and roll their eyes. POCD sufferers run, cry, self-punish, self-criticize and torture themselves for the crime of noticing.




Children should never come in contact with your groin.

Nice idea, but completely unrealistic. Your groin is a child magnet. It’s at eye level, it’s where little ones reach to grab a hand, and it’s where one sits when one sits on someone. Ask any person without POCD what it’s like to take a toddler to the movies. They want to sit on mommy or daddy’s lap. To them it’s safe. To the POCD sufferer it’s “dangerous.” It’s two hours of having a child sit, squirm, wiggle, and bounce on your groin (I warned you this would be uncomfortable). And for several years, being face-to-face you’re your child means them being foot-to-groin with you. Physical contact with one of the most sensitive parts of the human body causes nerve endings to fire. Mindfulness simply suggests you notice nerve endings have fired. OCD wants you to interpret those firings in the way that most bolsters the obsession. Nerve endings firing in your groin while having incidental contact with your children is uncomfortable. OCD wants you to interpret that discomfort as denial, romance, pedophilia, or whatever is likely to push you into compulsions. Life may be unfair for OCD sufferers, and OCD sufferers may be particularly sensitive to injustice, but at some point we have to choose our values (what kind of parent you want to be) over our fears (what kind of monster your OCD is making you out to be). This means learning how to be in the presence of the inevitably uncomfortable.

Self-compassion and POCD

If you’ve ever experienced group therapy for OCD, you’ve experienced someone saying, “Oh, I wish I had that person’s OCD instead of mine.” And then everyone silently thinks, “Yeah except POCD.” All OCD is cruel, but POCD is perhaps a special kind of cruel. It takes the most loved and makes it the most horrifying. Your body does what bodies do and your OCD says it’s doing it wrong and the self-critical voice comes diving in for the kill. You’re disgusting. You’re a monster. You’re the absolute worst. And it’s easy to forget, these are just thoughts. These are little stingers your OCD uses to get you to scratch, to irritate yourself into doing more compulsions.

Self-compassion can be understood as having three pillars: mindfulness, common humanity, and self-kindness. (Neff, 2011) Mindfulness simply means being honest about what an experience is as opposed to getting lost in interpretations over what an experience could be. Your child crawls all over you just a little too close for comfort or your child smiles at you like you’re some kind of mythical god wizard fairy, and then your junk says, “Hey, what’s goin’ on?” OCD wants you to run that data through a lens that points everything toward sexual perversion. Mindfulness asks only that you note, “I experienced a sensation.”

The concept of common humanity simply requires that you also notice you are not alone. Many traditional models of CBT and ERP emphasize the worst, shying away from anything that could be remotely self-reassuring, but I think this is being too black-and-white. The universe does provide reassurance and you are welcome to it. You just aren’t going to be helped striving for it and clinging to it. Be open to receiving it is all. 2-3% of the population has OCD and a meaningful percentage of OCD sufferers have sexual obsessions. Many people feel uncomfortable around their kids in the presence of body sensations. All people doubt their parenting worthiness.

Lastly, and the hardest to come by, is self-kindness. Clients I’ve seen with POCD have the cruelest inner dialogue taking place at all hours and for many, it’s not even an argument. The OCD says, “You’re a monster because you had this sensation around a kid.” And then the OCD sufferer says, “Oh, it’s so true, I can’t believe I’m this terrible. I’m the worst.” The key to accessing self-kindness is simply to notice (dare I say, mindfully?) the tendency to think top-down, as in, “How did I get so low?” Then, you can ask yourself what it looks like, bottom-up, as in, “How am I keeping it together despite such pain? How am I managing to cope? To deal?” Giving yourself credit for not abandoning parenthood (or any other kid-related environments) may feel a bit foolish, but again, it’s important to remember that while people without OCD certainly do feel uncomfortable (physically or otherwise) around their kids, people with OCD are carrying an unimaginable weight around. They carry with them suitcases full of guilt, self-doubt, anxiety, and false assumptions about the most terrible things conceivable. So credit for coping with this weight is well-deserved.

The lag of physical sensations

Behavioral therapy works on the premise that thoughts, feelings and sensations are often guided by behavior. The more a person goes to a rooftop and doesn’t die, the more they are going to think that rooftops are safe and ultimately begin to feel less anxiety. What is often forgotten is that physical sensations also follow this course, just at a different pace. A person can confront a fear of heights with exposure to rooftops and first they will start thinking that rooftops don’t automatically equate to falling. Some time later he will start to “feel” emotionally that rooftops are not so threatening. But a considerable time may pass before he can go on a rooftop and not have an increased heart rate. Sensations are sluggish to change course. So in doing ERP for pedophile fears and resisting compulsive behaviors, we can expect the same. You will stop buying into thoughts about being a monster, then later see the guilt and dread go down as you continue to behave like a parent who doesn’t find these obsessive concerns so important. But it will take more time and consistent effort non-responding to OCD before your junk stops tripping the alarm.

But what if…?

If you spend your days imagining how you’re going to get away with committing a pedophilic act, thinking that this would be a preferred course of action for you, and you have a history of sexual aggression and sexual impulse control problems, or you have been viewing child pornography or engaging in similar behaviors, it may be wise to seek consultation with a specialist in sexual disorders. But if you have OCD and you’re using an in-depth internal analysis of groinal sensations to get certainty about whether or not you’re a potential danger to children, it’s important to remember that this is not just bad evidence, it’s tainted evidence. The checking, the mental review, the reassurance seeking, the avoidance and all the other compulsions are mutually exclusive from getting clarity on any issue. They are actually intensifying the presence of sensations and the experience of noticing that presence.

POCD sufferers deal with a lot of shame and part of this comes from the fact that some OCD symptoms are so hard to talk about, you dare not share them even with a therapist. Social stigma around mental illness and misguided beliefs about the human body make it that much harder. But if you suffer from POCD and one of your symptoms includes over-attending to groinal sensations, try to remember that this over-attention is not about a flaw in your body or in your character. It is a symptom of OCD no different from those who over-attend to bathroom stall door handles. So if you have OCD and you’re struggling with triggers down below, my recommendation is that you treat intrusive sensations the way you would treat intrusive thoughts – with mindfulness, the rejection of distorted beliefs, and the courage to face uncertainty head on.

(cited: Neff, Kristin. 2011. Self-Compassion: Stop Beating Yourself Up and Leave Insecurity Behind. HarperCollins.)

Click here for POCD Part I: What Is Pedophile-Themed Obsessive Compulsive Disorder?

Click here for POCD Part II: Treating Pedophile-Themed OCD

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. 

What Makes IOCDF Different

I sat down to write a recap of my experience at this year’s IOCDF Conference, assuming I would talk about the humbling response to the mental rituals panel I put together with Jeff Bell, Monnica Williams, and Elspeth Bell, the joy of presenting with friends Shala Nicely and Amy Jenks on self-compassion, the hilarity of me being trusted to entertain kids during the keynote address, running an ad-hoc family members only “GOAL” OCD support group, or watching my dad get carded at a karaoke bar. But I would just go on and on about how it was cool, I was into it, and I’ll be grateful to do it next year. Instead I’d like to share about why I think the IOCDF conference really is different from other professional conferences I attend.

In 2010 at the IOCDF conference in Washington DC, I volunteered for the first time to help Jonathan Grayson with his annual “virtual camping” event. The event is hard to describe, a circus of sorts in which anywhere from 100-200 conference attendees convene to practice exposures together around the hotel and the surrounding area. It’s organized chaos to put it lightly, with some dumpster touching, tire kicking, superstition baiting, and of course, some knife-play for the Harm OCDers. That particular year, Dr. Grayson accidently nicked his thumb on a knife, drawing a small amount of blood, and while many were laughing and some were gasping, one young woman wasn’t really breathing at all.

There she was, holding her breath tightly, desperately trying to stave off a full-fledged panic attack. Her OCD told her she might have somehow made contact with the blood. Quite commonly, people who are afraid of contact with contaminants are not always so concerned with getting sick or disgusted. Sure, that’s triggering enough, but what really causes panic to set in is the recognition that hours upon hours upon days upon weeks of ritualizing may lie ahead. How would she wash her clothes? What if her clothes touched items in the hotel room? What would she, what could she sleep on? What about her luggage, the plane, her home after the conference? How could she get certainty that there wasn’t, well, Grayson plasma on everything?

I sat with her for some time that night, trying not to be her unsolicited therapist, trying to be empathic, trying to just be there. I introduced her to another conference attendee, an OCD sufferer I knew had a similar way of experiencing these things. I wouldn’t know if I was helping or being an additional irritant for some time. But I saw her at this conference, Boston, 2015. She came right up to me after a presentation I was involved in, shook my hand, re-introduced herself. Thanked me. She now volunteers at a blood lab. This is not a story about me making a difference. Right place, wrong time for someone, and maybe not saying anything too stupid would do the trick. Really this is a story about a brave woman taking the reins back from OCD and turning her life around.

This year a friend of mine brought his adolescent son to the conference. It’s an undeniably overwhelming experience, lots of moving parts, lots of strangers. Lots of expectation for being asked personal questions and being vulnerable in public. This kid was smart enough to know that inside the hotel room was safer than outside. When my friend emailed me with concern about his son not coming downstairs, I happened to be chatting with a nice couple I met in the lobby. The guy was a former hockey star who suffered a terrible injury and then spiraled out of control with OCD until he got help. Then he wrote a book to inspire others. And his wife, she stood by him through it all and never gave up on him, both superheroes in every sense of the word.

Turns out Clint and Joanie Malarchuck were the keynote speakers this year (note to self: actually read the whole conference brochure). My friend’s email asked if there was anyone I might be able to send up to the hotel room, maybe help convince his son to take the leap and join the conference. Shortly thereafter I found myself in this family’s hotel room, alongside the conference keynote speakers, chatting casually about sports (which I know nothing about) and OCD (which I have more than heard of). Again, I don’t know if we made a difference exactly. Hard to tell. But I did see the kid walking around the lobby with purpose not long thereafter.  Then I heard through the grapevine that he found his way to a teen session and made some new friends.  Then his dad lost track of him, and in a good way.

So what is it that makes the IOCDF conference different than other mental health conferences? A young woman getting triggered while for the first time being surrounded by people who understand triggers? An anxious kid talking man-to-man to the foundation’s guests of honor without anyone knowing about it? A therapist being in the wrong place at the right time or the right place at the wrong time, connecting people and witnessing sparks of liberation from OCD without really doing much of anything? That’s how it has seemed to me over the years; that just being a part of this conference system changes the larger system of suffering and growth. What will this young lady or this young man do next? Who will they share their experience with and what effect will it have? Who will those people go on to help?  There are many excellent conferences where I can learn more about mental health treatment and further develop competence within my profession.  This is the only one where simply being there seems to make some kind of difference in the lives of others.

Also, I now have enough pens to last me until Chicago, 2016.

Visit the International OCD Foundation at www.iocdf.org.

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. 

POCD Part II: Treating Pedophile-Themed OCD

The idea of actually getting treatment for POCD can be terrifying, especially when you think your obsession is unspeakable and untreatable. But OCD is OCD. POCD is not some untreatable separate diagnosis that requires some strange outlying treatment approach. The most effective treatment for obsessive compulsive disorder is cognitive behavioral therapy (CBT). Though there are multiple forms and variations on CBT, the ones that are most likely to help with OCD use a combination of cognitive, behavioral, and mindfulness-based interventions.

Cognitive Approaches to POCD

Cognitive approaches to the treatment of POCD focus on teaching you how to recognize when you are making assumptions that are problematic, unhelpful, or plain wrong about your pedophile fears. This might include addressing things like black-and-white thinking (if I have even one intrusive thought about a child, it means I am a pedophile) and magnifying (I noticed my baby’s cute bottom and that means I was leering at it inappropriately). Modifying distorted ways of thinking in this approach doesn’t involve trying to prove your fears are untrue (you’ve already tried that plenty), but instead works on drawing your attention to a more objective assessment of your experience. You can’t argue with the content of an obsession, but you can challenge the way in which you have formed your conclusions.

Behavioral Approaches to POCD

Behavioral approaches for OCD emphasize exposure with response prevention (ERP), which involves gradually training yourself to resist compulsions as you methodically confront your fears. Naturally, this does not involve putting you or any children in risk of any harm, but instead is designed to readjust your responses to the POCD triggers. This may involve resuming your role in challenging activities at home (e.g. bathing your children while not engaging in rituals), resisting the urge to do compulsions serendipitously (e.g. continuing to walk on the same side of the street as a child when you have an urge to avoid), purposely increasing closeness with children (e.g. babysitting your niece and resisting rituals), imaginal exposures (e.g. writing narratives about your pedophile fears potentially being true, reading triggering articles/websites without ritualizing), or any or all of the above.

Mindfulness for POCD

Incorporating mindfulness skills is often an important part of the CBT work, especially for POCD and other manifestations of the disorder that are maintained by mental rituals. Mindfulness skills are those which enable you to observe your thoughts, feelings, and sensations as they happen, without engaging them or judging them. You need to be able to see that you are ritualizing, to see the thought approaching and choose a response (often by not responding) instead of just reacting.  By accepting the presence of unwanted thoughts, you are not only doing exposure to your fear of not responding the “right” way, but you also lighten the burden of constantly having to punish yourself. The stuff that goes through your head is just that – stuff that goes through your head. Mindfulness work can teach you to make room for that “stuff” and reduce the power it has over you.

Sure, anything to get out of this living nightmare, but how am I supposed to accept something that is anathema to my values?

You’re not. You’re accepting that you have thoughts, that you have fears, that you are uncomfortable around uncertainty, that you very strongly wish no harm to come to anyone you love. You accept that you care strongly about the kind of moral person you are. You accept these things and learn that responding to these thoughts and fears the way you have been brings you no closer to the things you value and it’s time to identify new behaviors that will. That’s a different kind of acceptance.

Demystifying CBT for POCD

CBT treatment for POCD is a frightening prospect. You want to stop having thoughts about children that make your stomach churn, and your CBT therapist wants you to have them. Or, more accurately, your CBT therapist wants you to let them come, let them be, and ultimately let them go. It’s dirty work, but there’s a lot at stake. The OCD wants total submission. It wants total control over who you spend time with, what or who you make contact with, where you go, how you raise your children, what you listen to on the radio, what movies or TV to watch… It wants it all.

To the POCD sufferer, the idea of discovering that you are a pedophile means losing it all. Your identity, your legacy. ERP rebels against this oppression. Though you won’t ever have to do something that violates your ethical beliefs or do anything that could harm a child, you are going to have to put yourself in situations that trigger powerfully unpleasant thoughts and feelings. But when you develop mastery over this obsession, each step along the way you get rewarded by more freedom from the OCD. Freedom of movement, freedom to be with whomever you want to spend time with, freedom to watch or listen to whatever show or music you choose, freedom from the tyranny of OCD.

If you don’t have a longstanding history of OCD symptoms, and POCD crept up post-partum or at some other time in your adult life, you may be reeling from the shock of experiencing these frightening thoughts for the first time and not knowing why. If you have always had OCD and just found your fears evolving thematically in this direction, your experience is no less terrifying. However, you may already know how OCD works. If you can think it and it’s awful, then you’re doing to think it. This is not because you are some bad person with a broken moral compass or some closeted deviant wired the wrong way. It’s because this is how OCD works. Mastering your OCD means knowing all its tricks and how to outwit them.

The Trap of Convincing Yourself

Uh huh, freedom from OCD sounds great, but how do I know if I’m a pedophile or not? “Pedophiles are like this and I’m like that.” Looking for something like that to prove I’m not a child molester. I mean, what’s the difference between me and someone who’s a pedophile and is just afraid to act on it? Or maybe doesn’t want to act on it because they know it’s wrong or harmful? I need to know that I’m, not sexually attracted to children, that I’m not even capable of it.

This is an OCD trap. I could write about the diagnostic criteria for pedophilia and the basic premise that some people for some reason are either sexually wired toward children or somehow develop urges that result in preying on children. You could read it and find the thing you think makes you different or the same, but your obsession will persist regardless. It is the problem with certainty and capability. First, attempts to attain certainty suggests that certainty is somehow accessible with harder and deeper thinking. If this were true, you would not find yourself seeking out more information about POCD. You would have thought long and hard about it, figured it out, and moved on. Certainty is an illusion. I’ve managed to go my whole life without molesting anyone, but it doesn’t prove a thing other than saying that the attention I need to give to thoughts about potentially molesting children is probably very low. Certainty is perfect knowledge that something is 100% true. Rather than certainty, what we would be better off seeking is confidence, an internalized belief that something is true. This comes not from trying to prove things, but from accepting uncertainty and living in such a manner that “proof” seems superfluous.

The other problem with the never-ending quest to prove incapability is the implication that being capable of something means we will do something or means we are the kind of person who could do something. It’s a trap because if you have at least one arm, you are capable of punching someone. If you are physically larger and stronger than a child, then you are capable of abusing that child. Capable just means physically able, so being aware of capability is irrelevant when trying to determine likelihood of action. What’s more important than the potentiality is reality. If in the present moment you are having unwanted thoughts about children, then you are whoever you are and are having those thoughts. This doesn’t say anything about you other than what is happening. You could be thinking of anything, but happen to be aware of this obsession.

You Are Not Alone

You’re not alone and you’re not a freak (at least, not because of this). If you struggle with unwanted obsessive thoughts about children, and you live in fear and disgust over the presence of these intrusions, you may have a version of obsessive-compulsive disorder, a common mental health issue that really does respond well to the right treatment. If you can find the language to articulate your experience to a therapist who understands OCD, then you can learn the tools to develop mastery over your unwanted thoughts.

Click here for POCD Part I: What Is Pedophile-Themed Obsessive Compulsive Disorder?

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. 

POCD Part I: What Is Pedophile-Themed Obsessive Compulsive Disorder?

POCD (Pedophile-themed Obsessive Compulsive Disorder)

People will feel sorry for me if I get cancer. They’ll accept me if it turns out I’m gay. They’ll chalk it all up to me just being mentally ill if I lose my mind and push someone in front of a bus. But if these thoughts mean something, I am dead to the world and everything is wrong. What if I’m a pedophile?

This is the plight of the POCD sufferer (sufferer jargon for pedophile-themed obsessive compulsive disorder). OCD is a disorder characterized by obsessions (unwanted, intrusive thoughts and feelings) and compulsions (rituals designed to neutralize the obsessions). Many of the things people with OCD obsess about have to do with loss of identity. Someone with contamination OCD may be as concerned with being thought of as a fool for failing to wash appropriately as he is of dying from a disease. POCD is an obsessive fear of being or becoming a pedophile, what to many is considered the ultimate loss of identity. Justified or not, understood or not, the pedophile is the one character nobody can ever vouch for.   It is the last thing a person wants to be. So it comes as no surprise that the mother lode of horrifying ideas finds its home in the mind of so many OCD sufferers. Fear of being a pedophile combines the worst of several common obsessions, from Harm OCD (fear of acting violently against the vulnerable), sexual orientation OCD (fear of being attracted to the “wrong” kind of person), and moral scrupulosity (fear of breaking society’s strictest moral codes).

POCD obsessive thoughts may present themselves in different contexts:

Intrusive unwanted sexual thoughts/images/sensations around children (often but not exclusively one’s own children)
Fear that early experiences were signs of suppressed pedophilia (e.g. When I was 10 I had a crush on and kissed a 9 year old, which means I like 9 year olds.)
Fear that common childhood sexual play makes one a pedophile
Fear that having been a victim of childhood sexual abuse condemns one to become an abuser.
Fear that incidental contact with children was somehow intentional or pleasure-driven (e.g. a little girl sits in her father’s lap while he reads to her, he shifts her to be more comfortable and notices a shift in his groin – Did I move her for the purpose of pleasuring myself? he wonders)
Fear that positive emotions towards children could be sexual in nature (e.g. a woman feels overwhelmed with love for her son, wonders if the love is somehow romantic or sexual)
Fear that noticing beauty, cuteness, handsomeness, prettiness, etc. in a child is a sign of sexual intentions
Fear that noticing adult characteristics (e.g. specific body parts, body positioning, style of dress) of prepubescent children, pubescent adolescents, or of anyone “too young” is an indicator of pedophilia
False memory obsessions, such as obsessive concern that a pedophilic act occurred and was somehow blacked out of memory (e.g. Did I molest that little boy I walked by earlier and not remember? Why am I wondering?)
Not fearing being a pedophile but fearing that the presence of intrusive pedophilic thoughts will either ruin the possibility of being happy or somehow convert the thinker to become a pedophile over time.

POCD compulsions run across the spectrum of the disorder

Avoidance of children in multiple environments (home, school, playground, etc)
Avoiding potentially triggering imagery, such as the children’s clothing section of a store or a children’s television program
Avoiding holding children in ways that may involve accidental contact with sensitive body parts (e.g. trying to hold a toddler in such a way that their feet don’t accidentally bump into your groin)
Avoidance of adult relationships, intimacy, or sexual behavior for fear of triggering unwanted pedophilic thoughts
Mental review of all behavior and thoughts/intentions around children
Mentally reviewing/rationalizing whether noticing a person of a certain age is ok (e.g. I may have had a sexual thought about that teenager but she looks 18 and that would mean she is the legal age of consent but that girl over there may be 16 and I also noticed her and that means I could be a pedophile)
Reassurance seeking from others that inappropriate behavior did not take place, that you are not a pedophile, etc
Confessing of pedophilic thoughts to either manipulate others into reassuring you that you have OCD or reassure yourself that you are not hiding anything
Reenacting or repeating events (e.g. repeatedly picking up a child and putting him down again) for the purpose of proving no sexual act was done or intended
Researching the subject of pedophilia, trying to get certainty about what separates an actual pedophile from someone with POCD
Checking children for signs of abuse that you imagine could have occurred in your presence
Documenting where you’ve been as a form of self-reassurance that you could not have been molesting a child
Checking your body for signs of “inappropriate arousal” in the groin or elsewhere in the presence of children or thoughts about children.

Intimacy

If you find yourself in the beautiful position of having young children of your own or having a connection with a young niece or nephew or some other child you care about, the issue of intimacy with children can be a source of great pain if you have OCD. Consider a man with OCD holding his young daughter in his arms. She’s wrapped up in him, her head pressed against his chest, her little hands clutching his back or neck. His face is firmly planted in the top of her head, breathing in the smell of baby shampoo and, well, baby. He thinks, “I love this little girl.” This closeness, and the way in which it slows down time, is called intimacy.   But before having children, intimacy was what he experienced with his wife, and sometimes, as intimacy grew, it became sex. Long before that, intimacy was when he was a child, clinging to his parent, but that was too long ago to recall. No, the most recent association with intimacy was largely sexual. So the POCD sufferer finds himself struggling with two realities. One is the very genuine, present moment of intimacy he is sharing with his daughter. The other is the memory, the association of intimacy, with adult sexuality. It begins to feel like storing a cache of pornographic pictures in a computer file along with baby pictures and calling it “pics I enjoy.” It feels unacceptable, dangerous even, for these incongruent thoughts to share any mental real estate. So for the POCD sufferer, who is largely incapable of not noticing this incongruence in the mind, there comes an overwhelming urge to de-contaminate the file, so to speak.

Compulsions therefore derive from an attempt to create a sense of certainty that the two intimacies do not share the same space. The belief is that this shared space, of love for a child and sexual love must define pedophilia or some other kind of sexually unacceptable deviance. But if he can prove to himself that the two intimacies do not share space, any space, then he might feel safe from this internal accusation. The problem is that the very behaviors designed to solve this issue (hyper-analysis, checking for sensations, avoidance, etc.) actually magnify the unwanted thoughts and make them more intrusive, more invasive.

Can’t stop talking about it… and also can’t talk about it

You may feel stuck between a rock and a sick place. Part of you won’t shut up about how you had a sexual thought about a child, compulsively confessing, desperately needing your significant other to know you had the thought and tell you it doesn’t mean anything. Maybe, just maybe, your partner will even let you off the hook when it comes to dressing the kids this morning, seeing how distraught you are. Yet at the same time, part of you can’t even verbalize the words, so shameful, so horrifying, and so unsure you may be of how the other person will respond. So before you can get the confessing under control or before you can open up about even having the unwanted thoughts at all, you may need to speak with an OCD specialist trained in understanding what’s going on.

But what if they think I am a danger to children and they file some kind of mandated report?

This can be a serious and legitimate barrier to treatment, especially in the event that you are not seeing an OCD specialist. Therapists are trained to diagnose mental illnesses, but many are trained poorly in the diagnosis of OCD, disregarding anyone who doesn’t struggle with handwashing. Therapists are also trained in assessing safety risks, and in most cases are mandated by the government to report suspected danger to children. So this highlights the importance of seeking help from someone who specializes in the diagnosis and treatment of obsessive compulsive disorder, who can both identify the symptoms for what they really are and make the environment safe for you to overcome this obsession. If you are looking for OCD treatment, here’s a good list of questions to ask the provider: http://iocdf.org/about-ocd/treatment/how-to-find-the-right-therapist/

Anyone familiar with OCD knows that reassurance is part of the problem, not the solution.  But a basic reality check is not always compulsive reassurance and basic reality may be that this nightmare is just OCD and OCD is treatable.

Click here for POCD Part II: Treating Pedophile-Themed OCD

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. 

HOCD (Sexual Orientation OCD): Part Four – Denial

I don’t know if you’re gay.  I don’t know if what you are experiencing is a fraud perpetrated against yourself, identifying as one sexual orientation while secretly being of another, and having both the insight to know it’s a secret and the pre-meditation and masochism to keep that secret from yourself.  All I know is this – if you are obsessing and engaging in compulsions, it will fail to bring about certainty.

The word “denial” is at the root of all forms of OCD.  It is popularized culturally to relate to issues of sexual orientation, but every person with any form of obsessive compulsive disorder experiences the fear of “denial” whenever they choose to do exposure instead of rituals.  The compulsive hand washer who chooses to allow themselves to touch a dollar bill and then eat a french fry is sitting with the terror that they may be in denial of the cold hard fact that a molecule of someone’s feces may have made its way from the dollar, to the fry, to their mouth.  The Harm OCD sufferer, who lives in a war-torn mind of horrific images of violence against loved ones, holds a baby in their arms and tries to breathe evenly while covertly contemplating whether or not they are simply in denial of their closeted sociopathic “true” nature.  Still, nowhere does this word “denial” get tossed around more than in the context of HOCD, the obsessive compulsive fear of being or becoming a sexual orientation not your own.  So what is denial?

This?  http://www.youtube.com/watch?v=zsVpdBIi1BU

Unlikely.

Denial is actively choosing to behave in a way that directly opposes your values or beliefs without being aware of or acknowledging it.  An excellent example of this is the character Milton in the film Office Space.  He stops getting paid, loses his office, is completely rejected by everyone, yet shows up for work, and continues to clock in and out on time.  He gets his revenge in the end, but the character is mostly portrayed as a deranged idiot.  Somewhere at the core of HOCD is a fear that society at large will view you this way, as a deranged idiot who should have known what was going on.   A person in denial in the context of sexual orientation is a person who repeatedly engages in gay sexual activities and refuses to acknowledge that any part of him/her has a same-sex attraction.  It is not simply the behavior (many people of one orientation enjoy experiences of other-orientation), but the refusal to acknowledge the behavior that makes it denial.

A man who sneaks off from his wife in the middle of the night to have sex with other men is not necessarily in denial.  He may be fully aware of what he is doing and simply making a choice to do so.  We might say a woman who repeatedly blacks out after a night of binge drinking and misses work, but refuses to acknowledge the role alcohol plays in her getting fired, is in denial of her alcoholism.   Still, there remains some problems with attempting to define denial.  First, the term is laden with connotations popularized by psychoanalysts, springing from a theory of psychology that hinges on the idea that people suddenly discover who they are after relieving themselves of repressed thoughts and feelings.  This translates into pop culture commentary such as “he’s in denial” without the term actually meaning anything other than “I think that person’s gay.”  Second, obsessive compulsive disorder involves a deficit in tolerance of uncertainty, so when we try to define “denial” as the state of purposefully disregarding one’s genuine desires, it becomes a frustrating endeavor.  What does genuine mean?  How can we be certain that the thought about an act is different from the desire to engage in the act?

An easier exercise would be to identify what denial is not:

Denial is not:

Choosing to disregard thoughts, feelings, and sensations associated with another sexual orientation
Pursuing relationships of meaning and value despite thoughts and feelings whose content seems incompatible with this pursuit
Committing to relationships you are invested in despite the presence of doubtful thoughts about sexual orientation
Accepting the presence (without guilt, disgust or fear) of sexual fantasies outside of your historically preferred orientation
Letting go of seeking reassurance about your orientation
Accepting uncertainty regarding your sexual orientation and the label that goes with it

Love and HOCD

One common concern among HOCD sufferers is that if they choose to accept uncertainty and stop doing rituals, they may discover that they are gay and that discovery will result in a revelation to their loved ones that they have been lying about their orientation.  The fear thrives on an image of a tearful husband or wife feeling deceived, tricked, lead on a long and ultimately meaningless journey to middle age alone, the victim of a fraud perpetrated by the a fool who couldn’t come to terms with their homosexuality.  In other words, “I can’t just be with this person I love if there is any doubt as to the meaning of these gay thoughts, so I must get certainty to protect my loved one from a future betrayal.”  To the contrary, cognitive behavioral treatment for HOCD when there is a significant other involved must include exposure to the idea of denial and the way in which it could destroy the other person.  HOCD becomes a form of Harm OCD in this way.  So in addition to imaginal scripting exposures in which the sufferer could write out the feared consequences of persisting in gay denial in a relationship, the sufferer should also do exposures to strengthening their relationship.  By investing more fully and more completely in their love for their significant other (despite sexual dysfunction that may have occurred due to OCD anxiety), they are getting both exposure to the fear of destroying a loved one and, as an interesting side effect, a better, more meaningful relationship.  In short, invest in your relationships in such a way that if they fail, it will be the most devastating.  That is romance.

Loving Your Friends

People often write to me about their confusing feelings for their platonic friends (this is especially common in younger people it seems).  Not to put too fine a point on it, but what often distinguishes our friends from lovers is whether or not we stimulate each other’s genitals.  Much of the hallmarks of romantic relationships are congruent with platonic ones: mutual interests, unconditional respect, reliability, feeling good in the presence of each other, all of these experiences are indicators of healthy friendships.  Because these relationships are essential for healthy functioning on a very basic level (friends help watch your kids while you’re outside the cave hunting mammoths), they become a source of anxiety.  What if I lose my friend?  This makes them an easy target for OCD.  So while I can’t give you certainty about whether or not you are in love with your friend, I can tell you what HOCD sufferers often fear is gay denial and simply isn’t:

Anxious butterflies in your stomach when you get a call from or see your friend
Desiring physical closeness with a friend
Having intrusive sexual thoughts about a friend (note: people with Harm OCD have intrusive thoughts of harming the ones they care about)
Feeling love for a friend
Feeling no one else can understand you like your friend

Testing, Testing, One Two, One Two

The root of all HOCD evil is testing.  Testing means seeking out emotional or genital stimulation for the purpose of attaining certainty about your sexual orientation.  This often comes disguised as exposure with response prevention (ERP) but is actually a wolf in gay clothing.  What I mean by this is it’s a setup by the OCD to get you to think you are doing therapy when in fact you are just doing compulsions.  Watching gay pornography and masturbating to it for the purpose of checking to see how easy it was, then analyzing how easy it was in an attempt to prove to yourself that you are definitely straight or gay is just a convoluted compulsion and has no chance of benefit.  Exposure without response prevention is not OCD treatment.  It is just responding to unwanted thoughts with self-reassurance and mental review again.  Compulsively masturbating to different material, gay or straight, with the intention of proving something, will always backfire in the end.  People who get stuck on this compulsion create a feedback loop of gradually conditioning themselves to become more and more stimulated by their fears, but, sadly, without getting to really enjoy any of it.

There’s nothing wrong with enjoying sexual fantasies that feel taboo or are different in some way than the real sexual relationships you like to pursue.  But compulsive testing often leads to hours and hours of desperately trying to feel aroused by something and then studying the minutia of your response to it, killing any chance of it being genuine sexual exploration.  Was my orgasm as big as it is to my preferred orientation?  Did my penis swell the exact amount, less, or more?  Did my vagina respond the way it would to my husband?  These are bait laid out by the OCD for you to do more and more compulsions.  Only now they come with their own evidence, a mountain of gay porn and shaming sexual manipulation.  If it came without the shame and without the analysis, it could be a beautiful thing.  Exploring your sexual mind is as much an act of mindfulness as any.  But like all forms of mindfulness, the value exists only in non-judgmental, non-shaming exploration, curiosity about what you find, not desperation. It’s like demanding your doctor keep running tests for a disease you fear and then using all the testing as evidence that the doctor must think you have it!

Collecting evidence about your orientation by testing your reactions to sexual material doesn’t work.  Evidence collected during the course of a compulsion is no more evidence than a confession derived by torture is a reliable source of the truth.

Hello, Good Bi

In the end, unless you are willing to do ERP to the idea that you may be in “gay denial” and so long as you remain committed to achieving certainty about (instead of confidence in) your sexual orientation, there will always be material for your OCD to bait you with.  This is not a challenge unique to HOCD, though it often feels that way.  People with contamination OCD eventually need to expose to the uncertainty over whether they are just trying to get away with being irresponsible or disgusting.  People with Harm OCD still have to expose to the idea that they are just trying to blend in and not get caught being psychopaths.  The obsession with sexual orientation and labeling it correctly may go on for years, decades, coming and going throughout your life, being addressed with and without therapy, lurking in the shadows, then pouncing with the threat of gay denial when you least expect it.  Until you do exposure to denial, you are only scratching the surface.

ERP specifically targeted at denial fears may be more nuanced or abstract than ERP to a fear of being gay.  Typical exposures for HOCD fears may involve looking at triggering materials, listening to triggering music, and being around triggering people (all without doing compulsions of course).  But for the specific fear of being denial, life itself is the trigger and exposure means committing to that life.  This may mean following through on your plan to propose to your girlfriend, letting yourself enjoy a gay fantasy while having sex with your boyfriend, letting yourself really be moved by a homosexually-themed film, and so forth.  In other words, be yourself in the moment and really commit to that self even when it seems disingenuous.

Long Term Management – The Bigger Picture

It may feel like this, but this is irrational and that’s what makes it comedy:  http://www.youtube.com/watch?v=YyxqlA4rqaU

OCD is a chronic disorder.  No matter what level of mastery you develop, obsessions are going to show up sometimes and your instinct will be to engage in compulsions on some level.  What this means is remembering all along that the bigger picture is tolerance of uncertainty and acceptance of the presence of unwanted thoughts.  It is not the eradication of unwanted thoughts.  HOCD sufferers often become disheartened when, after effectively crushing the obsession with CBT/ERP, somewhere along the line finding themselves taking the bait again.  This is most often triggered by a fear that the essentially free and fulfilling life you’ve earned back from your OCD with treatment is really just a lie, a perpetuated act of denial.  So it’s important to approach the fear of denial, whether it is currently at the forefront of an active HOCD obsession or the product of a brief lapse after getting better, with the same tools.  Don’t buy in to OCD’s distorted logic that “because it came back, it must be the truth.”  Kill two birds with one stone by immediately going back to the mindfulness and CBT tools that worked last time.  By immediately returning to ERP and mindfulness tools, you not only put the OCD in its place, but you also get exposure to what may feel like an act of denial (Here I go again, pretending this is OCD).  If you’re new to OCD treatment, get help in whatever way you can access CBT.  If you are actively in treatment, use it to confront your fear of denial head on.  If you have had treatment in the past, don’t be afraid to check in with your OCD therapist to get back on track.  Booster sessions are a normal and healthy part of CBT for OCD.

Consider this – we may define denial as running from the truth.  If this is the case, then it is far worse to be in denial of your OCD (and not committing seriously to treating it with CBT) than it is to be in denial of whatever your OCD is talking about.  While the consequences of your fears coming true are quite unknowable, to deny yourself OCD treatment has clear and predictable consequences.

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. 

Click here for HOCD: Part 3

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Click here for HOCD: Part 1