ERP for Harm OCD: the Role of Uncertainty

Let’s start with some brief points and then I’ll explain each of them in more detail:

• Obsessive-Compulsive Disorder (OCD) is the result of a hypersensitivity to uncertainty in very specific areas.

• Hypersensitivity to uncertainty can be treated by repeatedly facing uncertainty and getting used to it. This doesn’t make the person more certain, it just helps them feel less distressed by the uncertainty.

• Attempts to avoid or resolve uncertainty provide short-term relief but ultimately make OCD worse

To help illustrate these points, let’s utilize the example of Harm OCD. Individuals with Harm OCD experience significant distress associated with the uncertainty that they may harm someone, or may already have harmed someone. They often experience unwanted intrusive thoughts of harming others in a terrifying way. They may get an image of stabbing someone in the throat and then feel highly uncertain about what this means and whether they would actually act on this thought. Or, they may be standing next to someone while holding a knife and suddenly become terrified that they might stab this person in the neck. Or, they may be eating lunch and suddenly become overwhelmed by the feeling that 5 years ago, they may have punched their friend in the face.

Now that we know a little bit about Harm OCD, I want to point out some things about the uncertainty that are uncomfortable and unpleasant. It’s tempting to avoid thinking about these things, but if we’re going to understand OCD, we’re going to have to confront these truths. 

Feeling uncertain and being uncertain are not the same thing

Every day, you face a lot of uncertainty that you probably don’t consider. You get in your car and drive to work and you feel certain about getting to work safely. But you aren’t certain. You could get into a car crash on the way to work which could result in serious injury, paralysis, or even death. The risk of this is quite low, but it’s still there. Now, you may say, “But I’m a very safe driver so that would never happen to me.” But you don’t control everything. What if you drive perfectly safely and someone else hits you from behind? You might have to stop suddenly on the freeway and a truck runs over your car. Or you could get hit at a stoplight by a drunk driver. 

Likewise, every day you eat food that could be contaminated and result in foodborne illness. Again, you bite into your burger or open your can of beans without any feeling that you’re taking a risk. You feel certain that it’s safe to eat, but you’re not actually certain. There is some small risk that you could get sick, or even violently ill.

These are improbable outcomes so people may say that there’s no point in thinking about them, but as you’re about to learn, improbable and impossible are not the same; that subtle distinction is critical to understanding OCD. 

People with OCD are hypersensitive to feelings of uncertainty in certain areas.

While the individual with Harm OCD may feel very little uncertainty about eating or driving, they may feel extreme uncertainty when they have violent thoughts, watch a violent scene on TV or stand near a knife. Now, you may hold a knife or have a thought about stabbing someone else and feel totally certain you won’t hurt anyone, but you’re not actually certain. People do get angry and do things that they regret later. Have you ever slammed your hand on a table in anger or screamed horribly nasty things at someone you love? If we lose control and do things we later regret, how do we know for sure what we’ll do the next time we lose control. Also, accidents do happen. You could accidentally drop a knife on someone’s toe and cause serious harm. Or, what if for reasons we can’t really understand, you suddenly have an overwhelming urge to stab your wife that you just can’t resist. Yes, it’s unlikely, but not entirely impossible. Maybe the urge is caused by a brain tumor or an acute chemical imbalance…These things, just like the car crash and food-borne illnesses, are extremely improbable, but not impossible. You feel certain that you won’t do these things, even though the truth is, you aren’t absolutely 100% certain. Just because these things haven’t happened before is not a guarantee that they will never happen. Of course, this uncertainty doesn’t bother you much because you don’t have OCD. But imagine if you were hypersensitive to uncertainty in this area. Imagine if holding that knife triggered such an intense feeling of uncertainty that you were terrified you might actually murder your family so you dropped it to the floor and went running out of your house just to try to keep your family safe. Or imagine if your own thoughts caused you such intense uncertainty and fear that you spent hours trying to figure out what they mean and why you’re having them. This is what people with Harm OCD face on a daily basis. 

Hypersensitivity to uncertainty can be treated by repeatedly facing uncertainty and getting used to those feelings.

You can’t 100% eliminate risks and you can’t 100% guarantee safety. As we showed in the various examples, even if someone without OCD thinks they’re safe and certain, they’re not actually safe or certain. They just feel that way. So trying to convince a person with OCD that there is 100% certainty and 100% safety is not helpful (in fact, it’s actually harmful). It’s not possible to convince them with 100% certainty that they are safe. Although many people may criticize the logic of the person with OCD and insist “they just don’t want to hear what I’m saying” but the truth is that the person with OCD actually is thinking logically: even if there’s only a one in a billion chance that something terrible could happen, that means that something terrible could happen. What is illogical in OCD is not the belief that risk exists, but the countless and fruitless attempts to eliminate all risk. 

Successful treatment always involves repeatedly facing uncertainty until you get used to it. You can get used to feeling uncertain. You can get to a point where a strong feeling of uncertainty no longer causes intense fear. You may have heard of exposure therapy. In this treatment, people with spider phobias first look at photos of spiders, then videos, and then eventually look at real spiders and finally pick and up and hold a spider.  Each step of the way, they feel fear at first, but it eventually passes and they get used to looking and being near spiders.  Likewise, when you were young, you were probably afraid of the dark or of swimming pools, or of being away from Mom or Dad, but after doing these things over and over again (exposure), you’re not afraid anymore.

In Harm OCD, the person feels high levels of fear as a result of an intense feeling of uncertainty surrounding possible harm to others. Therefore, just like facing a fear of spiders, the individual with Harm OCD has to face uncertainty. They have to hold a knife and feel uncertain about whether or not they’re going to hurt their family. They have to write down and listen to their scary thoughts about hurting people, even though they’re worried that these thoughts might make them hurt someone. They have to face their feeling of uncertainty over and over and over again until they get used to it.

Attempts to avoid or resolve uncertainty provide short-term relief but ultimately make OCD worse

Habituation is the psychological process by which human beings get used to feelings and situations. At first, a ticking clock drives you nuts, but after a while, you habituate and forget it’s there. At first, you feel intense distress when being around spiders, but after a while, you habituate and get used to spiders too. The first time you hold a knife or hear your intrusive violent thoughts, you may have a feeling of intense uncertainty that overwhelms you, but after a while you habituate, and it no longer bothers you at all. However, for habituation to occur, you have to remain in the situation.

For instance, if the ticking clock bothers you and leads you to put on headphones to drown it out, then the second you take the headphones off, you’re going to notice the stupid ticking clock again! You can’t habituate to the sound of the ticking clock, because you left the situation by putting headphones on. You have to keep hearing the clock tick for you to habituate to the sound.

Likewise, if you touch the spider and then immediately run out of the room, you can’t habituate to the spider. You have to stay with the spider until habituation occurs.  

Similarly, if you feel uncertain and then try to convince yourself that you’re actually certain and safe and there’s nothing to fear, then you’ll never habituate to being uncertain. So, if for instance, every time you have an unwanted intrusive thought of harming someone else, you say “that’s just an OCD thought, it doesn’t mean anything. I won’t hurt anyone” then you will never habituate to feeling uncertain about these thoughts. Instead of trying to avoid the thought and the uncertainty, you could go right towards it. You could write the thought down and read it over and over and over and over and over… And in 2 hours (and most likely far less time), you will habituate to the thought and the uncertainty it caused. Remember though, this only works, if you stay with the uncertainty. If after you write it down and read it a few times, you reassure yourself that the thought is meaningless or you call your husband to ask for reassurance that you’re not actually dangerous, you’ll never habituate. 

This process, of facing your fears while resisting your efforts to try and reduce uncertainty is called Exposure with Response Prevention.

In order to recover, you have to be willing to accept the risk that you might harm someone. 

Remember that all of us take risks every single day. Most people don’t mind taking them because they usually aren’t even aware of the risks. But whether people are aware of it or not, they still take the risks. They get in a car and risk death, paralysis, or serious injury every single day, often multiple times a day. The difference for the person with OCD is that, if you want to recover, you need to take the risk while also knowing you’re taking the risk. You hold the knife while knowing full well that there is a small risk that you could suddenly murder your entire family. Because you feel uncertain and are aware of this risk, holding the knife scares the heck out of you! Fortunately, that feeling will pass with time as you habituate to the situation and the uncertainty. After your first exposure, or possibly after your first few exposures, you’ll feel far less distressed. The small chance that you could wake up tomorrow with a brain tumor and kill your family will still remain, but you’ll learn to tolerate this risk without much fear.

Please note: I am occasionally asked by people with Harm OCD if they’re actually going to have to harm someone to face their fears. The answer to this is no. The role of uncertainty is paramount here. Given that the fear is uncertainty surrounding harming others, one only needs to put themselves in situations that trigger this feeling of uncertainty to get better. Harming others would be problematic for clear moral and ethical reasons and would not be an effective treatment for Harm OCD.

The material contained in this website is for informational and educational purposes only. It is not intended to diagnose or treat any mental health condition. It is not a substitute for psychological treatment provided by a licensed mental health provider. Nothing in this website should be construed as establishing a client-psychotherapist relationship between you and the OCD & Anxiety Center of Cleveland.