Of the many subtypes of OCD, I feel Harm OCD may be one of the most misunderstood and one of the most terrifying to experience. Harm OCD is characterized by intrusive, unwanted thoughts of hurting other people (often the people closest to the patient) and avoidance or reassurance behaviors which develop as the sufferer struggles to feel certain they will not act on the thoughts which plague them.

I remember once years ago carrying my baby sister through a hotel with a huge atrium in the center. As I walked next to the guardrail between me and the several story drop to the fountain in the center of the hotel, an image flashed through my mind of throwing my sister over the edge. I remember mentally recoiling at the image, holding my sister a little tighter, and walking a little faster to the elevator. I was disturbed by the thought - the fact I remember it now over ten years later speaks to that - but something important happened afterward. I shook it off, reminded myself I love my sister and would never intentionally harm her, and went about my day. The difference between someone with and without harm OCD is not necessarily the presence or lack of disturbing mental images, but the ability to mentally walk away from them.

If I had Harm OCD, after having this thought of killing my sister I might have spent the rest of the day interrogating myself to determine if this was something that I secretly wanted to do. Perhaps I would think through our interactions since her birth and recollect moments I felt resentment or frustration towards her and worry this was some sort of origin of a buried homicidal rage. On our return to the hotel I might refuse to carry her through that hallway again, deferring her to someone else out of fear I would act. Perhaps I would even start avoiding her more generally, keeping my distance any time she was near the edge of a road, or perhaps shirk back from chasing her through a playground or pushing her on the swings in order to maintain certainty that I wouldn’t succumb to this impulse and shove her to the ground. Perhaps I would start to hate myself. I would wonder how I could feel this awful way towards someone so innocent, someone I love. I would wonder how I could ever deserve to be loved, with this secret evil inside me.

And, most likely, the thoughts would come back. Thoughts are like anything else - given attention, they will grow. Perhaps I’d start having nightmares of harming my sister. Maybe I’d see her at the top of some stairs and visualize myself throwing her down. Each time I would feel horrified by the thought, and each time, I might believe myself capable of doing it a little more.

This is the torment of Harm OCD. The division of the self from the people we love. The division of self from self - the ghost of a shadow self whose actions never materialize, but are constantly monitored, constantly feared.

This fear is reinforced by society. In a culture that is beset by seemingly random acts of violence, thoughts of harming others are met with fear and suspicion. I had a patient who once confessed to a school counselor she was tormented by thoughts of hurting her mother. The counselor summoned a team of police officers to interrogate her. She was 10 years old. I am sure the counselor thought she was doing the right thing, but the internalized message that my patient is damaged and dangerous lasted for decades.

This is why I think greater understanding of the distinction between intrusive thoughts and fantasies is crucial, especially among mental health practitioners, but also in society at large. I bet you have thoughts you don’t like sometimes. We all do. Sometimes a mean thought, prejudiced thought, racist thought, or sexually disturbing thought might appear, seemingly out of nowhere. How do you react to that thought? Do you recoil? Do you remind yourself you are better than that? Do you try to ignore it and move on? Our values are best understood by our reactions to our thoughts, not each individual thought standing on its own.

If you have thoughts of harming someone and linger with them, enjoy them, expand on it, or make plans for how to carry it out - this is not OCD. Please find a qualified professional to help work though how to keep yourself and others around you safe. But if you recoil from these thoughts, want them away from you, would do just about anything to get rid of them - this suggests to me that these violent thoughts do not reflect your values, your morals, or how you live your life. If you are living with this, please know you are not alone. You are not broken. You are not beyond help.

OCD therapy can be scary because it will ask you to confront these thoughts head on, rather than giving you a magic bullet to avoid them. But in the end, the purpose of all exposure therapy boils down to this: trust yourself. Trust your senses. Trust your values. Trust yourself, even if 100% certainty can never be found. Trust yourself, even if a part of your mind is still whispering ‘But what if…’. Not every thought we might have is worthy of trust, but through the storm of our wild and perverse thoughts, we can be the captain of our own ships. You can guide yourself home.

If you are struggling with intrusive thoughts and want some support, please reach out. I’m here.