It’s helpful to think of taboo thoughts OCD as a preoccupation with the “worst case scenario” regarding identity. People who have a type of OCD primarily defined by intrusive taboo thoughts (harm OCD, incest OCD, pedophilia OCD, and Scrupulosity, and some types of Magical Thinking, to name a few) are usually fixated on the thought “what if (taboo thought) is true about me?” If we use a downward arrow to follow the thought to its deeper meaning, we typically find “it would mean I am essentially bad” or “I am essentially unacceptable” or “I would not be able to tolerate my true self” to be at the core of the obsession.
The OCD brain is determined to investigate in pursuit of the truth. Unfortunately, truth is elusive and completely subjective. The OCD brain is never satisfied with the conclusion it comes to based on the available evidence. It persists in investigating, ruminating, checking the environment and checking the body, and can usually find evidence in support of the taboo thought and the deeper worry.
Take the example of Gina, who experiences harm OCD and sexually taboo thoughts OCD. Gina
is babysitting her young nieces one night, and as she is helping them change into their pajamas, she has the fleeting worry “what if I were attracted to my nieces?”
Gina’s OCD responds in two ways. First, horror and anxiety at the idea that she might have had an inappropriate sexual response to her nieces, and second, a determination to figure out if there had indeed been an arousal response and, if so, what it means about Gina.
It’s important to point out that we all have these types of fleeting thoughts. Jon Hershfield and Tom Corboy- authors of The Mindfulness Workbook for OCD- call these “fringe thoughts.” For most people, they come and go on the fringe of conscious awareness. For OCD sufferers, these thoughts are exposed and scrutinized by the floodlight of the OCD brain.
After her nieces are in bed, Gina replays the scene in her head over and over, checking her body for any hint of arousal. If Gina feels any hint of arousal in her genitals, she panics, has the thought “oh god, does this mean I’m a monster?” and starts the checking process again, hoping to disconfirm her fear. In fact, even if Gina hadn’t felt any arousal, she would likely start the body-checking process again “just to be sure.”
What Gina doesn’t realize is that to the body, arousal is arousal. At the level of the nervous system, arousal from anxiety or fear is identical to sexual arousal. It is the interpretation that we give to this arousal– the focused attention, the accompanying emotions– that determine its meaning for us. If Gina is experiencing genital arousal (called “groinal response” in OCD treatment), it is likely because she has increased anxiety (which causes increased blood flow to the groin) and directed attention. Over time, with repeated body checking in triggering situations, this groinal response will become automatically paired with the triggering situation.
This process is called classical conditioning, and has been well researched and documented for over 100 years. In 1920 John Watson, commonly regarded as the father of behavioral psychology, published the results of a controversial experiment in which he and his graduate student Rosalie Rayner conditioned a phobia of white rats in an infant boy. The baby, called Little Albert, had no innate fear of the rats. At first, he was observed playing with the rats with no intervention, which he did with no signs of distress. Then, Watson made a loud noise every time the child was presented with the rat. The noise (a forceful clash of metal on metal) scared Little Albert. He cried, screamed, and exhibited all the typical symptoms of a baby in distress. He was subjected to the noise every time the rat was in sight. Eventually, simply seeing the rat even before the noise sounded elicited the child’s distress reaction. He had the same reaction to everything that reminded him of the rat: a white rabbit, a fur coat, even Santa Claus’ white beard. This process of conditioning is what underlies OCD obsessions and compulsion.
Regardless of how it feels to her, what Gina is experiencing is not sexual attraction. It’s a conditioned response, and it happens precisely because Gina is so threatened by the idea of being sexually attracted to children. It is important to remember that people who suffer from taboo thoughts OCD are the least likely to engage in harmful taboo behaviors.
John Watson’s experiment with Little Albert clearly raises some ethical concerns. The baby was removed from the experiment when his phobic symptoms were at their worst. Upon hearing of the results of the Little Albert experiment, psychologist Mary Carver Jones (the mother of behavior therapy) determined to find a way to reverse the symptoms conditioned in Watson’s experiment. She did this exactly the way Watson did—with conditioning.
Jones found a child with similar symptoms to Little Albert. She gradually presented him with the object of his fears, which she kept in his presence for prolonged periods. Eventually she paired his triggers with pleasant stimuli (candy). The child learned that the stimuli were not harmful, and that he could face them without distress. His symptoms were effectively eliminated.
The way for Gina to break out of her cycle of stress is to remove the meaning, and therefore the threat, from her intrusive thoughts. This may sound impossible, but the process is fairly straightforward. It follows Jones’ method, with some updates garnered from modern research. Gina would work with a therapist trained in Exposure/ Reponse Prevention (E/RP), the gold standard treatment for OCD. Together, they would systematically expose Gina to her intrusive thoughts, which she would practice tolerating without engaging in her reassurance-seeking ritual—in this case, checking her body for signs of arousal and ruminating about the meaning of her thoughts. Gina’s brain would gradually learn that thoughts are just thoughts, and they are not in themselves scary. As her fear diminished, so would her groinal response.
The magic of E/RP is that it directly, concretely employs neuro-elasticity in order to create lasting change. One way to ensure lasting change is to engage in exposures every day outside of the therapy context. The more the sufferer is exposed to their feared situation and refrains from ritualizing, the clearer it becomes to the OCD brain that the scrutiny and anxiety the trigger elicits are not necessary. Exposures are even more effective when employed in a variety of contexts and environments. Recent research in inhibitory learning shows that even if a sufferer’s anxiety level does not decrease immediately, learning still occurrs and neuroplasticity is doing its job.
Although Gina’s case of POCD (Pedophilia OCD) is common, so are other types of sexual obsessions. Sexual themes can include bestiality, incest, or simply the fear of being attracted to someone other than the sufferer’s partner (this theme may be paired with ROCD—Relationship OCD). Even today, we are reticent to discuss sexuality with people in our lives, let alone mental health professionals we’ve just met. Many OCD sufferers with taboo sexual themes have the understandable fear of being misunderstood, judged, or even reported. I often think about the OCD sufferers who never get the proper education and treatment for these themes. How many lives have been marred, or even ended, because of these symptoms? How many relationships have suffered? How many people go through life thoroughly alienated from themselves, from their source of self-love and compassion, because of these terrifying thoughts and their perceived meaning?
Seeking treatment for taboo sexual thoughts OCD takes tremendous courage, but the results are worthwhile. Finding someone who understands can be healing in itself. There are communities, both online and in-person, of people with these OCD themes whose objective is to understand and support each other. There are publications, podcasts, and books with life-saving information available. While useful, none of these resources are a substitute for therapy with a professional who does ERP. If you suffer from these themes, I encourage you to make the brave choice and reach out for help.