Unmasking Unacceptable Thoughts OCD: The Silent Suffering

Unacceptable Thoughts OCD, often misunderstood and unrecognized, can cause overwhelming dread, guilt, and shame in those who experience it. It is a private pain in which overt compulsions are subtle and not easily recognized.?

Part one of this article will delve into the operations of this form of OCD, shedding light on the intrusive and unwanted nature of obsessions that are accompanied by doubt and emotional distress.

Part two will discuss the common compulsions and maladaptive avoidance coping strategies associated with Unacceptable Thoughts OCD.

In part three, we will discuss evidence-based treatment for OCD known as Exposure and Response Prevention. This therapy, which is a form of cognitive behavioral therapy, specifically targets symptoms of OCD.

Clinical Obsessions

Obsessions are not regular worries, they are intrusive and unwanted thoughts, images, and urges that cause emotional distress and doubt. Despite efforts to ignore or suppress these thoughts, they persist and the individual is unable to escape from them.

Most people with OCD recognize that their thoughts are irrational and illogical. However, they all struggle with low confidence in their ability to make decisions because they don't trust the information they use to reach a conclusion.

Types of Unacceptable Thoughts in OCD

Unacceptable Thoughts often involve obsessions related to sex, violence, religion, or harm. This can lead to feelings of disgust and contempt due to conflicting thoughts within the individual. The cognitive dissonance emerges because of the contradiction between the person’s code of conduct and the presence of personally detestable thoughts.

The sufferer is overwhelmed with doubt, constantly questioning the meaning of their unwanted thoughts and what they say about their character. It is common for the person to believe they are evil and a burden to society. They fear ridicule, banishment, and even imprisonment. Consequently, these thoughts are often regarded as taboo.

For example, a loving father is overcome with panic,?and guilt over unwanted thoughts about sexually harming his beloved daughter. He cannot understand why he even entertains such disturbing thoughts. The idea of acting in such a manner is personally disgusting.

These unwelcome thoughts lead to self-blame. The person suffering imagines themselves as monsters or deviants, believing they deserve punishment like incarceration or death. There is a fear that if others knew about these thoughts, they would be hated and pushed away. Those who are religious may feel like they have strayed from God's love and guidance. The emotional agony is unrelenting.

Concurring Obsessions and Ruminations

Ruminations are a common aspect of OCD involving unacceptable thoughts. They feel similar to obsessions, as they are repetitive and cause emotional distress, but there are key differences.

Obsessions are involuntary and anxiety-based, focused on avoiding future outcomes. On the other hand, ruminations are voluntary, rooted in feelings of depression about loss of esteem or purpose, leading to self-loathing.

Guilt and shame often trigger ruminations. Guilt arises from doing something bad, while shame involves feeling inherently bad as a person.

The father in the example experiences a cycle of obsessions and ruminations, instigating more unwanted thoughts and continual self-condemnation. He worries about harming his child and fears losing control or committing incestuous acts. These intrusive thoughts make him feel like a horrible person who deserves punishment.

Addressing these ruminations is key to recovering from this type of OCD. Many clients struggle to allow themselves joy or pleasure when plagued by such disturbing thoughts, as any happiness triggers more negative rumination. They may believe they don't deserve happiness due to their unwelcome obsessions, leading to more feelings of guilt and self-deprecation.

In the first part of this article, we defined Unacceptable Thoughts OCD and examined how it impacts individuals. We discussed a specific example to illustrate the emotional consequences that often accompany this condition, such as fear, guilt, shame, and depression. Additionally, we delved into the role of rumination in exacerbating these symptoms.

We will now explore common overt and covert compulsions associated with OCD. We will discuss how these compulsions can have a negative impact on the individual's life. It is important to understand that maladaptive coping mechanisms play a significant role in how individuals with OCD interact with their environment, including relationships, work or school, faith, and personal interests.

Definition of Compulsions

Compulsions, like obsessions, are repetitive behaviors that are performed to alleviate emotional distress caused by doubt and unacceptable thoughts. The purpose of these behaviors is to provide temporary relief from the unpleasant emotions and unwanted thoughts associated with OCD. In essence, OCD can be seen as a disorder characterized by avoidance of aversive or painful emotions through compulsive actions.

The person with OCD places excessive importance on their thoughts and emotions, often viewing them as dangerous. They may go to great lengths to avoid or escape these feelings, even though they are not actually harmful. This maladaptive coping mechanism can lead to difficulties in daily life for individuals with OCD.

Types of Compulsions

Overt compulsions in individuals with OCD are easily noticeable as observers can witness them repeatedly performing physical actions. The most commonly recognized types of overt compulsions include perfectionistic and decontamination behaviors.

Perfectionistic compulsions involve the urge to make things look perfect by ordering, evening out, straightening, making symmetrical, or balancing objects. Examples include straightening picture frames, smoothing out wrinkles in pillows, and measuring furniture to ensure it is evenly spaced against a wall.

Decontamination compulsions occur when an individual feels the urge to clean excessively or avoid touching surfaces or objects that they think could make them sick or disgusted. In cases of OCD, the person is trying to alleviate distressing emotions by engaging in compulsive actions.

The suffering experienced by individuals with Unacceptable Thoughts OCD is often hidden because most of the compulsions are mental or covert. Even if there are observable compulsions, they are usually subtle and may not be easily recognized even by close relatives.

Mental compulsions in OCD include activities such as making mental lists, mental checking and reviewing thoughts, replacing negative thoughts with positive ones, suppressing thoughts, distracting oneself mentally, and seeking reassurance through questions like "What if" or seeking certainty. Logical reasoning is also considered a mental compulsion but it is ineffective in reducing pathological doubting associated with OCD.

In the example, the father may constantly monitor his thoughts for any signs of inappropriate behavior, like intentionally touching his daughter in a sexual manner when she accidentally bumps into him. He may also check for physical responses such as arousal or erection that could indicate sexual attraction. In extreme cases, he might completely avoid interacting with his daughter altogether, even during activities like playtime. This behavior is known as pure avoidance and is considered a compulsive response.

Debates on the reasoning behind such repulsive actions can lead to internal conflict or cognitive dissonance, where cherished beliefs clash with disturbing thoughts. For instance, a father may adamantly claim that he would never harm his daughter and finds the idea repulsive. However, he struggles with conflicting thoughts that suggest otherwise, causing inner turmoil.

Certainty Seeking as a Compulsion

Pathological doubting is characterized by a constant need for certainty and an inability to tolerate uncertainty. Rationalizing does not alleviate the distress experienced by those with this condition. Sufferers never feel a sense of closure or completion, as they do not trust the information they use to make decisions.

People with Unacceptable Thoughts OCD often struggle to make decisions due to fear of potential harm or danger. This fear leads to procrastination or avoidance of decision making altogether, as they are afraid of the consequences of their choices. They become trapped in a cycle of overthinking and are unable to move forward.

Distraction and Internet Checking as Compulsions

Distraction and Internet checking are subtle compulsions that may go unnoticed by loved ones of those with Unacceptable Thoughts OCD. It is common for individuals with this condition to engage in mentally stimulating activities, such as playing video games, in order to avoid unwanted thoughts. Spending excessive amounts of probing the internet to seek reassurance or disconfirmation is also a common behavior.?

Substance Abusing as a Compulsion

Maladaptive coping can lead to substance abuse as a potential complication. People with Unacceptable thoughts OCD often turn to alcohol, benzodiazepines, and cannabis for relief. This can create a harmful cycle of craving, temporary release, and feelings of guilt and shame from constantly ruminating on their actions.

To ease his anxiety about harming his daughter, this father listens to music whenever he is alone with her. He spends hours searching the Internet to reassure himself that he does not exhibit any signs of being a pedophile. His anxiety is most intense at bedtime, so he uses marijuana to relax thus mitigating thoughts about harming his daughter while she sleeps.

Other Complications from Compulsions

Feelings of guilt and shame from having unacceptable or taboo thoughts can have a negative impact on both work life and worship. In this example, the father is concerned that his productivity at work is suffering because he is consumed by obsessions. He also avoids interacting with coworkers out of fear that they will discover his struggles. Additionally, he avoids going to church because he believes God will never forgive him.

In the final section of this article, I will explain how Exposure and Response Prevention (ERP) can aid in recovering from OCD related to taboo or unacceptable thoughts. Using the example from this article, we will examine common therapeutic interventions. While treatment plans differ for each individual, this discussion will provide an accurate representation of ERP.

ERP: The Gold Standard Treatment for OCD

ERP is a powerful therapeutic approach. The process involves gradually exposing an individual to distressing thoughts, feelings, images, and urges without allowing them to escape or seek relief through compulsive behaviors. Essentially, the person confronts their fears directly while resisting the urge to perform any rituals that might alleviate their anxiety. Over time, this helps the individual learn that these feared situations are not actually dangerous, leading to a reduction in anxiety and compulsive behaviors.

ERP is an active or doing form of therapy, not just a talk-based one. It involves incorporating new information through hypothesis testing. People with OCD generally believe that their thoughts and feelings are intolerable and that they must escape to avoid imagined, feared, or unbearable consequences. This perceived threat is always focused on the future.

In our example, the father experiences intrusive thoughts about sexually harming his daughter. He interprets these disturbing thoughts and the accompanying fear as indicators that he might lose control in the future. To prevent this feared outcome, he feels compelled to take extreme measures to avoid it at all costs.

Graduated Exposure

Facing one's fears can be daunting, so a skilled therapist assists the client in breaking down their core fear into manageable parts. This process involves gradually exposing the client to their fears in a hierarchical manner, starting with the least distressing situations and progressing to more challenging ones. This approach helps facilitate engagement in therapy. Although it may seem counterintuitive to confront what you want to avoid, this method is essential for overcoming fear.

Motivational interviewing can improve client engagement by emphasizing the negative impacts of their OCD and the potential advantages of therapy. This method helps clients realize that giving up is not a productive option, while committing to effective strategies can lead to the recovery they desire and support a life consistent with their values. For instance, this father could be reminded that his love for his daughter is a strong motivator to abandon avoidance coping and focus on what he truly wants: being present with his child. Examples will follow shortly.

Exposure Types

There are two effective forms of exposure therapy: imaginal exposure and in vivo (or live) exposure.

1. Imaginal Exposure: This method involves using one's imagination to evoke strong emotions. It can include trigger words, worry scripts, pictures, drawings, news stories, or video clips.

2. In Vivo Exposure: This approach is generally considered more powerful. It requires the person to confront their triggers in real-life situations.?

ERP is a collaborative process. Therapist and client work together to build the therapy program. The client is never coerced to do anything against their will or that will violate their personal values. It is important to note that, likewise, the client will never be asked to do anything illegal and unethical.?To keep things concise, I'll provide one case of imaginal and live or in vivo exposure.

Imaginal Exposure Example

In our example, the therapist and client agree that a good starting point for ERP is to help the father confront words and phrases that trigger feelings of fear, guilt, and shame. Common examples include:

- Pedophile

- Sex with children

- Erection

- “Want to play with daddy on his lap?”

- Grooming children

- Bath time

- Seeing my naked daughter

- Vagina

I would ask the client to rank these words and phrases from least distressing to most distressing. Then, he should say each word and phrase aloud slowly, altering his tone and inflection to mimic desire and longing. This method is effective because it challenges the father's deeply held conviction to love and protect his daughter, which should evoke strong emotional distress.

The father will likely want to avoid confronting this situation. He might rationalize that he would never harm his daughter or mentally list all the ways he has lovingly supported her. Since OCD targets what one cares about most, he is likely to experience doubt about his convictions and obsessively worry that he might derive pleasure from these thoughts.

Individuals with Unacceptable Thoughts OCD face the challenge of confronting their worst imagined outcomes and painful feelings. In this scenario, the father would be encouraged to use techniques like imaginal flooding and exaggerating absurdities. Although these strategies can be distressing, the goal is for him to accept these unwanted thoughts and emotions without getting caught up in endless mental debates about their significance or whether he might act on them.

Imaginal flooding is a therapeutic technique where an individual deliberately and intentionally imagines the worst possible outcome. Unlike intrusive thoughts, which happen involuntarily and are often resisted, imaginal flooding involves purposefully focusing on distressing thoughts and mental images with intensity and repetition. The key aspect of this method is that the narrative or self-talk aligns exactly with the feared outcome the person envisions. This precise focus triggers the painful emotional responses needed to facilitate recovery.

Here is an illustrative example:

"I constantly fear that one day I will lose control and harm my daughter. The thought of it is unbearable and disgusting. If it happens, I would lose my entire family and end up in prison, where I would be raped and beaten. Ultimately, I would die in misery, completely abandoned.”

In Vivo Exposure Example

This father dislikes being alone with his daughter without the distraction of music. For live exposure, he can begin by spending time playing her favorite game, allowing music only 50% of the time. Gradually, this safety-seeking behavior will be phased out. The goal is for him to eventually spend hours alone with his daughter without any distractions.

In Exposure and Response Prevention (ERP), intensity is gradually increased. Subjective Units of Distress (SUDS) are measured during each exposure trial, typically focusing on peak distress—the highest level of discomfort experienced during the trial. The aim is to reduce peak distress by 50% before progressing to more challenging exposures.

Effective exposure trials require frequency, intensity, and adequate duration—typically three to four sessions per week lasting 45 minutes to an hour each. This level of intensity helps diminish the emotional brain's threat response. OCD therapists do not aim to eliminate distress entirely, as that is unrealistic. Instead, they help clients move from a state of intolerability to mere dislike. I often tell my clients: "You don't have to feel comfortable with your mental experiences; you don’t have to like them, but you should still be able to cope effectively. We do many things daily that we don't like but accept.”

Pathological Doubting in OCD

OCD is often referred to as the "doubting disease" because it causes individuals to constantly question and worry. This father, in our example, might be plagued by the thought, "What if I sexually harm my daughter?"

Pathological doubting is characterized by an inability to tolerate uncertainty and a constant need for certainty. For individuals with OCD, the unpredictability of future events feels threatening. The reality is that it is impossible to be completely certain about whether a feared outcome will occur or if one might inadvertently cause it through negligence or antisocial behavior. Strictly speaking, this father can never be absolutely certain of harming his daughter in any form or fashion.

Problems in living arise from the need for a sense of closure. Individuals with OCD often report that something always feels off or wrong. This leads to an attentional bias, where they believe that unless this ‘bad feeling’ disappears, taking any desired action seems too risky and must be avoided.

Summary

The new insights gained through ERP enable individuals with Unacceptable Thoughts OCD to focus on the present moment instead of futilely seeking answers to unknowable questions. This approach allows a father to live more fully by acting according to his cherished values rather than resorting to avoidance coping. He can love his daughter, even though he cannot be certain if he will ever harm her.

The best way for any of us to live is by embracing uncertainty, accepting discomfort, and acting in alignment with our core values. This is the goal of Exposure and Response Prevention (ERP) therapy: to challenge the rigid rules imposed by OCD, accept uncertainty, and embrace the inherent risks of living in the present moment where life truly happens.

In this article, I aimed to offer insight into the suffering experienced by individuals with Unacceptable Thoughts. I hope it has helped you understand this often perplexing type of OCD, where much of the pain occurs in silence and the compulsions are primarily mental and subtle.

Are you or a loved one struggling with OCD? Find hope and healing at ChangeYourThinking.com, founded by Frank Morelli, LMHC. As Clinical Director, and OCD & Anxiety Disorder Treatment Specialist, Frank is dedicated to helping you overcome intolerable thoughts and sticky behaviors. Don't wait—take the first step towards a better life today. Call Frank at 904-410-6324 now!