The Treatment of Pure Obsessions

Since I put up a post describing pure obsessions, a considerable number of readers have written to ask me if I know of a treatment center in their area. Usually, I do not. I recommend contacting The Obsessive-Compulsive Foundation. They know of trained therapists in different areas of the country.

But there is no standard treatment for this condition, so I feel I should describe what I do. Let me remind the reader, pure obsessions are intrusive thoughts that are often the worst sort of things that that person can imagine. They are unaccompanied by compulsive behaviors, except, perhaps, to avoid situations where those thoughts are likely to be most troubling. They fall more or less into a few distinct categories:

1. Violent thoughts, often against helpless individuals. An example might be stabbing a child in the eye with a scissors.
2. Forbidden sexual thoughts, usually homosexual. “Wouldn’t it be awful, if I suddenly kissed that person bending over me?”
3. Just plain disgusting thoughts, such as drinking urine from a puddle on the floor. Or kissing someone’s behind.
4. Sacrilegious thoughts, such as picturing the Virgin Mary with a penis.

These obsessions have a few elements in common:

1. They are unwelcome and come repeatedly and are very upsetting. Usually the obsessive person worries (some, at least) about actually engaging in these behaviors. That person almost always thinks that these thoughts must come from some unconscious urge and that only a despicable person could have such a thought.
2. In fact, no such awful behavior is ever engaged in by these individuals.
3. Besides being appalling, these thoughts are often ridiculous to everyone except the person having them.
4. They may get worse if the affected person is stressed or depressed.
5. Like all fears, they get worse with avoidance.

My experience is that after a number of months of treatment these awful thoughts tend to subside. But, frankly, as happens sometimes in treatment, it is not always clear to me exactly what has helped the patient. Anyway, this is what I set out to do:

1. It is important to communicate successfully that these behaviors are never engaged in by an obsessional person. (Other people who do not wince at these thoughts, or dread them, do, indeed do such awful things. But they are a different sort of person.)
2. These thoughts seem designed to reprimand the affected person. They occur, in my experience, in people who never give any evidence of behaving in such hostile ways—or in other such embarrassing ways.) I try to convince the patient that these thoughts, therefore, do not represent an unconscious urge to be a terrible person. (I do think they may occur in people who are especially bound to ethical ideas, and they may represent a desire to be less rigid.)
3. I talk calmly about the details of the obsession. Awful fantasies, (like fantasies, in general, tend to lose their ability to excite or frighten when they are made explicit by talking about them.) I try to get the patient to see the fantasies as others see them, as outlandish and ridiculous. If possible, as funny.
4. In situations where the patient can be made to approach the feared situation, I will encourage confrontation–for example, by tying a scissors around the neck of the affected person so that there is always an opportunity to stab someone with it.  That is a statement, first of all, of my confidence in her not doing it. Secondly, the patient can see for herself that she will not impulsively engage in such an act.
5. Sometimes I will make a special effort to make the thought specific and ridiculous by asking the patient to write it out with colored pencils.
6. Finally, I do, as I usually do in therapy, end up talking about important matters: work, relationships and so on; and I think doing so allows these other thoughts to seem unimportant, as they are. (c) Fredric Neuman   Author of “Caring.”