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The One Diagnosis All Therapists Should Understand

It pertains to limits of confidentiality and keeping clients safe.

Ussama Azam/Unsplash
Source: Ussama Azam/Unsplash

Therapists are intimately familiar with limits of confidentiality and mandated reporting laws. They understand what is required of them to keep their clients safe and protect others. However, the lack of understanding about one particular diagnosis often deters therapists from protecting their clients. This diagnosis is Obsessive Compulsive Disorder (OCD).

You may be thinking, “What does a love of organization or a lot of hand-washing have to do with limits of confidentiality?” If you’re asking that question, that is exactly why you should be reading this.

OCD is portrayed in the media as a quirky personality trait of people who love to organize their closets by color or keep their coffee tables tidy. Reality star Khloe Kardashian, with a following of 140+ million people on Instagram and Twitter alone, created a series titled “Khlo-C-D” to highlight her love of organizing her pantry (among other things). It is no wonder why OCD is so misunderstood. While the general population might not have an investment in learning about the disorder, every single therapist should because of its relation to the limits of confidentiality.

OCD is characterized diagnostically by the presence of obsessions and compulsions. Obsessions are intrusive and unwanted thoughts, urges or impulses that cause the sufferer considerable anxiety. Compulsions are physical or mental acts that the sufferer carries out to alleviate anxiety or prevent a dreaded outcome from happening.

In plain and simple terms, think of the last thing you would ever want to think. For people with OCD, that thought pops into their mind all day long without their control. Because of the anxiety and distress that the thought (obsession) induces, they try to make it go away by doing something physically or mentally (compulsion) to make sure that nothing bad happens.

While the fear of contamination is the most well-known obsession, and handwashing is the most well-known compulsion, the reality is that contamination concerns make up a small percentage of obsessional themes.

Obsessions of OCD vary widely and often involve the very content that makes up mandated reporting laws. Below is a list of a few common OCD themes that you may not be aware of, along with common compulsions associated with these obsessions (including, but not limited to):

Harm OCD

  • Obsessions: unwanted violent thoughts about others, fear of harming other people, unwanted thoughts about suicide (the fear of dying by suicide).
  • Compulsions: avoiding knives or any sharp objects, asking another person to be with them at all times so they don’t accidentally do something, refusing to drive in case they hit someone.

Pedophile OCD

  • Obsessions: unwanted sexual thoughts and images about children, fear of being a pedophile.
  • Compulsions: avoiding children, avoiding TV shows and movies with children so as not to be triggered, asking for reassurance, ruminating about the thoughts to try to seek certainty that they will not harm a child.

Perinatal OCD

  • Obsessions: unwanted sexual or violent thoughts about a newborn baby, the fear of causing injury or death to a newborn child, irrational fear of harm befalling the child (such as it stops breathing in its sleep).
  • Compulsions: avoiding contact with the newborn to ensure that the baby is safe, no longer changing the baby’s diaper because of intrusive sexual thoughts, checking the baby’s pulse repeatedly during the night.
  • It is important to note that Perinatal OCD is different than Perinatal Psychosis. While both disorders involve violent thoughts, the OCD sufferer experiences intrusive thoughts that they know are irrational and antithetical to their values and morals. On the other hand, those with perinatal psychosis experience delusions that they align with or believe are true.

Other common obsessional themes include scrupulosity (religious and moral obsessions), sexual orientation obsessions (fear about not knowing one’s true identity), existential obsessions (persistent questioning about philosophical matters such as reality and the meaning of life), and somatic obsessions (hyperawareness of automatic body functions like breathing or blinking).

It can be confusing for clinicians without an understanding of OCD to hear clients say things such as, “I have repetitive thoughts and images about harming myself” or, “I keep having an image of smashing my baby’s head on the wall pop into my mind.” It can be equally as confusing, and awfully terrifying, for clients to experience unwanted intrusive thoughts that they would never want to carry out—let alone think.

As it is a therapist’s greatest responsibility to keep their clients safe, words like “suicide,” “pedophile,” and “kill” can (rightfully) be triggering for them. We are taught in our graduate programs, trained in our internships, and reminded by our supervisors that we must assess for danger when we hear such words.

What therapists are often not taught about is OCD and the treatment of it. I have to admit that if I did not suffer from one of the “taboo” themes myself, I likely would know very little about the ways that OCD manifests because there is such a large misconception about the disorder.

Contrary to popular belief, obsessions of OCD are ego-dystonic: disturbing and inconsistent with the sufferer’s values and self-concept. The sufferer does not align with the content of the obsessions, finds them distressing, and tries to get rid of them by performing compulsions. A person with OCD goes out of their way to make sure that nothing bad ever happens to anyone, which is far different from a person who aligns with their thoughts and wants to carry out plans.

However, because the client’s thoughts are comprised of content similar to mandated reporting laws, a therapist who does not understand OCD may misdiagnose or break confidentiality when the client is the farthest thing from being of danger to themself or others.

While it is not always clear-cut, a few key characteristics of OCD are as follows:

  • Intrusive and unwanted thoughts/images/urges that continuously pop into the client’s mind and cause them heightened anxiety and distress.
  • The presence of physical compulsions and/or mental compulsions (OCD is not always visible to the eye. Someone can suffer from obsessions and mental compulsions, which is nicknamed Purely Obsessional OCD.)
  • Avoidance of anxiety-provoking stimuli.
  • Inability to connect with what is rational, making reassurance about the obsessions insufficient.

On average, studies show that those with OCD suffer 14 to 17 years from the onset of their symptoms to the time they access proper treatment. This is sadly often the result of shame that many people with OCD experience because of the content of their obsessions, misconceptions about the disorder, and an overall lack of understanding about OCD by many therapists.

The good news is that OCD is treatable, but it requires a particular form of Cognitive Behavioral Therapy called Exposure & Response Prevention (ERP). ERP is evidence-based and is the gold standard treatment for OCD. If you would like to learn more about OCD and it’s treatment, reach out to an OCD specialist for consultation or visit the below resources. By doing so, you could save people years of suffering. You could save people time and money spent on ineffective treatment for OCD (such as traditional talk therapy). You could save lives.

Additional OCD Resources:

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