What We Miss By Saying “The Content of Obsessions Does Not Matter”

If you are an OCD specialist, you have likely reiterated to your clients that the content of obsessions does not matter. 

Whether it is a sexually intrusive thought about a child or a thought about feared contamination, the thoughts are ego-dystonic obsessions of OCD and they are treated the same. We utilize Exposure & Response Prevention (ERP), the gold standard treatment for OCD, for all obsessional themes because an obsession is an obsession regardless of the content.  

The idea that the content does not matter makes sense from a clinical perspective, because we treat all thoughts the same, and is often utilized in an attempt to normalize intrusive thoughts.

However, by equating all content as the same, we may be invalidating the shame and stigma associated with particular obsessions. We may also be invalidating the difficulty that those experiencing taboo obsessions face when both trying to understand what is going on in their brain and accessing help.

This is not to say that OCD is more painful depending on the theme, but rather that certain obsessional themes do carry an added layer of shame and stigma that impacts the sufferer.

The reality is that those living with OCD often suffer in silence for years because of the content of their thoughts. Those with harm obsessions about their children often fear seeing a therapist because they do not want their baby taken away. Those with pedophile obsessions often fear seeing a therapist because they do not want to be reported. 

As an OCD specialist who lives with OCD, I can attest to the confusion I faced when my sexually intrusive thoughts about children surfaced, the unwillingness and overwhelming difficulty to disclose my thoughts to a therapist because I feared being reported, and the deep shame I felt telling absolutely anyone because of stigma.

If you think of the worst thing that a human could be, I can almost guarantee that a pedophile comes to mind because — rightfully so — pedophilia is highly stigmatized. I’ve had clients actually say to me “I am so glad I do not have the pedophile obsessions.” Pedophilia is also illegal. Contracting a virus is not illegal. Praying in the wrong way is not illegal. Being in the wrong relationship is not illegal. You may be able to explain murder to someone but there is no explanation for sexually molesting a child. Certain obsessions involve content that violates the law and this, in and of itself, naturally carries increased stigma. 

While I wish it were not so, not everyone understands OCD. It is why some therapists and organizations are reluctant to talk about the more stigmatized themes. As a therapist who utilizes Instagram as a platform to advocate for OCD, I have received some backlash when posting about pedophile obsessions from people who do not understand what OCD entails.

Moreover, those who speak to another person about taboo obsessions are at a higher risk of someone deeming them as a danger to themselves or society than those experiencing more benign obsessions.

Think about the client struggling with suicidal obsessions who is hospitalized because the therapist does not understand. When I first opened up to a friend about my intrusive thoughts, the very friend who pushed me to see a therapist, she said something along the lines of “Maybe you should have your therapist explain it to your parents because this sounds concerning.” This read as “Your parents will likely be worried because the thoughts that you’re having don’t sound normal.” If I opened up to this friend about a fear of contracting an illness or a fear of contamination, I can guarantee that the reaction would have been different.

In addition to shame that arises because the content is stigmatizing, OCD sufferers often feel shame because of what feels like a loss of identity associated with certain obsessional themes. 

I have always adored kids, so much so that I worked at a daycare in college. Never once did I have the intrusive thoughts that accompanied my onset of OCD. When the one intrusive thought derailed my life and sent me into a dark few years, it was so disorienting because of the content of the thoughts. Everything that I knew about myself, about me loving children and being attracted to adults, felt like it had gone out the window. 

For those whose obsessions target a part of themselves, this loss of identity wreaks havoc on their lives. This often leads to comorbid depression that may need to be worked through in addition to ERP. While focusing on behavior change is the goal of treatment, the changing of behavior does not take away the pain the sufferer has experienced living with a debilitating disorder. It does not take away the years lost suffering, what feels like a loss of identity, and the trauma that may have arisen from living with OCD.

While the content of the thoughts is not relevant in regard to treatment and the changing of behavior, it undoubtedly plays a role in the emotional side of living with OCD. It undoubtedly deters sufferers from accessing treatment and asking for help. It undoubtedly needs to be addressed more, by mental health clinicians, organizations and advocates.