Don’t let what happen to me? Did I read this right? Now that my title has grabbed your attention, I hope you will allow me to explain: By “you” I am referring to you, the therapist; by “this” I am referring to a potential misdiagnosis; and by “Pedophilia OCD” I am referring to a form of Obsessive-Compulsive Disorder that is one of the worst types there is. With POCD, the person is worried that they might be a pedophile. But they aren’t.
This is perhaps your potential new client – someone who was finally brave enough to make it through your door and share their most unspeakable fear – that they might be a sexual predator of children. In actuality, this is a harmless human being who was beseeched by a “what if” thought that entered their mind at the most inopportune moment. Perhaps they heard the word “pedophile” in the news or watched an evil predator on TV. They might have had a random image of a child flash through their mind right when they were in the middle of making love. Or, at another ill-timed moment, they saw a photo of a child next to someone’s bed, or heard the voice of a child playing outside – right at the moment of orgasm.
In that split second, these paired associations partnered together “Pavlovian style” and did a hostile takeover on somebody’s brain. And now that person fears they are somebody evil. From that day forward, “What if I’m a pedophile?” is a thought that never stops running through their mind. Combining the scariest form of “Harm OCD” with the worst of “Sexual Orientation OCD,” POCD is a shameful, isolating experience. As they come to you for help, you are likely to ask your own set of questions: “Is this about sexual attraction? Is it Pedophilic Disorder? Is the client a danger to others?”
These are questions that previous therapists also had. Many of them took the clients’ words prima facie, leaving them feeling more worried and shameful. According to my clients, psychodynamic therapy came at great financial cost and over many long years, but exploratory work did nothing to ease their pain. Aversion therapy encouraged techniques like snapping their wrists or making themselves sick, an ineffective and demoralizing process. Old school CBT therapists, not current with the research on “thought suppression,” unsuccessfully recommended “thought-stopping.” Psychoanalytically trained therapists urged them to talk about repressed sexual urges, creating an inference of plausibility. Trauma-based therapists conveyed the possibility of a past molestation, an event that never occurred. Some therapists produced needless fear by mentioning that this might be “reportable.” Specialists in paraphilic (sexual) disorders often took the lead, leaving clients feeling even more deviant and defective than before.
“Well,” you might be thinking, “what if this OCD specialist is also looking through her narrow lens, and overlooked the fact that this really is a pedophile?” To answer this very valid question, Pedophilic Disorder can and should be ruled out, and if there is no desire to view child pornography, that is a very strong clue. There is also almost always some history of OCD in the person’s past, even if it used to be counting or checking, and often there is a family member who also suffers from OCD. But the real litmus test is how the client feels about their intrusive thoughts. If they’re breaking down in your office, and saying their thoughts are disturbing, it’s ego-dystonic. It’s their worst nightmare, not someone else’s.
None of us ever wants to confuse a diagnosis or offer the wrong treatment, but missing this diagnosis, when it applies, has the potential to forever desecrate a client’s life. This is a diagnosis we have to try never to get wrong. Imagine, for a moment, just how many other lives would be impacted if someone with POCD (or their therapist) never knew just what it was. These are clients who make false confessions, or isolate themselves for the purpose of “protecting” children. Imagine . . .
- A woman ends a relationship with her dearest friend who opens a daycare center.
- A nurturing mother no longer touches her baby.
- A wedding is called off after the couple decides to share all of their innermost thoughts.
- A gifted fifth grade teacher abruptly ends his career.
- A loving husband and would-be father reneges on his promise to start a family.
In my article, Searching for Bad News: The Circuitous Path of Obsessive Thinking, I describe how people with obsessive types of OCD use a form of internal hypervigilance; checking their minds to see if certain thoughts have gone away, checking their body to see if they feel aroused when thinking about a child, or checking their character to see if they feel like a bad person inside. None of that is possible, by the way. As we learned from Daniel Wegner’s “White Bears” experiment, we have to conjure up a thought in order to reject it, and once that happens things get sticky from there. Clients who focus on their genitals don’t truly get an answer about whether they feel anything. Many males report feeling a vague uneasiness in their groin area, and because they feel “something,” they worry it is evidence of sexual arousal. Checking their character involves trying on different scenarios to investigate what their reactions “might” be, but in this dissociated game of speculation, they can’t really be sure. (Was that a surge of repulsion or excitement? It’s hard to tell).
Whether they feel something or they feel nothing, checking rituals become self-reinforcing. Behavioral compulsions, if there are any, might include checking the news to see if they were identified as a criminal, or checking children’s faces to see if they look frightened or uneasy in their presence. But children may wince or turn away for a variety of reasons, including the discomfort of being stared at. Sadly, POCD clients are likely to dismiss such reasonable explanations, making up their own “evidence” to vilify themselves.
When clients ask the question, “What if I’m a pedophile?” I tell them they’re not asking the right question. The question they should be asking is, “Do I have OCD?” Rather than researching the characteristics of predators on-line and running a side-by-side comparison (an ill-advised “checking” compulsion), we look at the diagnostic criteria of OCD.
If the first goal of therapy is psychoeducation, another important aim is to convey the futility of checking. When I hear clients insist on “knowing” who or what they are, I do various experiential exercises to demonstrate that “some things are impossible to check.” These clients are not just pondering, “What if I’m a child molester?” they are really wondering, “What if I’m a child molester and I don’t know about it?”
This subtle distinction is actually a blatant diagnostic clue. “It might be real even though I don’t know about it” is a nothingness, a void, an empty space that cannot be examined because nothing is there. Even though it is an amorphous idea that cannot be explored, OCD clients are determined to unravel this type of paradox. To them, a lack of verification seems like a guilty “yes” when it is really a sincere “no.” Different images, different thoughts, different situations, different states of arousal – all need to be investigated and exhausted until the “there is nothing” answer remains. As one client explained, “You want to be 100% certain that something isn’t true. So you search really, really hard to make certain. But in the process, you get so attached to the idea that you start to believe it.”
Exposure-based treatment in CBT isn’t about watching child pornography or encouraging inappropriate interactions with children. Rather, the work is to achieve habituation. Clients may be encouraged to write or say triggering words, look at their niece or nephew’s picture, listen to children’s voices, or show up at events where children are present. Moving up the “hierarchical scale,” we work with an imaginal exposure that the client writes, records, and listens to in their own voice. The script contains their worst scenario: being accused and convicted of child molestation, devastating their loved ones who ultimately disown them, losing their sense of who they once were, and watching their lives come crashing down. Having no more threats left in its arsenal, OCD relents. Treatment is surprisingly quick (weeks to months), and, when introduced in the right way, remarkably effective.
So, now that you recognize this disorder:
- A friendship endures through a lifetime of seminal moments.
- A child sleeps in her mother’s arms.
- A couple’s wedding vows express wholehearted trust.
- A teacher touches the lives of two generations of children.
- A husband strokes his pregnant wife’s belly.
All because you didn’t miss Pedophilia OCD.
©2016 Heather Stone, Ph.D.
13 readers shared their feedback on this article.
I want to applaud and thank Dr. Heather Stone for her very informative and important article on Obsessional OCD in the last newsletter. I have had a number of similar patients who worry they might be pedophiles when indeed they are simply having intrusive and checking thoughts which are characteristic of OCD. I recommend the article to everyone in the Redwood Psychological Association. Bravo Heather!
(Pychologist; Director of Behavioral Health clinic)
After several decades treating OCD, with many similar patients, I want you to know that you nailed it!! Thank you for the clear, informative article on POCD.
Hi Heather, Thank you for writing this great article. You have enriched us with this very important information that will extend to all of the individuals we work with. You are amazing!
(LMFT; Author: New Harbinger Publications)
Fantastic Heather! Great article and such needed education, good job taking the risk, it serves therapists and especially this vulnerable population!!
Wow, Heather, this is a fabulous article! I love your writing too. Inspired, moving, and helpful, very, very helpful. Also, your treatment is fully consistent with ACT, resting on promoting client’s curiosity, willingness and self-as-context, and thus moving towards words and feelings not for the purpose of elimination but of encouraging a new, broader consciousness, at the service of valued living. You turned worry exposure into what is supposed to be, a mindfulness of our deepest fears practice. And the use of the one-liner human cases: what a beautiful, effective way to introduce the true purpose and significance of therapy. No relapse there! Beautiful. I’d love to hand it out to my students at University.
Hi Heather, I just wanted to chime in with the others, congratulating you on your well-written article. You did a really nice job of conveying what the reader should be aware of, in a relatively short space. As always, I really liked what you had to say!
Thank you, Heather, I really enjoyed your article in the RPA newsletter on Pedophile OCD. Both of your articles are very helpful, given my current work with a patient with the OCD dynamic you describe. Speaking as a writer myself, you write very well and should be publishing, if you do not do this already.
Hi Heather, I’m just echoing the comments on the listserv about your well-written article.In addition, it was fun, personable and very understandable. A few months ago when faced with a client with challenging OCD symptom, I had been musing over the different types of OCD and the diagnostic implications and challenges, which when faced with your article permits me to see more acutely how the topic you were addressing is important, subtle, and tricky. Bravo!
(Online OCD Publication)
Hi Heather, That is a brilliant article. One of the best I’ve seen on POCD. Thanks for sharing, I enjoyed reading it! To your success,
This is such a thoughtful article, written so clearly, with such a friendly, empathic, respectful and compassionate tone to it! This will be a great addition to your website or to give to clients.
(International OCD Foundation)
Great article! Sending it along to my editor. Thanks for the work you do!
Hello Heather. This article is
Hello Heather. This article is a breath of fresh air for me as I have been working with a client with POCD. My gut has been telling me that I am on the right path, but my fear of misdiagnosis is always present. The client told his psychiatrist about his thoughts and was told he ought to be locked up, away from society. He approached a treatment team for help and was told they don’t treat pedophiles. He has severe OCD and is also worried he might be a rapist and a serial killer. Thank you so much for this article that provides so much grounding.
I just read your thoroughly informative article on POCD, shining a cautionary light into a dark and stigmatized corner of clinical practice that really deserves more conversation. Thank you for advocating for the need of extreme discernment in cases that have elements of the presentation you described.
Leave us a comment if you like...