One of the most common OCD’s that I’m seeing lately is pedophilia OCD; or, as some call it, POCD. I prefer that people state the full name, pedophilia OCD, so as to demystify it and realize it for what it is, an obsession that is ego dystonic and not a part of one’s true being. However, for purposes of this blog, I will use the shorthand and call it POCD.
People ask me how it develops, and I wish I could give a simple answer, but I can’t. It seems to me it is an outgrowth of a form of scrupulosity. Because the idea of being attracted to a child sexually in any way is so taboo and so wrong that those that have an overly scrupulous mind will often lock onto this form of OCD. Backtracking even further, an overly accommodating person will often have scrupulosity. And from scrupulosity, often harm obsessions haunt the person, and sexual shame often appears; and taking it full tilt, we may see POCD. Anxiety therapists see various manifestations/symptoms from a patient who has sexual shame; but when the person locks onto a specific belief that is intolerable, ego dystonic and irrational, it is more than anxiety, it morphs into OCD; and as mentioned, per the course I just charted, POCD. *This link might be helpful.
Thus, we begin the treatment: First, a thorough history is taken, and this encompasses a YBOCs assessment, replete with checklist and scale. A trigger chart is employed, which consists of three columns: triggers, obsessions, and compulsions: first we mark down the triggers, both internal triggers (mood and feelings are internal triggers and important to identify) and external triggers (a more concrete type of trigger; i.e., seeing a child), the obsessions (or feared consequences), and the compulsions (avoidance is a compulsion). As I have mentioned in other blog posts, theoretically if one can approach the triggers without giving in to the compulsions, the obsessions will lose their momentum. This is because the stimuli is no longer as frightening and one doesn’t imagine the worst anymore. One becomes habituated. Our job is to make the theoretical concrete. By charting out the triggers, and further, a SUDs hierarchy, one can practice imaginal and situational exposures with the hopes that the fear will subside. This takes time – often a good six months to a year. If it took a lifetime to develop this disordered way of being, one can’t expect to completely reprogram themselves in a few weeks.
Some of the exposures might very well be uncomfortable. For POCD, the ERP is a bit more delicate. The patient may experience overwhelming anxiety while bathing their children or getting them dressed or simply being around other parents’ children. One might shiver at the thought of passing a playground. It's important to distinguish the cognitive errors of one’s thinking. For example, noticing a child’s bottom while putting on diapers doesn’t make one a child molester. (A side point here is that OCD attacks one’s value system, so it is not unusual to see a person who works with children or has desires of being a parent to fear content involving children. OCD is nasty that way; it scrambles content and context.) I think it’s very important to distinguish between thoughts and behaviors. I strongly believe that thoughts are not a crime, nor a sin. However, if your religious beliefs are that thoughts are indeed a sin, then obviously it’s important to make peace with this way of thinking – and often the cognitive discussions between therapist and patients will help in this endeavor. This is why every individual case is unique. One size does not fit all, and I’ve been outspoken about this over the years. The subtleties must be acknowledged, which is why an ongoing investigation into one’s motivation and the course of one’s life must always be examined in parallel with any ERP or CBT work. It is where the psychodynamic meets the behavioral. As we unpack the shame and anxiety around one’s sexual beliefs, often people will reveal a host of other sexual taboos that are either not in accordance with one’s beliefs or are fairly benign, however to the sufferer they seem so wrong. I have found that discussing one’s sexual fantasies, not unlike discussing one’s dreams, opens up a world of information – thoughts and feelings become less abstract and thus less frightening.
Everything we do together is headed toward a goal of letting a person have what I call OCD fatigue, where one finally simply does not care anymore. They shrug their shoulders and say, “The hell with it; I’ve got to live my life!” It’s at this point that the benefit no longer outweighs the cost, and a true acceptance is realized.