A Knife in Session: Thoughts on treating OCD

OCD can make simple tasks like cutting food unimaginable

I’ve been trying to write this post for several days now. I keep starting – and then I get stuck.  I can’t seem to think of the right way to write or how to organize it – so let me just start:

Last week, in Fullerton, California, a mental health therapist was stabbed and held at knife point by a patient. The ordeal ended with the patient being shot and killed by the police. The therapist survived. A tragic scenario all around and my heart is with everyone affected.

As the mental health community takes a few steps back to reflect and recalibrate, I find my own thoughts drifting to my work with Obsessive-Compulsive Disorder (OCD). Our psychological associations use happenings such as these as an opportunity to remind us how important it is for mental health practitioners to have a “safety plan” in place in case a patient turns violent. In the 2008 article “How to: Stay safe in practice,” published by the American Psychological Association (APA), author Christopher Munsey notes that mental health practitioners ought to “remove potential weapons” from our offices. This includes “letter opener(s) or heavy paperweight(s).” And yet this goes counter to the work I do in my office with my patients.

A Knife in My Office

Less than a week before the stabbing in California, I sat on the floor of my office with a young adult patient. We were no more than a couple of feet from one another. Poised between us, on a cutting board was a paring knife, an essential tool for the exposure we were doing. You see, my patient had not held anything sharper than a butter knife for over one year. Formerly a joyful chef in his home, his OCD caused him to worry over intrusive thoughts in his head that made him fear he might stab a family member (or anyone close by) if he held a knife. His cooking all but ceased. The whole family missed his meal preparation. And so, on that day on my office floor, we faced his OCD head on by placing a knife of his choice (I’d brought in an assortment) on a cutting board that he dared to get close to.

My patient’s anxiety skyrocketed as he approached the knife. He shook and he sweated as he inched closer and his hand reached toward it. We ended the exposure, 45 minutes later, with him having managed to place two fingers on the handle (lest you wonder if this was progress, it is of note that he began on the other side of the room, about six feet away). Tears fell out of his mother’s eyes as she watched from the sidelines and began to fully comprehend the extent of her son’s fears, as well as the bravery he possesses.

But, are we foolish…

Bringing a knife into session is not so unusual for those of us who treat OCD. If our patient has harm obsessions, sometimes a knife is just what is needed to stand up to the disorder. It is a reclaiming of what OCD steals from the sufferer, the ability to do a simple task most of us do not think twice about – cut our food.

Yet, the non-OCD community regards us, at times, as outlandish, misguided, or downright wrong about our approach to treatment. An extremely well-respected and experienced psychologist I know once shared a story in an OCD workshop I attended about how an insurance company representative questioned his methods. The conversation began something like this:

Well, Dr. X, if your patient is afraid she will harm someone with a knife, isn’t it ill advised to be using knives in your treatment?

The psychologist then had to explain to the representative, also a psychologist, how OCD is treated. It was completely a foreign concept to the representative. A sad state when insurers of treatment do not understand how a disorder is treated. But they are not alone. I’m fairly certain much of the psychology community does not understand what goes on in a treatment setting when OCD is the focus, and I’m pretty sure they’d be aghast upon first learning about it.

So, while my professional organization suggests I remove all items that might be used as weapons against me from my office, my treatment with patients with “harm” OCD often involves noticing what items in my office might actually be used as weapons. Of course our focus is on helping them to tolerate their anxiety about being in the presence of their feared thoughts and the everyday items that might trigger these. My taking these steps in treatment means I must do a very thorough evaluation of my patient and have come to a well-thought out treatment plan that is in keeping with their diagnosis.

What about the patients…

I also know that incidents such as the one in California will trigger many OCD sufferers. A population that already regularly questions its own sanity may point to this incident as evidence that they may go “crazy” and attack someone. It could make them fearful of doing exposure work in session (“I might crack while doing an exposure and hurt my therapist.”). Worse, it could make them delay attending therapy for fear they will do something similar.

Where am I going with this? Mostly, I am saddened that incidents like this ever occur. They are apparently rare, but they do happen. As an OCD therapist, like all mental health practitioners, I must stay aware of this and not take safety in the office in a cavalier way. At the same time, I must do a thorough evaluation of my patients and act in the best interest of helping them to get healthy and functioning again.


11 thoughts on “A Knife in Session: Thoughts on treating OCD

  1. HyperchildChillmom

    My Daughter is having intrusive thoughts, has become obsessed about the thought of suicide, not that she wants to do it, but that she will someday want to do it. She has ADHD and anxiety and I have for some time thought she is OCD as well. We are seeing a psychiatrist tomorrow because as soon as I mentioned suicide they got the ball rolling. She has had intrusive thoughts for some time about our house fire we had almost 10 years ago, she keeps thinking it will happen again, always has to have the doors locked at night and has separation anxiety, never feels like I am safe. I wish I could take all her worry away from her, but the only thing I can do is push everyone around her to help her. It is a never ending battle at school, I feel like the teachers do not understand and now she is overwhelmed with her work load.
    Thank you for your posts, it makes us understand a little more every time.

    1. Thank you for reading and commenting. It’s an honor to be able to share with others. Wishing you all the best with the psychiatrist and with treatment. Certainly, sometimes OCD presents with intrusive thoughts of suicide that frighten the person – and it can be very scary for everyone as it is sorted out. I’m glad that you’ve been an advocate for your daughter. Thinking of you and sending healing thoughts. – Angie

    2. If it comes as any comfort, I also used to struggle with intrusive thoughts about suicide. It was difficult to figure out and frustrating to deal with. However, with treatment and support, things have gotten a lot better for me, and I hope the same for your daughter.

      1. HyperchildChillmom

        We have some really good news that I will be posting about soon…We had a Prom last night so getting ready for that has kept us busy!!!

  2. Dr. Sarah Haider

    I had no idea about that incident. So sad. When one of the OCD shows was on air, I remember a therapist explaining to the viewers when discussing the general concept of self-harm, “I can trust any OCD patient to hold a knife to my throat the same amount I trust a family member to hold a knife to my throat.” And went on to explain levels of high empathy in OCD-sufferers, and the etiology of the disease and necessity of ERP. It is a lone I often reference the myself. Thanks for your insights.

  3. A lot to think about. As you say, a thorough evaluation of your patient is so important. I guess what it boils down to,ironically, is the need for all of us to embrace uncertainty to a certain degree. Thanks for all you do to help those with OCD!

  4. I’m glad you’re willing to “break the rules” to do what we all know is best for patients. Sometimes patients needs don’t align perfectly with the guidelines and realizing the patients’ needs ought to come first is something I think a lot of people may struggle with.

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