Understanding the Taboo Themes of OCD—and How ERP Therapy Can Help

When people hear "OCD," they often think of handwashing, checking locks, or color-coordinated shelves. But for many living with Obsessive-Compulsive Disorder, the experience is far less visible—and far more distressing. Some of the most common forms of OCD revolve around intrusive thoughts that are violent, sexual, or blasphemous in nature. These are often referred to as taboo themes.

Despite being widespread among OCD sufferers, taboo themes are rarely discussed, leading many to suffer in silence. In this post, we'll explore what taboo-themed OCD is, how it manifests, and how a powerful treatment method called Exposure and Response Prevention (ERP) therapy is helping people reclaim their lives.

What Are "Taboo Themes" in OCD?

Taboo-themed OCD involves intrusive, unwanted thoughts or mental images that are considered socially or morally unacceptable. These thoughts clash with the person’s values, causing intense guilt, shame, and anxiety.

Common taboo themes include:

1. Sexual Intrusive Thoughts

• Unwanted sexual thoughts about children (pedophilia OCD or “POCD”)
  

• Incestuous thoughts
  

• Thoughts of being sexually attracted to family, friends, or religious figures
  

• Worries about one’s sexual orientation (not to be confused with healthy questioning)
  
  2. Violent or Harm-Based Intrusive Thoughts

  • Fear of hurting a loved one, stranger, or oneself
    

  • Fear of committing a violent crime
    

  • Intrusive images of stabbing, hitting, or killing
    

  3. Religious or Moral Obsessions ("Scrupulosity")

  • Fear of offending God or being sinful
    

  • Obsessions over moral perfection
    

  • Excessive concern about religious rituals being performed "perfectly"
    

  These thoughts are ego-dystonic, meaning they are out of alignment with the person's values and beliefs. That’s what makes them so distressing: the person does not want to have them.

  How Taboo OCD Affects People

  People with taboo OCD themes often experience:

  • Crippling shame and isolation: They may fear being judged or misunderstood, even by therapists.
    

  • Avoidance behaviors: Avoiding children, knives, religious places, or anything that might "trigger" the thought.
    

  • Mental compulsions: Reassuring oneself, praying, reviewing past behaviors, or "testing" whether the thought is true.
    

  • Relationship strain: Difficulty forming or maintaining relationships due to fear of acting on unwanted thoughts.
    

  • Misdiagnosis: These individuals are often misdiagnosed with conditions like psychosis or personality disorders.
    

• It’s important to understand: having an intrusive thought does not mean someone wants to act on it. In fact, the distress comes because the thought is so out of character.

  The Role of Exposure and Response Prevention (ERP) Therapy

  ERP is the gold-standard, evidence-based treatment for OCD—especially taboo-themed OCD. Here's how it works:

  Exposure:

  The person is gradually exposed to thoughts, images, or situations that trigger their obsessions. This could involve:

  • Writing down or reading feared thoughts ("I might harm my child")
    

  • Looking at images that provoke anxiety (e.g., family photos if dealing with incest OCD)
    

  • Watching media that includes religious content
    

  Response Prevention:

  The key is not to engage in the compulsive behavior that usually follows. This helps the brain learn that:

  • The thought doesn’t need to be neutralized
    

  • Anxiety will decrease on its own over time
    

  • Thoughts do not equal actions
    

  Over time, the brain learns that the thought is just a thought—not a threat.

• Effectiveness:

  ERP has been found to be highly effective, with studies showing that 60–80% of people experience significant symptom reduction. When combined with education and the support of a trained therapist, ERP can help individuals take their lives back from OCD.

  What ERP Is Not

  It’s not about proving you’re “safe” or “not a bad person.”

  
  It’s not about reassurance.

  
  It’s not about erasing thoughts—but learning to coexist with them.
  
  This process can be uncomfortable, especially at first—but it is life-changing.

Final Thoughts

Taboo-themed OCD is more common than people realize, yet it’s one of the least talked-about forms due to stigma and fear of judgment. But having intrusive thoughts does not mean you're dangerous, immoral, or broken. It means you have OCD—a treatable condition.

If you're struggling, you're not alone—and you deserve help. ERP therapy offers a path forward grounded in research, compassion, and real-world success.

You are not your thoughts. You are the one observing them—and you are not alone.

Bella’s Journey through ERP for Emetophobia (Fear of Vomit)

To bring  therapy to life, let’s meet Bella, a 28-year-old teacher who struggled with emetophobia since childhood.

Bella’s fear of vomiting controlled nearly every aspect of her life. She avoided plane travel, public speaking, new restaurants, and even children—worried they might bring germs. She maintained an extremely restrictive diet and carried anti-nausea remedies everywhere she went. Despite being healthy, she often misinterpreted normal sensations like hunger or bloating as signs she was about to vomit.

After years of trying to manage the fear on her own, Bella sought help and was referred to a therapist who specialized in ERP. At first, the idea of confronting her fears seemed terrifying, but her therapist explained that they would go at a manageable pace and that Bella would be in control of each step.

They started with small exposures: saying the word "vomit" aloud, then watching short videos of people pretending to be sick. Over time, she worked up to sitting in crowded restaurants, eating previously "unsafe" foods, and even caring for her niece when she had the flu.

It wasn’t easy—Bella had moments of high anxiety, doubt, and even considered quitting. But she learned to sit with the discomfort without trying to “fix” it. Slowly, her brain stopped seeing nausea as a threat. One day, months into therapy, she realized she'd gone out to dinner with friends, ordered a meal she used to fear, and never once thought about getting sick.

Today, Bella still experiences occasional moments of anxiety, but they no longer control her. “ERP gave me my life back,” she says. “I no longer live in fear—I live in freedom.”

How ERP Works for Emetophobia

ERP for emetophobia typically begins with building a fear hierarchy—a list of feared situations ranked from least to most anxiety-provoking. These can include:

• Saying the word “vomit” aloud

• Watching a video of someone gagging

• Reading a story that includes someone getting sick

• Eating a food that the person has avoided

• Sitting in a crowded restaurant

  Therapy starts with lower-level exposures and gradually moves up the hierarchy. Each exposure is repeated until the person’s anxiety decreases through a process called habituation—where the body and mind learn that the feared outcome doesn’t happen, or if it does, it is manageable.

  At the same time, the therapist helps the client prevent compulsive responses—for example, resisting the urge to research food poisoning, constantly check expiration dates, or repeatedly ask for reassurance from others.

  Why It’s Effective

  ERP works because it helps retrain the brain.

  In emetophobia, the brain is sending out false alarms—treating nausea or the idea of vomiting as a life-threatening event. Avoidance reinforces this belief, keeping the anxiety cycle going. ERP breaks the cycle by helping individuals learn that anxiety, while uncomfortable, is not dangerous—and that they can survive and even thrive without being ruled by their fear.

  Challenges and Considerations

  ERP for emetophobia can be emotionally demanding, especially early in treatment. Many people are understandably terrified at the idea of confronting their biggest fear, even in small ways. That’s why it’s important to:

  • Work with a therapist trained in ERP and familiar with treating emetophobia
    

  • Go at a pace that’s challenging but manageable
    

  • Recognize and celebrate progress, no matter how small
    

  • Address underlying perfectionism, control issues, or trauma if they’re contributing factors
    

  Medication, such as SSRIs, may also be recommended in some cases to help reduce baseline anxiety and support the therapy process.

• Final Thoughts

  Emetophobia can feel isolating, exhausting, and endless—but it doesn’t have to be. Exposure and Response Prevention therapy offers a structured, effective pathway out of fear and back into life. With patience, courage, and the right support, it is possible to stop avoiding life out of fear of vomiting—and start reclaiming joy, freedom, and peace of mind.

  Just like Bella, you can face the fear—and find freedom on the other side.
  
  
  
  

Anticipation Anxiety

Anticipation anxiety is the anxiety that we experience prior to a feared trigger. This trigger can really be anything: Monday morning, a job interview, a plane ride, a test, an unwanted conversation, a medical appointment, trying a new food or activity. This common type of anxiety can range from mild and barely noticable to incredibly impairing. Many times, the discomfort from anticipation anxiety can be far worse the the discomfort experienced during the actual event. Have you ever wondered why this happens?

The human brain has a unique ability to create an emotional response to a feared or imagined stimuli that is just as painful and vivid as a real event. It has obviously served us in positive ways. It has allowed us to create safety measures that protect us from future or possible threats (locks on doors, seat belts, helmets, etc). The downside is that it also allows us to think and imagine detailed, terrible, scenerios that lead us to feeling uneccessarily miserable at times as well.

Some of the congitive distoritons (negative patterns of thinking) that can maintain this type of the anxiety are: fortune telling (predicting a bad or scary outcome), overgeneralization (assuming that because something turned out badly in the past, it will always turn out the same way) and mind reading (assuming that we know what others are thinking or are going to think about us).

If anticipation anxiety about an upcoming situation or event has you on the hook right now, you can try a few of my favorite tips to tame it:

1. Practice staying in a curious, present mindset by saying “ Let’s see” or “Let’s see how this goes”. Sticking with a “let’s see” mindset allows us to stay in the moment and let the situation unfold instead of staying focused on our future expectations. Spoiler alert*** Humans are not great at seeing into the future or reading minds****

2. Postponing the worry. This is particularly helpful when the feared trigger is weeks or months away. Basically, when you notice the thought pop into your head, you tell yourself “I will focus on this later” or “I will focus on this when the event gets closer”. Most of us are better at letting our guard down and shifting our awareness away from the worry when we know that we have a plan to deal with it at some point in the future.

The goal is to get back to trusting in your own ability to handle life as it comes. Most of the people that I work with are MUCH better and handling life events than they think. I bet you are are as well.

Face you Fears with the Help of Virtual Reality

Last night I read my son’s letter to Santa. He asked for a VR headset for gaming. Here in 2023, Virtual Reality has become popular enough in the world of gaming that 8 year olds are asking for it.

Did you know that is has been used in mental health therapy since the 1990’s? Well - it has.

Previously, the technology was expensive and only used by large healthcare systems. But now, individual providers can use it to improve the effectiveness mental health therapy for different issues. In my practice, I use it to help clients face fears like flying, needles, heights, elevators, small spaces, driving, and public speaking.

Exposure therapy really means going towards the thing that you are afraid of in a safe environment. The goal is to reduce fear and avoidance. The immersive experience used in Virtual Reality Therapy can be a great way to build your confidence in going towards both the situation that you fear and the discomfort associated with it. Typically, in exposure therapy, clients go towards the thing they fear over and over again until the fear decreases. Using Virtual Reality to do this is a great option for fears like flying where the in vivo (aka - real life) exposure of boarding an airplane, taking off, experiencing turbulence, etc. is incredibly time consuming and expensive to do on repeat.

The only things that are needed to experience the benefits of therapist-led Virtual Reality Therapy from the comfort of home are: a smartphone (to use the VR app), a computer, and a universal VR headset ($20-$40 depending on the brand). Kind of wild, but it feels like the future is here!

Supporting a Loved One with OCD

It's incredibly hard to see someone you care about dealing with OCD. It doesn't matter if they're a child or an adult. They might avoid doing things they enjoy, have a hard time going to school or work, and feel constantly frustrated or stuck. While finding a therapist who specializes in treating OCD is crucial, there are other ways you can provide support.

First, learn about Obsessive Compulsive Disorder (OCD) by visiting a website like: www.iocdf.org. Understand that people with OCD find their obsessive thoughts and compulsive behaviors as frustrating as we do. Many individuals I've assisted with OCD express phrases such as "I know this thought isn't true, but I can't stop thinking about it" and "I know doing x, y, or z won't truly help, but I can't stop." Recognizing that you and your loved one share a common goal of overcoming OCD can strengthen your sense of unity.

Second, learn about the importance of family involvement and accommodation in maintaining symptoms of OCD. The phrase "OCD loves company" suggests that human interaction can influence OCD symptoms. Researchers and mental health professionals have been studying this (Ex. Eli Lebowitz and the Yale Child Study Center). When your loved one is struggling, it's tempting to either demand that they stop their rituals or to change your own behavior to accommodate the rituals. However, neither approach is helpful in the long run. Instead, try validating your loved one's pain by acknowledging how difficult it is for them right now. You can also boost their confidence by expressing your belief in their strength to overcome it.

As a therapist, I've witnessed the immense strength in facing OCD on multiple fronts. If your loved one isn't ready for help yet, you can support them by learning to confront OCD in a supportive way. It's a tough but rewarding process. Reach out to a professional for guidance and set yourself and your loved one up for success.

Help for panic attacks.

Panic attacks feel awful. Even if they only last for a short amount of time, it can feel like an eternity. What exactly are they? And how can I take care of myself when I have one?

The definition of panic is: the fear of fear. It is when we think of and behave as though anxiety sensations are a threat. If I were to feel my heart beating faster and think “oh no! I don’t want to feel this again!”, then I have just treated a bodily sensation like a threat. Now my body gives me a boost of energy to protect me from the threat. Now I have the energy to fight or run for our life. My heart might be pounding, it’s feels hard to breath, maybe even like Ii am choking, palms sweaty, dizzy, vision blurry, a general sense of doom……. It feels awful.

Over the course of our lives, most people will experience one or more panic attacks. Panic attacks only become a problem when we start to fear the next one. Once we start to fear the next one, our lives can start to get smaller. We might avoid the place or situation that we were in when the last one occurred. It can all pick up pace quite fast.

So what can I do in the moment when I have a panic?

Well, first of all reminding ourselves that as bad as this feels, it is NOT dangerous, and it WILL pass. (There is no record of anyone having a panic attack that lasted forever). Really, the way that we think about these normal albeit unplesant sensations is the MOST important part. The attitude that will really set us free sounds something like: “I’m feeling anxious, so what?”

Then, refocus on the world outside of our body. As long as we keep looking for internal sensations that we don’t like, we will find something. (If I told you not to focus on your big toes right now, you would probably start noticing how they feel).

Grounding is a great way to refocus on our surroundings instead of our internal sensations. There are many ways to practice this, but one of my favorites is color counting. All you need to do is pick a color (really, any color) and start counting all of the things that you see that are that color. You can sit still or walk around. Spending a few minutes doing this will give your brain a small solvable task to focus on.

Finally, go back to doing what you were doing before you started to notice the sensations of anxiety. The less space you give anxiety, the less of you it will take.