Trigger warning: this article discusses suicidal thoughts and self-harm. If you or someone you know is in immediate danger, call emergency services right now. In the U.S. call 988 for the Suicide & Crisis Lifeline; if you are elsewhere, contact your local emergency number or crisis line.

Carmen had a long day at work. Her husband was supposed to help her prepare for guests that evening, but he wasn’t home. Tired and irritated, she reached for a knife to cut vegetables — and an intrusive thought appeared: “I’m so tired. I could just kill myself right now.” The thought terrified her. She tried to push it away, but the harder she tried to ignore it, the more present it became.

By the time her guests arrived she put on a smile, but she was exhausted. The next morning she read about a woman in her community who had taken her life. For a moment she wondered, “What if I end up doing the same thing?” She shook her head, hoping that action would make the thought disappear.

That evening Carmen told her husband about the thoughts. He became alarmed, misunderstanding her to mean she was actively suicidal. He said, “Honey, you have a great life. Why would you want to kill yourself? Just think happy thoughts and push those ugly thoughts away.” Carmen replied, “I’m trying — it’s not working.” Her husband decided she should see a psychotherapist.

Carmen’s mental health provider recognized that she was experiencing harm-related OCD — sometimes called “suicidal OCD” — in which intrusive, unwanted thoughts focus on self-harm or suicide. With appropriate treatment for OCD, Carmen began to get better. Her husband joined some sessions to learn how to respond without unintentionally strengthening the OCD through reassurance or avoidance.

Why the distinction matters

When someone reports intrusive thoughts about self-harm, family members and even some providers can mistake those thoughts for active suicidal intent. That misunderstanding can lead to responses (for example, strict removal of household items or frequent reassurance) that are intended to keep someone safe but may actually worsen OCD symptoms.

OCD treatment generally relies on exposure and response prevention (ERP): gently confronting feared thoughts or situations while refraining from compulsive responses (including reassurance-seeking or avoidance). If a person with harm-related OCD is treated as if they are actively suicidal — and is managed primarily through avoidance or constant reassurance — their obsessions and compulsions can intensify. They may feel increased shame, guilt, and depression because they don’t want the thoughts and worry something is fundamentally wrong with them for having them.

How to tell the difference: harm-related OCD vs. suicidal ideation

These are general differences that clinicians consider — they are not a substitute for a professional evaluation.

Harm-related OCD (self-harm / “suicide OCD”)

• Thoughts are unwanted and inconsistent with the person’s values and life goals.
• Thoughts provoke intense anxiety, shame, and distress.
• Thoughts are ego-dystonic: the person does not want to act on them and is horrified by the idea.
• The person engages in repetitive mental or behavioral rituals to reduce anxiety (e.g., checking, reviewing past behavior, seeking reassurance, mental neutralizing).
• The person worries about having the thoughts (“Why won’t these go away? Do I want them? What if I end up doing it?”) rather than experiencing relief from them.

Suicidal ideation (active intent)

• Thoughts are congruent with how the person feels about their life; they may see ending life as a solution to unbearable pain.
• Thoughts can bring a sense of relief or calm from distress and are often ego-syntonic (aligned with the person’s desires).
• The person believes their pain is intolerable, inescapable, or interminable and may express concrete plans, intent, or preparation.
• There is a real risk of acting on the thoughts and a need for immediate safety planning and clinical intervention.

What to do if you or a loved one is experiencing unwanted self-harm thoughts

• If there is any immediate danger or you believe someone intends to act on suicidal thoughts, call emergency services or take them to the nearest emergency room.
• If you are in the United States and need urgent support, call or text 988 for the Suicide & Crisis Lifeline. If you are elsewhere, contact your local emergency number or suicide/crisis hotline.
• Seek a mental health professional experienced in treating OCD (including harm-related OCD). Evidence-based treatments for OCD such as acceptance and commitment therapy (ACT) with exposure and response prevention (ERP), Inference-based Cognitive Behavior Therapy (I-CBT) and, when appropriate, medication such as selective serotonin reuptake inhibitors (SSRIs).
• Family members and friends can be helpful by validating the person’s distress without reinforcing compulsions (for example, avoid repeated reassurance that “you would never do that” in a way that becomes a ritual). Clinicians can teach loved ones how to respond supportively and effectively.

A hopeful note

Pain is part of being human — unavoidable at times — but suffering can be reduced. With the right treatment, people who experience intrusive self-harm thoughts can recover and live fulfilling, meaningful lives. Therapy can teach skills for tolerating distress, choosing where to focus attention, and reconnecting with values and joy even when pain is present.

“The joy we feel has little to do with the circumstances of our lives and everything to do with the focus of our lives.” — Russell M. Nelson

References

McCann, M. C., Bocksel, C. E., Goodman, W. K., & Storch, E. A. (2018, March). Obsessive compulsive disorder and suicidality: Understanding the risks. International OCD Foundation. https://iocdf.org/expert-opinions/obsessive-compulsive-disorder-and-suicidality-understanding-the-risks/

Chiles, J. A., Strosahl, K. D., & Roberts, L. W. (2019). Clinical manual for assessment and treatment of suicidal patients (2nd ed.). American Psychiatric Association Publishing.

By Annabella Hagen, LCSW

Photo by Manish Tulaskar on Unsplash