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ERP: How Exposure and Response Prevention Treats OCD · RECOVERable: Mental Health and Addiction Experts Answer Your Questions

• 0:13
  SPEAKER_01: OCD is a two-part problem.
• 0:15
  SPEAKER_01: We have the obsessions and the compulsions.
• 0:17
  SPEAKER_01: So exposure and response prevention is the two-part solution.
• 0:20
  SPEAKER_03: OCD specialist Jenna Overbaugh breaks down exposure and response prevention and how ERP helps break the anxiety cycle.
• 0:28
  SPEAKER_01: It's worthwhile to ask yourself what are the things that I do that if anxiety and fear weren't part of my life, that I probably wouldn't do.
• 0:39
  SPEAKER_03: Welcome to Recoverable.
• 0:40
  SPEAKER_03: I'm your host, Terry McGuire.
• 0:42
  SPEAKER_03: This podcast is brought to you by Recovery.com, the best place to find mental health and addiction treatment for anyone anywhere.
• 0:50
  SPEAKER_03: Find the right treatment for you or a loved one at recovery.com.
• 0:55
  SPEAKER_03: Imagine looking your deepest, most terrifying thought right in the eye and choosing to do nothing.
• 1:02
  SPEAKER_03: That's the heart of exposure and response prevention, or ERP, the gold standard therapy for obsessive compulsive disorder.
• 1:10
  SPEAKER_03: In today's episode, we are breaking down why leaning directly into uncertainty isn't just uncomfortable.
• 1:16
  SPEAKER_03: It's the path to taking your life back.
• 1:19
  SPEAKER_03: OCD expert Jenna Overbought joins us again to do a deep dive into the very therapy that she uses with both her clients and herself to deal with OCD.
• 1:28
  SPEAKER_03: Welcome back.
• 1:29
  SPEAKER_03: Thank you so much.
• 1:30
  SPEAKER_03: I'm so excited to have this.
• 1:31
  SPEAKER_03: And I want to know it seems like a very, very hopeful treatment.
• 1:36
  SPEAKER_01: It is.
• 1:36
  SPEAKER_01: And it's actually been part of my life for a very long time.
• 1:40
  SPEAKER_01: I was always an anxious kid.
• 1:42
  SPEAKER_01: And I always knew, as scary as it was to, for instance, raise my hand to answer a question in school or to sit with a new group of people in class.
• 1:50
  SPEAKER_01: I always knew challenging myself and to just do it was somehow better and easier than letting the anxiety fester.
• 1:56
  SPEAKER_01: And so I would raise my hand and I would sit with the scariest people.
• 2:00
  SPEAKER_01: And so when I found out that that was actually a treatment for OCD and anxiety, I was like, I have to do, I have to do this.
• 2:07
  SPEAKER_01: This is amazing.
• 2:08
  SPEAKER_01: I love it.
• 2:09
  SPEAKER_01: I see it be successful for people every single day.
• 2:11
  SPEAKER_01: And I know from a personal standpoint that it works.
• 2:13
  SPEAKER_03: When you say you see it being successful, you mean in your own therapy practice.
• 2:18
  SPEAKER_03: And what does successful mean?
• 2:19
  SPEAKER_01: Successful means to me that people are making choices to make their lives bigger.
• 2:24
  SPEAKER_01: And as a result, OCD gets smaller.
• 2:26
  SPEAKER_01: And so they don't necessarily just experience fewer intrusive thoughts or less anxiety right off the bat, although obviously that is a secondary goal.
• 2:34
  SPEAKER_01: What I see them doing is they are doing the things that they've reduced or stopped doing.
• 2:38
  SPEAKER_01: They're able to take better care of themselves.
• 2:40
  SPEAKER_01: If they've reduced or stopped hanging out with their family, they're doing that more.
• 2:44
  SPEAKER_01: They're watching movies, even though it used to make them scared to do so.
• 2:47
  SPEAKER_01: They're driving again and not letting anxiety metaphorically take the wheel.
• 2:51
  SPEAKER_01: So they're doing things more and more that they want to do and that they value, and they're not letting anxiety make all of their decisions.
• 2:58
  unknown: Excellent.
• 2:58
  SPEAKER_03: So we're going to start as we did last episode with a lightning round of myth or fact questions.
• 3:03
  SPEAKER_03: Myth or fact, Jenna.
• 3:04
  SPEAKER_03: ERP works by throwing patients directly into their worst-case scenario on day one.
• 3:09
  SPEAKER_01: That is a myth.
• 3:10
  SPEAKER_01: So while eventually we will gradually make exposures harder and harder in a way that's collaborative and, you know, we work together with the client to make that happen.
• 3:19
  SPEAKER_01: It's not the situation where we go right into the deep end right away.
• 3:22
  SPEAKER_01: And is that a fear of people when they think about getting treatment for OCD?
• 3:26
  SPEAKER_01: People absolutely mistakenly believe that by doing this work, they're going to have to start right away doing their absolute worst case scenario.
• 3:33
  SPEAKER_01: This work is all about engaging in your valued activities more, not necessarily just doing scary things for the sake of doing scary things.
• 3:40
  SPEAKER_03: Myth or fact, traditional talk therapy works just as effectively for OCD as ERP therapy does.
• 3:46
  SPEAKER_01: That is a myth.
• 3:47
  SPEAKER_01: So traditional talk therapy, while it might seem like it's helpful initially, it actually can be not helpful whatsoever and can in some situations actually be detrimental and contribute to the OCD cycle making it worse.
• 3:58
  SPEAKER_01: Is that because you're talking about what it is that you are fearing and that feeds it?
• 4:04
  SPEAKER_01: OCD really requires you to challenge your way out of the OCD cycle by changing your behaviors, not by talking about it.
• 4:11
  SPEAKER_01: And so oftentimes when you have OCD, you do just want to talk about it.
• 4:14
  SPEAKER_01: You want to understand it more.
• 4:16
  SPEAKER_01: You want to get to the root cause or kind of fantasize about the whys.
• 4:20
  SPEAKER_01: And it can really be avoidance.
• 4:22
  SPEAKER_01: It can be verbal rumination.
• 4:23
  SPEAKER_01: And in some instances, you might even do rituals with your therapists, like confessing your worst thoughts to them.
• 4:29
  SPEAKER_01: So what needs to happen is that there's some actionable change happening and you're reducing those compulsions over time.
• 4:35
  SPEAKER_03: Myth or fact, the ultimate goal of ERP or exposure response therapy is to stop intrusive thoughts from ever happening again.
• 4:41
  SPEAKER_01: That is a myth.
• 4:42
  SPEAKER_01: So while everybody probably wants that to be the goal, that wanting it to go away, that resisting the thoughts and wanting them to go away in the first place is actually kind of what has contributed to this problem in the first place.
• 4:54
  SPEAKER_01: So exposure and response prevention is really all about more of an acceptance mentality versus a get rid of mentality.
• 5:01
  SPEAKER_01: So we're going to work with the person on reducing their compulsions, reducing their avoidance, getting outside of their comfort zone.
• 5:07
  SPEAKER_01: As a result, hopefully their anxiety will come down, hopefully their intrusive thoughts will come down.
• 5:12
  SPEAKER_01: But this is much more about them getting into a place of acceptance versus get rid of.
• 5:16
  SPEAKER_03: Myth or fact.
• 5:18
  SPEAKER_03: OCD response prevention applies to invisible mental actions as much as it does to physical compulsions.
• 5:24
  SPEAKER_01: That is a fact.
• 5:25
  SPEAKER_01: So even though it feels like, oh my gosh, how could that possibly work?
• 5:28
  SPEAKER_01: A really good OCD and anxiety trained therapist who specializes in ERP will absolutely be able to do exposures with you and teach you and guide you as to how to resist even the unobservable mental compulsions.
• 5:40
  SPEAKER_03: Myth or fact.
• 5:41
  SPEAKER_03: ERP forces patients to engage in genuinely dangerous or unethical behaviors.
• 5:46
  SPEAKER_01: That is a myth.
• 5:47
  SPEAKER_01: So there should never be any forcing.
• 5:49
  SPEAKER_01: I always tell my clients, I don't want you to do anything that you don't want to do unless you know why you're doing it.
• 5:54
  SPEAKER_01: And it should never be this forceful situation.
• 5:56
  SPEAKER_01: It should be very much collaborative.
• 5:58
  SPEAKER_01: And we don't do the worst case scenario right off the bat if we ever get to it at all.
• 6:03
  SPEAKER_03: Myth or fact.
• 6:04
  SPEAKER_03: Modern ERP focuses more on learning to tolerate uncertainty than on waiting for anxiety to drop.
• 6:10
  SPEAKER_01: That is a fact.
• 6:11
  SPEAKER_01: So with ERP, we're all about getting the person to increase their tolerance for discomfort, getting them to increase their tolerance for uncertainty while living their life more and engaging in the compulsions less.
• 6:22
  SPEAKER_03: Myth or fact.
• 6:23
  SPEAKER_03: Daily homework outside of therapy sessions is essential for ERP to succeed.
• 6:28
  SPEAKER_01: That is a fact.
• 6:29
  SPEAKER_01: So research shows that upwards of 80% of your treatment gains are not going to happen in your therapy session.
• 6:34
  SPEAKER_01: They're going to happen from you actually implementing those skills outside of your treatment.
• 6:38
  SPEAKER_03: Sounds like physical therapy, right?
• 6:40
  SPEAKER_03: If you're not doing the exercises.
• 6:42
  SPEAKER_03: Exactly.
• 6:42
  SPEAKER_01: So your therapist is there to provide you those interventions, but you need repetition.
• 6:47
  SPEAKER_01: So if you think about it as though everything that you do is either a vote for OCD or a vote for your life, if you're only putting in a couple of votes in that your life bucket with your therapist, that's great.
• 6:58
  SPEAKER_01: But then if the rest of the six days of the week you're putting a ton of votes in the OCD box, OCD is still going to win.
• 7:04
  SPEAKER_01: And so it's really all about gaining more repetitions, just like you would at the gym.
• 7:08
  SPEAKER_01: You need repetitions, you need experienced learning.
• 7:10
  SPEAKER_01: And that comes from continuing to do the work even outside of therapy.
• 7:13
  SPEAKER_03: The votes is a great metaphor.
• 7:15
  SPEAKER_03: Myth or fact.
• 7:16
  SPEAKER_03: If a patient feels a spike of intense anxiety during an OCD therapy exposure, the exercise has failed.
• 7:24
  SPEAKER_01: That is a myth.
• 7:25
  SPEAKER_01: And so I could look at this a couple of different ways.
• 7:28
  SPEAKER_01: We need the person in order to do the exposure.
• 7:31
  SPEAKER_01: We expect, we want that person to feel more anxious.
• 7:34
  SPEAKER_01: Of course, sometimes they get more anxious than we'd like.
• 7:37
  SPEAKER_01: And they might get to say a 10 out of 10 anxiety, more anxiety than we had anticipated.
• 7:42
  SPEAKER_01: And if that happens, we try to just ride it.
• 7:44
  SPEAKER_01: We try to work with it in the moment, but that's never the intention.
• 7:47
  SPEAKER_03: And what are some of the things that you would do with a client to ride that out?
• 7:52
  SPEAKER_01: So if somebody were experiencing really heightened unexpected anxiety and we weren't planning on it, because again, the intention is never to do a 10 out of 10 exposure.
• 8:01
  SPEAKER_01: We usually aim for things that are much more challenging but still manageable.
• 8:04
  SPEAKER_01: But if that happens, because it often does, I'm not going to encourage them to right away go and do their compulsions.
• 8:10
  SPEAKER_01: That's just going to be very reinforcing.
• 8:12
  SPEAKER_01: It's going to, again, show that this is important, this is dangerous.
• 8:16
  SPEAKER_01: And so while they might not be able to resist the compulsion completely in that situation, what I would work with that person on is okay, can we postpone that compulsion?
• 8:25
  SPEAKER_01: I know you really want to go and call your doctor right now because you unexpectedly saw this mole that you really want to get reassurance about.
• 8:32
  SPEAKER_01: Instead of calling him right now, let's maybe can we wait for five minutes together?
• 8:37
  SPEAKER_01: Can we wait for two minutes together?
• 8:39
  SPEAKER_01: Instead of calling him right now, can we just postpone it a little bit?
• 8:43
  SPEAKER_01: There's also a scenario where we could reduce the compulsions.
• 8:46
  SPEAKER_01: So let's say somebody wanted to wash their hands for typically five minutes under really hot water with three pumps of soap.
• 8:53
  SPEAKER_01: We would maybe try to reduce that compulsion.
• 8:56
  SPEAKER_01: Is the person able to use one pump of soap instead of three?
• 8:59
  SPEAKER_01: Can they wash their hands for one minute instead of five?
• 9:02
  SPEAKER_01: So it's just all about finding ways to not give OCD exactly what it wants when it wants it.
• 9:07
  SPEAKER_03: Myth or fact.
• 9:08
  SPEAKER_03: ERP delivered virtually via telehealth can be just as effective as in-person therapy.
• 9:14
  SPEAKER_01: That is a fact.
• 9:15
  SPEAKER_01: So research shows that after COVID especially, we had to do a lot of our treatment sessions virtually.
• 9:21
  SPEAKER_01: And research has shown that it can be effective.
• 9:24
  SPEAKER_03: Good.
• 9:25
  SPEAKER_03: Okay, so the bigger questions now, and these are from the internet as an OCD therapist.
• 9:30
  SPEAKER_03: Tell us what ERP or exposure and response prevention therapy is.
• 9:35
  SPEAKER_01: So OCD is a two-part problem.
• 9:37
  SPEAKER_01: We have the obsessions and the compulsions.
• 9:39
  SPEAKER_01: So exposure and response prevention is the two-part solution.
• 9:42
  SPEAKER_01: We have exposures and then we have response prevention.
• 9:45
  SPEAKER_01: Exposures are where you are intentionally going outside of your comfort zone to do the scary thing.
• 9:50
  SPEAKER_01: That's really important because you need to have this continued experience of learning and teaching your brain again that, hey, this isn't as dangerous as I once thought.
• 10:00
  SPEAKER_01: This isn't as relevant or as important as I once thought.
• 10:02
  SPEAKER_01: So that's the exposure piece.
• 10:05
  SPEAKER_01: But then what's almost as important, if not more important, is the response prevention piece.
• 10:10
  SPEAKER_01: A lot of people forget about that.
• 10:11
  SPEAKER_01: So response prevention, otherwise known as ritual prevention, is basically not doing the rituals or the compulsions that you typically do to feel better about this trigger.
• 10:22
  SPEAKER_01: And so a really common example would be contamination.
• 10:25
  SPEAKER_01: If somebody would typically wash their hands after touching something dirty, we would expose them to touching something dirty.
• 10:31
  SPEAKER_01: And then they have to not wash their hands afterwards.
• 10:33
  SPEAKER_01: So if somebody were to just touch something dirty and then wash their hands right afterwards, that's not doing anything different.
• 10:39
  SPEAKER_01: Nothing has really changed.
• 10:40
  SPEAKER_01: That's what they've done all the time with OCD.
• 10:43
  SPEAKER_01: So ritual prevention is really okay, I'm going to do this anxiety-provoking thing and I'm not going to do my compulsions before, during, and after.
• 10:52
  SPEAKER_01: And that is really what allows you to have a different relationship to that trigger in the first place.
• 10:58
  SPEAKER_01: So whereas so many people do think that it's exposure therapy and I'm just doing scary things, the ritual prevention piece is actually the most important piece.
• 11:05
  SPEAKER_01: So that's again where you're going to actually show up differently when the trigger happens and you're giving your brain new learning.
• 11:11
  SPEAKER_01: You're giving your brain new messages.
• 11:13
  SPEAKER_03: In doing the research for these questions, ERP just didn't come up as often.
• 11:18
  SPEAKER_03: I mean, it's always exposure therapy.
• 11:20
  SPEAKER_03: Is that just shorthand or is that really missing the point?
• 11:24
  SPEAKER_01: I think sometimes it's a little bit of both, unfortunately.
• 11:27
  SPEAKER_01: I do think that sometimes it is shorthand.
• 11:29
  SPEAKER_01: And I think that it's detrimental to the space in general to continue saying that it's exposure therapy.
• 11:35
  SPEAKER_01: Because again, people who need these services, they get this idea that it is just doing exposures and that I do just go outside of my comfort zone.
• 11:42
  SPEAKER_01: I do just need to have conversations or take the freeway, but they don't realize, oh, I'm actually going to have to do something differently than I've always done.
• 11:51
  SPEAKER_01: So for instance, if somebody is really afraid of driving on the freeway, they're afraid of having panic attacks.
• 11:56
  SPEAKER_01: The exposure might be to drive on the freeway, but they're still doing their compulsions or safety behaviors of having their out of van or having their sour candies or having their essential oils with them.
• 12:08
  SPEAKER_01: They're still learning, okay, I can go on the freeway as long as I have my out of van.
• 12:13
  SPEAKER_01: I can go on the freeway as long as I have my sour gummies.
• 12:15
  SPEAKER_01: I don't want that.
• 12:16
  SPEAKER_01: I want somebody to know I can go on the highway without any of that stuff.
• 12:21
  SPEAKER_01: And so we will gradually work on reducing the reliance on those things.
• 12:25
  SPEAKER_01: And so if you aren't doing the response prevention piece and you're just doing exposures, you're just making yourself anxious and you're probably just doing your rituals right after, which is not going to be effective.
• 12:37
  SPEAKER_03: So that's a great example because I've never thought of sour candies or essential oils.
• 12:42
  SPEAKER_03: And I can imagine someone listening thinking, who cares?
• 12:45
  SPEAKER_03: Like, like those aren't going to harm anybody.
• 12:47
  SPEAKER_03: Why not have your candy and your oils?
• 12:50
  SPEAKER_01: And if it works for you to have those things, then that's great.
• 12:52
  SPEAKER_01: But chances are, and what I see a lot is that that reliance on these things, it snowballs.
• 12:58
  SPEAKER_01: And so it doesn't just start as having like a nice little calming essential oil in the car for anxiety-provoking situations.
• 13:04
  SPEAKER_01: It ends up being that I have to have these candies with me.
• 13:06
  SPEAKER_01: And then I have to have these medications, and then I have to have this, and then I have to have that.
• 13:11
  SPEAKER_01: And it's very insidious.
• 13:12
  SPEAKER_01: It doesn't happen all at once, but your tolerance for anxiety starts to decrease.
• 13:17
  SPEAKER_01: You start to attribute your success to the sour candies.
• 13:21
  SPEAKER_01: You start to attribute your success to the emotional support snacks and water bottle that you have, as opposed to, hey, I went on the freeway and I didn't even have my candies with me.
• 13:31
  SPEAKER_01: I went on the freeway and I didn't need any of that stuff with me.
• 13:34
  SPEAKER_01: So I always tell people if it's working for you, then that's great.
• 13:37
  SPEAKER_01: But if it's not working for you, or if you'd like to practice not being so reliant on these things, it might be worthwhile to get curious about could I maybe go on the freeway without having those things with me and how might that change your anxiety in the first place?
• 13:51
  SPEAKER_03: Thanks.
• 13:52
  SPEAKER_03: What do you ask and what do you not ask clients when you are doing OCD therapy?
• 13:59
  SPEAKER_01: So at first, I want to always know.
• 14:02
  SPEAKER_01: We want to talk about what their compulsions are because that's the bulk of the work.
• 14:05
  SPEAKER_01: Yes.
• 14:06
  SPEAKER_01: I am most interested in what are the things that I need to get them to reduce or stop doing.
• 14:11
  SPEAKER_01: So I'm really interested in getting them to understand that these are your compulsions.
• 14:15
  SPEAKER_01: This is gonna be us working on reducing these things.
• 14:18
  SPEAKER_01: So whether it is asking for reassurance, checking, avoiding, making things perfect or just right, mental compulsions like rumination, we need to have a really good solid understanding of what those compulsions are so that you cannot do them and not just do them automatically or on autopilot.
• 14:34
  SPEAKER_01: And then as far as the exposure piece, I'm generally asking them, you know, what would be the things on a day-to-day basis that OCD gets in the way of?
• 14:43
  SPEAKER_01: So start in the morning.
• 14:44
  SPEAKER_01: Start from the first thing that you experience when you wake up in the morning.
• 14:48
  SPEAKER_01: A lot of people experience intrusive thoughts before they even get out of bed.
• 14:51
  SPEAKER_01: They have intrusive thoughts of, oh my gosh, am I anxious right now?
• 14:54
  SPEAKER_01: I feel anxious right now.
• 14:55
  SPEAKER_01: What does that mean about me?
• 14:56
  SPEAKER_01: The rest of my day is going to be off.
• 14:58
  SPEAKER_01: And then suddenly they're scanning their entire body.
• 15:00
  SPEAKER_01: They're doing this almost mental health audit as opposed to just getting up and starting their day.
• 15:06
  SPEAKER_01: Uh, so I'll ask, you know, take me through your morning routine, you know, brushing your teeth, showering, getting ready for work.
• 15:12
  SPEAKER_01: You know, what does that look like with OCD?
• 15:14
  SPEAKER_01: What would it look like if you didn't have OCD?
• 15:16
  SPEAKER_01: If OCD wasn't part of the picture, what would your morning look like?
• 15:20
  SPEAKER_01: What would your work experience look like?
• 15:22
  SPEAKER_01: What would it look like when you're home from work?
• 15:23
  SPEAKER_01: What would your weekends look like?
• 15:25
  SPEAKER_01: And we start to get a really good picture of what their life looks like with OCD.
• 15:30
  SPEAKER_01: And then we get a really good picture of what their life would look like ideally if OCD weren't part of the picture.
• 15:35
  SPEAKER_01: And it's my job to help them bridge that gap.
• 15:37
  SPEAKER_01: And so if they are doing a lot of rituals with brushing their teeth, maybe they have religious OCD and they need to pray five times before they brush their teeth.
• 15:45
  SPEAKER_01: It's gonna be my job.
• 15:46
  SPEAKER_01: It might be an exposure, okay.
• 15:48
  SPEAKER_01: Let's try four times praying before they brush their teeth.
• 15:50
  SPEAKER_01: Let's try three times praying before they brush their teeth.
• 15:52
  SPEAKER_01: If they've always wanted to go to the movies with their children, but they're afraid of being alone with their kids because they're afraid of getting in a car accident with their kids.
• 16:01
  SPEAKER_01: That's gonna be an exposure idea that we come back to.
• 16:03
  SPEAKER_01: I might ask them, okay, how difficult would it be for you on a scale of zero to 10?
• 16:07
  SPEAKER_01: Zero being no anxiety, 10 being the most anxiety, how anxiety-provoking would it be for you to go to the movies with your friend, with your kids?
• 16:14
  SPEAKER_01: And that if that's a 10, we'll get there eventually.
• 16:17
  SPEAKER_01: We're not gonna start with that.
• 16:18
  SPEAKER_01: But then it's my job to help them break that down and make it more manageable.
• 16:22
  SPEAKER_01: So I'm thinking about how we can just bridge the gap between what their life is with OCD and what they would want it to be.
• 16:29
  SPEAKER_03: What percentage of the things you do to control your anxiety with OCD are you aware you're even doing?
• 16:38
  SPEAKER_03: Like when your earlier example with uh essential oils, for example, if I were talking to you and you said, you know, what are the things you do?
• 16:44
  SPEAKER_03: I might not even think to bring that up.
• 16:47
  SPEAKER_01: I don't know that there is necessarily a percentage, but I would say that for the most part, I work with a lot of people who have the same exact experience that you just had, which is, oh my gosh, I would have never thought of that as potentially a compulsion or potentially a safety behavior.
• 17:01
  SPEAKER_01: And again, I don't want anybody to be overly obsessive or, you know, overly critical about their behaviors.
• 17:06
  SPEAKER_01: This is all just about you being more functional.
• 17:08
  SPEAKER_01: This is about you being able to enjoy your life again.
• 17:11
  SPEAKER_01: And so if you're now becoming obsessive over all of your behaviors and you're trying to be perfectionistic about, oh my gosh, I have to make sure that I'm not doing any of these safety behaviors, that can become its own thing.
• 17:20
  SPEAKER_01: That's not ideal either.
• 17:22
  SPEAKER_01: But it's worthwhile to ask yourself, you know, what are the things that I do that if anxiety and fear weren't part of my life, that I probably wouldn't do?
• 17:31
  SPEAKER_01: Like, what are the things that I do?
• 17:33
  SPEAKER_01: What are the things that I avoid that if fear weren't part of the equation, probably would not be part of my life?
• 17:38
  SPEAKER_01: And if you want to address that, we can address that.
• 17:41
  SPEAKER_01: If you don't and it's working out fine for you, then by all means, keep doing it.
• 17:45
  SPEAKER_01: But it's worthwhile to get curious about.
• 17:47
  SPEAKER_03: Is fear the basis of most compulsions?
• 17:50
  SPEAKER_01: I would say that a lot of times it is fear driving a lot of compulsions, but a lot of times it's uncertainty.
• 17:55
  SPEAKER_01: So uncertainty as it relates to fear, potentially.
• 17:58
  SPEAKER_01: Um, so a lot of times people do have this fear of uncertainty, right?
• 18:02
  SPEAKER_01: This fear of I have to be 100% sure, or else I have to be sure that I'm not a bad person.
• 18:08
  SPEAKER_01: They want to be 100% sure that they're not gonna die, 100% sure that they're not gonna make some irreversible mistake.
• 18:13
  SPEAKER_01: They want to be 100% sure that they're not gonna suffer forever.
• 18:17
  SPEAKER_01: And it comes down to that 100% need for certainty.
• 18:20
  SPEAKER_01: But a lot of times people also with OCD struggle with this disgust.
• 18:24
  SPEAKER_01: They don't really relate to this concept of fear as much.
• 18:27
  SPEAKER_01: Like I'm not afraid to touch that.
• 18:29
  SPEAKER_01: I just find it absolutely disgusting.
• 18:31
  SPEAKER_01: Like I know that it's gross, I know that it's I'm not scared of it.
• 18:35
  SPEAKER_01: I know that it's gross.
• 18:36
  SPEAKER_01: And in that case, we're still working on a lot of the same things.
• 18:39
  SPEAKER_01: We're working on acceptance.
• 18:40
  SPEAKER_01: We're working on, okay, for instance, if you experience disgust with picking up your dog's poop, that's an objectively disgusting kind of experience.
• 18:49
  SPEAKER_01: Most people would say that that's not clean and that that's not ideal.
• 18:52
  SPEAKER_01: But if you have a dog and you value taking care of your dog, how do we work with that?
• 18:56
  SPEAKER_01: How do we get you to tolerate that feeling of disgust or fear or discomfort or uncertainty, whatever it might be?
• 19:03
  SPEAKER_01: How do we get you to tolerate these feelings of discomfort so that you can live a life that you love and value?
• 19:07
  SPEAKER_03: What does it feel like to sit with anxiety without doing your compulsion?
• 19:12
  SPEAKER_03: And what skills do you teach?
• 19:13
  SPEAKER_01: It often feels for people that they're doing something wrong.
• 19:16
  SPEAKER_01: It feels for people that they're missing something, especially in the beginning when they're just doing it.
• 19:21
  SPEAKER_01: It feels like they're missing something.
• 19:22
  SPEAKER_01: It feels like they're making a mistake.
• 19:24
  SPEAKER_01: I hear from people that, oh my gosh, it just feels so real.
• 19:27
  SPEAKER_01: It feels so real.
• 19:29
  SPEAKER_01: But this is very common when people have OCD and anxiety.
• 19:32
  SPEAKER_01: It's basically like a kid throwing a tempered hand drum.
• 19:35
  SPEAKER_01: And I try to do a lot of good education about this before we do exposures so people know what to expect.
• 19:40
  SPEAKER_01: So I give the example of my son.
• 19:42
  SPEAKER_01: If he were younger and I took him to Target, for instance, and every time we were there, we got him a toy.
• 19:48
  SPEAKER_01: He asked for a toy, and every single time we said yes, here's your toy.
• 19:51
  SPEAKER_01: And then all of a sudden, I just decided, for whatever reason, to no longer give him a toy.
• 19:56
  SPEAKER_01: We could go to Target and I would expect him to still ask for the toy.
• 20:00
  SPEAKER_01: Why wouldn't he?
• 20:01
  SPEAKER_01: But I'm going to all of a sudden say, no, buddy, we're not doing that today.
• 20:05
  SPEAKER_01: He's not going to just say, Okay, mom, no problem.
• 20:08
  SPEAKER_01: He's going to throw a fit.
• 20:10
  SPEAKER_01: He's going to be a little bit more convincing to start.
• 20:13
  SPEAKER_01: He's going to ask more repeatedly.
• 20:15
  SPEAKER_01: He's going to maybe even go and ask dad instead.
• 20:17
  SPEAKER_01: He's going to maybe throw a temper tantrum.
• 20:20
  SPEAKER_01: That's what we call an extinction burst.
• 20:22
  SPEAKER_01: And it's not even OCD specific.
• 20:24
  SPEAKER_01: It's just what we experience when we've typically no longer when we when we have typically reinforced a behavior and we withdraw that behavior, we typically see an increase in the unwanted behavior.
• 20:34
  SPEAKER_01: So it's like a temper tantrum.
• 20:36
  SPEAKER_01: I'm no longer reinforcing the toy.
• 20:38
  SPEAKER_01: And so he's having a temper tantrum to try to get the toy.
• 20:42
  SPEAKER_01: That's what our anxiety is doing.
• 20:44
  SPEAKER_01: You have been reinforcing your anxiety for so long by doing these compulsions.
• 20:49
  SPEAKER_01: You've been making it worse.
• 20:50
  SPEAKER_01: Now, when you are in therapy or hearing this podcast, and all of a sudden you're not doing your compulsions, your anxiety is going to have a little bit of a fit.
• 20:58
  SPEAKER_01: It's going to be like, hey, you've been telling me this whole time that this was important.
• 21:02
  SPEAKER_01: You've been telling me this whole time that this was dangerous.
• 21:05
  SPEAKER_01: What the heck?
• 21:05
  SPEAKER_01: My job is to keep you alive.
• 21:08
  SPEAKER_01: It's really important for people to know their brain exists to keep them alive, not to keep them happy or to keep them fulfilled.
• 21:15
  SPEAKER_01: Their brain exists to keep them alive.
• 21:17
  SPEAKER_01: And so when you've done these rituals and compulsions, thinking that it's dangerous and that it's do or die, and I have to do this, or else something bad is gonna happen.
• 21:25
  SPEAKER_01: Your brain gets the message that it's dangerous and that it's important and that you have to do these things.
• 21:30
  SPEAKER_01: So when you suddenly decide not to do the to do the compulsion, you're gonna be more anxious to start.
• 21:35
  SPEAKER_01: That's just gonna happen.
• 21:36
  SPEAKER_01: And so I educate people about that so that they know what to expect.
• 21:40
  SPEAKER_01: I educate them on the natural nature of emotion that as long as you let it ride, eventually it will come down on its own.
• 21:47
  SPEAKER_01: I talk to them about how it all ultimately kind of peaks and then it kind of decreases on its own without us having to do anything about it.
• 21:54
  SPEAKER_01: A lot of times people don't believe that because they don't believe, like Jenna, my anxiety never comes down.
• 22:00
  SPEAKER_01: My anxiety never goes away.
• 22:02
  SPEAKER_01: I would challenge that though, by getting curious about okay, have you ever really let it?
• 22:07
  SPEAKER_01: Or do you get so anxious about it peaking that you are just like, okay, here fine, here's the toy.
• 22:12
  SPEAKER_01: Do you Get so anxious about the kids' temper tantrum that you're just like, okay, you're fine.
• 22:16
  SPEAKER_01: Just like quit yelling, and here's the toy.
• 22:19
  SPEAKER_01: I I find that a lot of people do that instead.
• 22:22
  SPEAKER_01: So what we do when they are anxious, we just our goal is to not do our compulsions.
• 22:27
  SPEAKER_01: Our goal is to, okay, you're anxious right now.
• 22:29
  SPEAKER_01: Yep.
• 22:30
  SPEAKER_01: You're anxious right now.
• 22:31
  SPEAKER_01: A lot is uncertain.
• 22:33
  SPEAKER_01: It's kind of these non-engagement affirmations of like, yes, it is anxiety provoking.
• 22:39
  SPEAKER_01: Yes, I I don't know that.
• 22:41
  SPEAKER_01: It is uncertain.
• 22:42
  SPEAKER_01: And we don't engage with it.
• 22:44
  SPEAKER_01: We're not arguing with it.
• 22:45
  SPEAKER_01: We're just really letting it be there and letting time pass is really the most important skill, just letting time pass.
• 22:51
  SPEAKER_03: So that's the mental equivalent of picking the kid up off the floor during the tantrum and bringing them to the car.
• 22:56
  SPEAKER_03: It's just allowing yourself to de-escalate and get back.
• 23:01
  SPEAKER_01: And a lot of what exposure and response intervention is, it's one, letting yourself get the experience that this isn't as probable as I thought, two, that it's not as catastrophic as I thought.
• 23:11
  SPEAKER_01: And three, that I can handle it.
• 23:13
  SPEAKER_01: When you jump in and you're anxious and you do a compulsion, you violate all three of those things.
• 23:18
  SPEAKER_01: And so it's really just about keeping your eye on the prize.
• 23:21
  SPEAKER_01: The whole purpose of this is getting the learning that you don't need to do these compulsions in order for your anxiety to go away.
• 23:28
  SPEAKER_01: It's giving your brain the new experience that my anxiety can come and go.
• 23:32
  SPEAKER_01: I don't need to treat every intrusive experience as an emergency.
• 23:35
  SPEAKER_03: So it's easier for me to envision someone not the standard things you think of, not washing their hands, not whatever, whatever the compulsion is.
• 23:44
  SPEAKER_03: How do you deal with the mental compulsions?
• 23:47
  SPEAKER_03: Because how do you not have a thought?
• 23:49
  SPEAKER_01: So you're bringing up such a really great point, and it's a really big sticking point for so many people.
• 23:53
  SPEAKER_01: I do a lot of good education to start about the difference between a thought and thinking.
• 23:57
  SPEAKER_01: So a thought is something that pops up.
• 24:00
  SPEAKER_01: You can't help it.
• 24:01
  SPEAKER_01: It's something that just pops up.
• 24:02
  SPEAKER_01: It's like four plus four.
• 24:03
  SPEAKER_01: We just we don't have to do any analytical effort to figure that out.
• 24:06
  SPEAKER_01: Thinking, on the other hand, is more effortful.
• 24:08
  SPEAKER_01: And there's some analytical processes there.
• 24:11
  SPEAKER_01: It takes some mental capacity.
• 24:13
  SPEAKER_01: And so that would be the equivalent of like 587 plus 729.
• 24:17
  SPEAKER_01: It takes a little bit more effort.
• 24:19
  SPEAKER_01: We have to conjure up more of it.
• 24:20
  SPEAKER_01: A really good analogy that's used in our field is you can't necessarily help a bird landing on your head, but you can help whether it builds a nest.
• 24:28
  SPEAKER_01: And so that's the difference between a thought and thinking.
• 24:31
  SPEAKER_01: I really like to boil it down to the difference between a question and you answering that question.
• 24:37
  SPEAKER_01: So a lot of times when it comes to OCD in particular, it does come up in the form of a question.
• 24:42
  SPEAKER_01: What does that mean about me?
• 24:44
  SPEAKER_01: Is my son gonna die in school shooting today?
• 24:46
  SPEAKER_01: Did I hit that person with my car?
• 24:48
  SPEAKER_01: Am I in the wrong relationship?
• 24:49
  SPEAKER_01: Am I gonna go to heaven or hell?
• 24:51
  SPEAKER_01: Even if it comes up in the form of an uncomfortable sensation or feeling or image, there's usually a question afterwards, right?
• 24:58
  SPEAKER_01: There's usually a question of what does it mean about me?
• 25:00
  SPEAKER_01: When is that gonna go away?
• 25:02
  SPEAKER_01: It's a lot of questions.
• 25:04
  SPEAKER_01: I try to get my clients to understand and catch the question.
• 25:08
  SPEAKER_01: I always say, your only job is to not answer the question.
• 25:11
  SPEAKER_01: Just like I don't know the answer to 587 plus 729.
• 25:15
  SPEAKER_01: I didn't do anything to not answer that question.
• 25:17
  SPEAKER_01: I'm just here focusing on you right now.
• 25:20
  SPEAKER_01: I would, in order to answer that question, I would have to either significantly reduce my attention on you to allocate mental resources to that or tune you out completely.
• 25:28
  SPEAKER_01: And so I always tell people the things that we're worried about with OCD and anxiety, they're way more complicated than 587 plus 729.
• 25:36
  SPEAKER_01: They don't have answers oftentimes.
• 25:38
  SPEAKER_01: There's no end to it.
• 25:39
  SPEAKER_01: It's not like if we got more information than we'd feel better about it.
• 25:42
  SPEAKER_01: And so there's a lot of education that has to take place first.
• 25:45
  SPEAKER_01: I'm not interested, I don't need you to resist the thought popping up.
• 25:49
  SPEAKER_01: I want you to catch the question, and your only job is to not answer it.
• 25:52
  SPEAKER_01: So not answering the question is the response prevention when it comes to mental compulsions, just letting that question be there and not answer it.
• 26:00
  SPEAKER_01: And yes, it's going to feel irresponsible.
• 26:02
  SPEAKER_01: It will feel wrong, it'll feel like you're missing something, but that feeling doesn't necessarily mean that you're doing anything wrong.
• 26:08
  SPEAKER_01: It just means that you're doing something different.
• 26:09
  SPEAKER_01: And different is good.
• 26:10
  SPEAKER_01: We want different.
• 26:11
  SPEAKER_03: And when you do, in that example, you know, not think about it, how long is it before that peak starts to come down so that you have a bit of relief?
• 26:21
  SPEAKER_01: I mean, there's a lot of research that shows that emotions take 90 seconds to rise and fall.
• 26:26
  SPEAKER_01: I think it's different for everybody.
• 26:27
  SPEAKER_01: I can imagine that if you've been doing this, these compulsions for a really long time, it's going to maybe take a lot longer for your anxiety to come down.
• 26:34
  SPEAKER_01: I would really challenge people to consider the goal here, although it's what we want and I understand why people want it.
• 26:40
  SPEAKER_01: The goal isn't necessarily to have the anxiety come down.
• 26:43
  SPEAKER_01: There are two processes behind why exposure and response prevention works.
• 26:48
  SPEAKER_01: One of them is the habituation model.
• 26:50
  SPEAKER_01: Habituation means you basically get used to it.
• 26:52
  SPEAKER_01: The same way that we get used to a really cold pool, we eventually are in the cold pool and we get used to it.
• 26:58
  SPEAKER_01: We don't have to do anything to get used to the water, it just happens.
• 27:02
  SPEAKER_01: So we naturally habituate.
• 27:04
  SPEAKER_01: That was typically the model reigning over ERP and why it was so successful for the longest time.
• 27:09
  SPEAKER_01: And so we would look for people to get used to the anxiety.
• 27:12
  SPEAKER_01: We would look for them to get used to it.
• 27:15
  SPEAKER_01: But a lot of research has shown that a lot of treatment goals don't align with that.
• 27:20
  SPEAKER_01: People who don't necessarily experience that habituation or that decrease in anxiety, they still go on to leave to live really beautiful, fulfilling lives.
• 27:29
  SPEAKER_01: And so it's not really indicative of long-term recovery.
• 27:32
  SPEAKER_01: Instead, I really like coming back to what's called the inhibitory learning model.
• 27:36
  SPEAKER_01: So the inhibitory learning model really emphasizes that an exposure is successful when you've learned something new.
• 27:43
  SPEAKER_01: So a lot of times people will think, oh, an exposure was only helpful if my anxiety went down.
• 27:49
  SPEAKER_01: That's great.
• 27:50
  SPEAKER_01: And I love that for you, but it's really more about did you learn something different?
• 27:54
  SPEAKER_01: Did you learn that you didn't need to avoid the freeway and that you're still alive?
• 27:59
  SPEAKER_01: Did you learn that you didn't need to call your doctor right away, even though you really, really wanted to?
• 28:05
  SPEAKER_01: Did you learn something different?
• 28:06
  SPEAKER_01: That's the most important piece to me.
• 28:08
  SPEAKER_03: And does that learning give relief to someone?
• 28:12
  SPEAKER_03: Or do they think, I did it once?
• 28:14
  SPEAKER_03: I mean, what's the normal pattern of actually learning that long term?
• 28:18
  SPEAKER_01: It's actually really helpful.
• 28:19
  SPEAKER_01: Research has shown that after you do an exposure, it's helpful to kind of process it a little bit.
• 28:24
  SPEAKER_01: And so some of the worksheets that I give my clients after we do an exposure, we'll even have them rate, you know, how difficult do you anticipate this exposure to be?
• 28:32
  SPEAKER_01: Okay, well, after the fact, how difficult actually was it?
• 28:34
  SPEAKER_01: Uh, was there anything that you were surprised by?
• 28:36
  SPEAKER_01: Was there anything pleasant about the situation?
• 28:39
  SPEAKER_01: Was there anything that worked out differently in this situation?
• 28:42
  SPEAKER_01: And that processing can be so helpful in an ideal situation.
• 28:46
  SPEAKER_01: Obviously, we're looking for them to say things like, it was easier than I thought, and everything worked out, and I did great.
• 28:51
  SPEAKER_01: Um, but it's it's not always gonna work out their way that they want to.
• 28:57
  SPEAKER_01: So, a really good example is I worked with somebody who had really debilitating social anxiety.
• 29:01
  SPEAKER_01: And this was maybe 15 years ago before dating apps and social media.
• 29:05
  SPEAKER_01: And it was very typical for us to just like go and ask for someone's number.
• 29:09
  SPEAKER_01: I know that's not very typical right now, but if you can imagine, that was what happened back in the day.
• 29:14
  SPEAKER_01: And it was one of his treatment goals over time.
• 29:17
  SPEAKER_01: He wanted to eventually ask girls for their number.
• 29:20
  SPEAKER_01: He wanted to ask women for their numbers.
• 29:22
  SPEAKER_01: And so after working together for several weeks and several months, of course, it started off as like saying hi or shaking hands, but he really wanted to before he discharged, he wanted the experience of challenging himself to ask women for their numbers.
• 29:35
  SPEAKER_01: And so we're at the mall together.
• 29:36
  SPEAKER_01: And I remember he's going and he's initiating conversation.
• 29:39
  SPEAKER_01: He's doing a great job.
• 29:41
  SPEAKER_01: And he did get one or two women's numbers, but we were actually both so excited because he got rejected.
• 29:47
  SPEAKER_01: And that was, I have chills even thinking about it.
• 29:50
  SPEAKER_02: Sweet.
• 29:50
  SPEAKER_01: I have chills even thinking about it because I mean, that's what it's about.
• 29:54
  SPEAKER_01: It's not about just doing this work and okay, I got lucky.
• 29:57
  SPEAKER_01: Like, okay, I touched the thing and I didn't get sick, or okay, I went in the freeway and I didn't, you know, have a panic attack.
• 30:03
  SPEAKER_01: It's can you do the hard thing and can you grow your capacity even when it doesn't work out in your favor?
• 30:09
  SPEAKER_01: Like it was so much more meaningful for him to have gotten rejected and to know that he could handle that.
• 30:14
  SPEAKER_01: And like the world kept spinning.
• 30:16
  SPEAKER_01: The world didn't end.
• 30:17
  SPEAKER_01: He didn't combust into a pile of anxiety dust because he got rejected.
• 30:22
  SPEAKER_01: And so, how meaningful is that?
• 30:23
  SPEAKER_01: That he can handle it when it goes well and he can handle it when it doesn't go well.
• 30:27
  SPEAKER_01: That's the learning that we're looking for.
• 30:29
  SPEAKER_03: So, in the freeway example, it would not necessarily be I experienced no anxiety while I was driving, but I got there.
• 30:37
  SPEAKER_01: Exactly.
• 30:37
  SPEAKER_01: I was working with somebody who, let's just say, for instance, they really wanted to go um and go on the river walk.
• 30:44
  SPEAKER_01: They really wanted to practice being alone.
• 30:45
  SPEAKER_01: They they had a hard time being alone.
• 30:48
  SPEAKER_01: If their goal was, I really want to go for a walk by myself and not be anxious, I would say, that's actually not my goal for you.
• 30:55
  SPEAKER_01: My goal for you is to go for a walk and be anxious.
• 30:59
  SPEAKER_01: Learn that you can tolerate any emotional state that you're in and you keep doing it, right?
• 31:05
  SPEAKER_01: To me, that's just getting lucky.
• 31:07
  SPEAKER_01: If you just go for a walk on on the by yourself and you're just not anxious, that's great.
• 31:12
  SPEAKER_01: That's a that's you roll the dice and you got lucky.
• 31:15
  SPEAKER_01: I want to know can you tolerate discomfort?
• 31:17
  SPEAKER_01: Can you get better at handling anxiety when it happens?
• 31:20
  SPEAKER_01: This is all about tolerating discomfort.
• 31:22
  SPEAKER_01: And so if you do these exposures and you're just not anxious, I mean, that's great.
• 31:27
  SPEAKER_01: That's that's okay.
• 31:28
  SPEAKER_01: But I'm more interested in, okay, when it gets hard, how can you show up differently?
• 31:36
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• 31:40
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• 31:46
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• 31:50
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• 32:09
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• 32:15
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• 32:18
  SPEAKER_03: Does exposure and response prevention work for all types of OCD?
• 32:23
  SPEAKER_01: It does work for all types of OCD.
• 32:25
  SPEAKER_01: So as long as somebody is experiencing compulsions, which I'm assuming if they're this debilitated and they are experiencing distress and impairment in their day-to-day life, there's something there, even if it's avoidance.
• 32:35
  SPEAKER_01: I do work with sometimes people who say, I don't have any compulsions, I don't do anything, I don't ask for reassurance, but they avoid a lot.
• 32:42
  SPEAKER_01: And so that's kind of the sneaky compulsion of all of them is you probably don't need to do too much of your compulsions if you're just avoiding constantly.
• 32:50
  SPEAKER_01: And so it's breaking that avoidance pattern as well, getting them outside of their comfort zone.
• 32:55
  SPEAKER_01: Avoiding what?
• 32:56
  SPEAKER_01: Sometimes even just leaving their house.
• 32:58
  SPEAKER_01: So if someone is really afraid of social interactions, for instance, they might not say that they mentally replay conversations or that they, you know, avoid eye contact and conversation.
• 33:08
  SPEAKER_01: But if they just stay in their house all day and they avoid living and they avoid, you know, anything like that, then they probably don't say that they have too many compulsions because they're just living in a bubble.
• 33:20
  SPEAKER_03: Is ERP the same as exposure therapy or cognitive behavioral therapy?
• 33:24
  SPEAKER_01: So cognitive behavioral therapy is a very broad, generic umbrella term that basically says that the therapy or the therapist that you're working with agrees and understands that behaviors, emotions, and thoughts play off of each other.
• 33:38
  SPEAKER_01: And I think many of us would agree that that's basically true.
• 33:41
  SPEAKER_01: Um, and so underneath cognitive behavioral therapy, we have other more specific modalities.
• 33:46
  SPEAKER_01: One of them is exposure and response prevention, but another one is dialectical behavioral therapy, for instance.
• 33:51
  SPEAKER_01: And so, while exposure and response prevention is an evidence-based treatment for OCD, dialectical behavioral therapy is great for other conditions, but it's not evidence-based for OCD.
• 34:01
  SPEAKER_01: So it's really important when you are working with somebody who says that they do CBT, it's really important to ask, you know, what types of modalities do you mean by that?
• 34:09
  SPEAKER_01: It's just so vague.
• 34:10
  SPEAKER_01: It's like saying, I like the movies.
• 34:12
  SPEAKER_01: Well, what kind of movies, right?
• 34:14
  SPEAKER_01: Like, do you like comedies?
• 34:16
  SPEAKER_01: Do you like romance?
• 34:17
  SPEAKER_01: Do you like sci-fi?
• 34:18
  SPEAKER_01: What kinds?
• 34:19
  SPEAKER_01: We need to be more specific about that.
• 34:20
  SPEAKER_01: And so I would also be careful if somebody, especially a licensed clinician, is saying exposure therapy because they should know better.
• 34:28
  SPEAKER_01: They should know that it is exposure and response prevention just because how important the response prevention piece is, I would want them to be sure that they're not just using that term in a way that doesn't indicate that they know the difference.
• 34:41
  SPEAKER_01: They should absolutely be doing exposure and response prevention because that response prevention piece is so important.
• 34:46
  SPEAKER_03: Yeah, I get it.
• 34:47
  SPEAKER_03: But what does improvement mean with ERP therapy?
• 34:51
  SPEAKER_03: And is it a cure for OCD or a way to manage it?
• 34:54
  SPEAKER_01: When people ask about a cure, I really want to be careful that we are acknowledging the natural nature of these experiences.
• 35:01
  SPEAKER_01: So just as there's no cure for sadness, there's no cure for a cold or tummy issues, right?
• 35:09
  SPEAKER_01: We can't cure anxiety.
• 35:11
  SPEAKER_01: We can't cure intrusive thoughts.
• 35:13
  SPEAKER_01: What we can do is we can get way better at handling them when they come up.
• 35:16
  SPEAKER_01: And so I don't want people to get discouraged when people say, oh, there's no cure for OCD.
• 35:21
  SPEAKER_01: What I think they're saying is that there's no cure for anxiety.
• 35:24
  SPEAKER_01: There's no cure for intrusive thoughts.
• 35:26
  SPEAKER_01: And that's fine.
• 35:27
  SPEAKER_01: There's a difference between having anxiety and having intrusive thoughts and having OCD.
• 35:32
  SPEAKER_01: Having anxiety and having intrusive thoughts is a naturally occurring human experience.
• 35:36
  SPEAKER_01: We all experience those things from time to time.
• 35:38
  SPEAKER_01: Of course, when we're talking about OCD, it's very debilitating.
• 35:42
  SPEAKER_01: It takes up a lot more time, it's a lot more severe, it's a lot more frequent, it impacts your day-to-day functioning.
• 35:47
  SPEAKER_01: We can definitely get somebody from where they meet diagnostic criteria for OCD to where they no longer meet diagnostic criteria for OCD.
• 35:55
  SPEAKER_01: What that looks like is that they do experience anxiety and intrusive thoughts.
• 35:58
  SPEAKER_01: They might avoid every once in a while because we're human, but it's no longer debilitating.
• 36:03
  SPEAKER_01: It's no longer distressing.
• 36:04
  SPEAKER_01: It's no longer impacting their day-to-day functioning.
• 36:06
  SPEAKER_01: I forget the first person.
• 36:08
  SPEAKER_03: Is that where you are now in your own experience?
• 36:10
  SPEAKER_01: I would say that I no longer meet diagnostic criteria for obsessive-compulsive disorder.
• 36:15
  SPEAKER_01: I still experience intrusive thoughts.
• 36:17
  SPEAKER_01: I still experience anxiety.
• 36:19
  SPEAKER_01: Even on my way to the studio today, I, of course, had some intrusive thoughts of, you know, oh my gosh, is there going to be traffic?
• 36:25
  SPEAKER_01: I'm not used to doing traffic.
• 36:26
  SPEAKER_01: I live in a small town.
• 36:27
  SPEAKER_01: And so it's new for me.
• 36:28
  SPEAKER_01: It's novel.
• 36:29
  SPEAKER_01: And even just leaving my son, I had the intrusive thought, as a lot of parents do every once in a while.
• 36:35
  SPEAKER_01: You know, what if that's the last time that I kiss him?
• 36:37
  SPEAKER_01: What if something bad happens and I was working?
• 36:40
  SPEAKER_01: And, you know, what if something bad happens to my son while I'm gone or it's my last time seeing him because something bad happens to me.
• 36:46
  SPEAKER_01: And I sometimes have this urge to go and kiss him again or tell him again, like, I love you so much.
• 36:51
  SPEAKER_01: But that would be fear-based.
• 36:52
  SPEAKER_01: That wouldn't be really love-based.
• 36:54
  SPEAKER_01: I would be doing that out of fear and out of an OCD compulsion that I used to have.
• 36:57
  SPEAKER_01: And so I've been really good consistently at, okay, I can witness that that's not out of love, that's out of fear.
• 37:04
  SPEAKER_01: I'm not giving into that.
• 37:05
  SPEAKER_01: I know where that goes.
• 37:06
  SPEAKER_01: So I still have anxiety, I still have intrusive thoughts, but I do a really good job of consistently not giving into it as much as I possibly can.
• 37:14
  SPEAKER_03: The first part of that earlier question was what does improvement mean?
• 37:17
  SPEAKER_03: And I think you just answered it.
• 37:19
  SPEAKER_01: So improvement to me means that they're doing more in their day-to-day life.
• 37:22
  SPEAKER_01: It doesn't necessarily mean that right away their intrusive thoughts go down, although that would be icing on the cake.
• 37:27
  SPEAKER_01: Of course, I want that for people.
• 37:29
  SPEAKER_01: Of course, I want them to have fewer intrusive thoughts.
• 37:32
  SPEAKER_01: Of course, I want them to have fewer bouts of really debilitating anxiety.
• 37:36
  SPEAKER_01: That would be icing on the cake.
• 37:37
  SPEAKER_01: And we can get there.
• 37:38
  SPEAKER_01: I do believe that that's possible, possible for people.
• 37:41
  SPEAKER_01: At the same time, though, that's going to come as a natural byproduct of us living our life, of us giving our brains and giving our bodies the message that we're safe.
• 37:50
  SPEAKER_01: We give our brains and we give our bodies the message that we're safe by living.
• 37:53
  SPEAKER_01: We give our brains and our bodies the message that we're safe by feeling a certain way and continuing to do things anyway.
• 37:59
  SPEAKER_01: So feeling anxious and still driving, feeling anxious and still going and doing the things we need and love to do.
• 38:06
  SPEAKER_03: How long does ERP take before a client would experience significant improvement in relief?
• 38:12
  SPEAKER_01: I generally find that people experience relief from the first session just from experiencing this cycle in real time and they're no longer feeling like they're going crazy.
• 38:22
  SPEAKER_01: They no longer feel like they're the only one experiencing it.
• 38:25
  SPEAKER_01: There's something so healing and refreshing about seeing this as a cycle versus something that's happening to you.
• 38:32
  SPEAKER_01: This is something that we have some say over.
• 38:35
  SPEAKER_01: This is not just something that is happening to you.
• 38:37
  SPEAKER_01: This is something that you can definitely take control of.
• 38:40
  SPEAKER_01: It's like throwing logs into a fire by doing these compulsions, and you can definitely learn the skills to not put the logs on the fire anymore.
• 38:48
  SPEAKER_01: I would say that within the first couple of sessions, especially my focus in the first couple of sessions is education, getting them to understand what's going on.
• 38:57
  SPEAKER_01: I think that can of itself be so important and so refreshing and relieving.
• 39:02
  SPEAKER_01: But then we start to work on identifying the compulsions.
• 39:05
  SPEAKER_01: We work on identifying them, we work on reducing them.
• 39:08
  SPEAKER_01: That's going to be a little bit anxiety-provoking at first, but it's going to hopefully change already their experience with this anxiety, hopefully give them some of their time back, some of their day back.
• 39:18
  SPEAKER_01: And then once they've built that mental muscle of doing the response prevention a little bit, then we would jump into exposures.
• 39:24
  SPEAKER_01: And again, exposure should be collaborative.
• 39:27
  SPEAKER_01: This is not something where I'm like, I think this would be a good exposure for you.
• 39:30
  SPEAKER_01: I want you to go and give this a try tonight.
• 39:32
  SPEAKER_01: I would love to talk to people about, hey, here's what I'm thinking based on what you've been struggling with, based on what you want.
• 39:37
  SPEAKER_01: What are some good exposures that you think would be good for you to try?
• 39:40
  SPEAKER_01: And it should just be much more collaborative in that way.
• 39:43
  SPEAKER_01: So hopefully sooner rather than later, they should definitely be feeling some relief from the initial education of it all.
• 39:49
  SPEAKER_01: They should be feeling some relief from no longer having to do as many compulsions.
• 39:53
  SPEAKER_01: And hopefully, as we soon get into exposure work, they should start to be feeling some relief pretty soon.
• 39:58
  SPEAKER_03: That's really good news.
• 40:00
  SPEAKER_03: Is ERP therapy effective by itself, or does it need to happen in combination with meds or group therapy or that sort of thing?
• 40:08
  SPEAKER_01: They've actually done research to show that exposure and response prevention combined with medication, namely SSRIs, is the most effective for people who have OCD.
• 40:17
  SPEAKER_01: But they did really cool research to show that exposure therapy in and of itself, or rather exposure and response prevention therapy in and of itself isn't that much less effective than the combined of the therapy plus the medication.
• 40:31
  SPEAKER_01: And so while therapy plus medication does seem to be the most effective for the vast majority of individuals, just exposure and response prevention in and of itself is only a little bit less effective in terms of large-term scales, um, large in terms of long-term studies.
• 40:45
  SPEAKER_01: And so medications can be helpful, but I always tell people medications aren't going to run the race for you.
• 40:51
  SPEAKER_01: Medications aren't going to do the work.
• 40:53
  SPEAKER_01: It might get you to the starting line, but it's not going to do the race for you.
• 40:57
  SPEAKER_01: So you actually do need to do the work in terms of exposure and response prevention.
• 41:01
  SPEAKER_01: If somebody is not willing or able to take medications, that's really good news because they can do exposure and response prevention.
• 41:08
  SPEAKER_01: And for the most part, if they're doing it correctly with the right guidance, they can still experience a large benefit from it.
• 41:13
  SPEAKER_03: ERP as the gold standard for treating OCD as opposed to talk therapy.
• 41:18
  SPEAKER_03: And one of the things I kept reading was analyzing why you feel anxious gives your OCD exactly what it wants.
• 41:24
  SPEAKER_03: What does OCD want?
• 41:26
  SPEAKER_01: OCD wants your attention without you taking action to change it.
• 41:29
  SPEAKER_01: So OCD wants the spotlight on it.
• 41:32
  SPEAKER_01: OCD wants you to be engaging with it.
• 41:34
  SPEAKER_01: It's very much like a bully in that way.
• 41:36
  SPEAKER_01: It just wants your attention.
• 41:37
  SPEAKER_01: It doesn't matter if it's negative attention, it doesn't matter if it's positive attention or just you thinking and talking about it.
• 41:42
  SPEAKER_01: It wants your attention.
• 41:44
  SPEAKER_01: It wants to be front of mind.
• 41:45
  SPEAKER_01: What it absolutely does not want is for you to have this irreverence about it.
• 41:49
  SPEAKER_01: It doesn't want you to ignore it.
• 41:51
  SPEAKER_01: It doesn't want you to just let it be there.
• 41:53
  SPEAKER_01: That is the most frustrating thing to a bully.
• 41:55
  SPEAKER_01: And that is exactly what we need to do with OCD.
• 41:58
  SPEAKER_01: It doesn't mean that you're not scared of it.
• 41:59
  SPEAKER_01: It doesn't mean that you're not shaking in your boots a little bit the first time that you stand there and look at it right in the eye and don't give him your lunch money.
• 42:06
  SPEAKER_01: It means that you're just not going to contribute.
• 42:09
  SPEAKER_01: You're not going to give it attention that it wants.
• 42:11
  SPEAKER_01: And so that's often what we're looking for when we're doing ERP.
• 42:15
  SPEAKER_03: In ERP, when they talk about an anxiety ladder or a hierarchy, what is that and how does it help?
• 42:20
  SPEAKER_01: We work with individuals to come up with a fear hierarchy or an exposure hierarchy.
• 42:26
  SPEAKER_01: And so we're working with people about the things that they want to do, the things that they have a hard time with.
• 42:31
  SPEAKER_01: And we will, as the exposure therapist, we will work on a fear hierarchy for them.
• 42:36
  SPEAKER_01: And we work first on what are called a sud scale, so a subjective unit of distress scale.
• 42:41
  SPEAKER_01: Okay.
• 42:41
  SPEAKER_01: And you could do a zero to 10, you could do zero to 100.
• 42:44
  SPEAKER_01: It doesn't really matter.
• 42:45
  SPEAKER_01: But for simplicity's sake, I would always use zero to 10.
• 42:48
  SPEAKER_01: So zero is no anxiety whatsoever.
• 42:50
  SPEAKER_01: 10 would be the most anxiety that you could possibly imagine.
• 42:53
  SPEAKER_01: And it would be my job to, with the person's collaboration, come up with exposures that that person could do that are zeros, ones, twos, all the way through tens.
• 43:03
  SPEAKER_01: And we don't necessarily start with the zeros or the ones or the twos.
• 43:06
  SPEAKER_01: Chances are they're doing that stuff already.
• 43:08
  SPEAKER_01: It's not that anxiety provoking.
• 43:10
  SPEAKER_01: So we are trying to get things to be challenging but manageable.
• 43:14
  SPEAKER_01: And to me, that has always been a three or a four on that zero to 10 scale.
• 43:19
  SPEAKER_01: You have some urge to do your compulsion, but you feel like you can probably resist it.
• 43:23
  SPEAKER_01: You don't want to start too easy because it might just be a waste of time.
• 43:26
  SPEAKER_01: You don't want to start too difficult because you might get the person to do this anxiety-provoking thing.
• 43:31
  SPEAKER_01: They feel a 10 out of 10 anxiety, they freak out and they never want to do it again.
• 43:35
  SPEAKER_01: And it just backfires.
• 43:36
  SPEAKER_01: So challenging but manageable is really what we're aiming for.
• 43:40
  SPEAKER_01: So we come up with those lists of exposures, and ideally, we would do them together.
• 43:44
  SPEAKER_01: We would look at the three years or the fours.
• 43:46
  SPEAKER_01: And it's really important that they understand that they're going to do these exposures and not do their compulsions.
• 43:52
  SPEAKER_01: I try to be very, very clear and overly abundantly specific about that because I will work with people who say, oh yeah, I could do that as long as I could wash my hands after, or, oh yeah, I could do that as long as I could call my doctor or talk to my doctor about it at the next session.
• 44:08
  SPEAKER_01: That's not what we want.
• 44:09
  SPEAKER_01: I want you to be able to touch the thing and hypothetically not do any of your compulsions after.
• 44:13
  SPEAKER_01: So really important that they know that.
• 44:16
  SPEAKER_01: We start, we identify what exposure they want to try, we go and we do it together and we do it from there.
• 44:22
  SPEAKER_01: The cool thing is that these exposures, if they're done correctly, they generalize.
• 44:26
  SPEAKER_01: And so I, if done correctly, the person's never really doing a 10 out of 10 exposure.
• 44:32
  SPEAKER_01: By the time that you do some of the threes and some of the fours, they all kind of come down a peg because it should generalize.
• 44:38
  SPEAKER_01: And that is something that happens even with phobias.
• 44:40
  SPEAKER_01: If you're doing exposure work to spiders, you find that the person is less fearful of other fuzzy black things that are small or like black snakes, right?
• 44:51
  SPEAKER_01: Fear exposure kind of generalizes in that way, which is really nice.
• 44:54
  SPEAKER_01: And so by the time that they get to the sixes or the sevens, they've all kind of knocked themselves down a peg.
• 45:00
  SPEAKER_01: There is another way to go about exposure development where you kind of do it more randomly.
• 45:05
  SPEAKER_01: I like the exposure hierarchy because it's more predictable for people, especially if they're afraid or hesitant about this process.
• 45:12
  SPEAKER_01: You can kind of do it in a little bit more of a collaborative process.
• 45:15
  SPEAKER_01: Uh, but there is this other element to it, which is that exposures aren't really in real life predictable like that.
• 45:22
  SPEAKER_01: You know, I can't predict that there might have been a car accident on my way here.
• 45:26
  SPEAKER_01: I can't predict, you know, something really terrible happening at school for my son or something like that.
• 45:32
  SPEAKER_01: So sometimes people don't like the predictableness of the hierarchy.
• 45:36
  SPEAKER_01: And so you might actually, depending on what you want and what your therapist suggests for you, you could take a bunch of ideas for exposures and literally throw them into a hat and just pick them out randomly out of a hat.
• 45:45
  SPEAKER_01: It depends.
• 45:46
  SPEAKER_01: I'm a fan of both.
• 45:47
  SPEAKER_01: Try out whatever works best for you.
• 45:49
  SPEAKER_01: But there's there's so many bells and whistles here.
• 45:52
  SPEAKER_01: There's so many different ways to make it work for you.
• 45:55
  SPEAKER_03: Good to know.
• 45:56
  SPEAKER_03: Can you do ERP at home by yourself?
• 45:58
  SPEAKER_01: As much as I would love for people to be doing this work with a therapist, a licensed and trained specialist who gets it, I understand that that's not everybody's situation.
• 46:07
  SPEAKER_01: They don't have the finances for it, they don't have access to this kind of care.
• 46:11
  SPEAKER_01: And it's not like having OCD therapists at the ready is a situation that we're experiencing.
• 46:16
  SPEAKER_01: There's such a shortage of people who do this type of work.
• 46:18
  SPEAKER_01: And so while I would always recommend working with a therapist as much as possible who understands this work, of course, that's just not the case.
• 46:25
  SPEAKER_01: What somebody could do if that is absolutely not an option for them.
• 46:29
  SPEAKER_01: There are so many great books out there.
• 46:30
  SPEAKER_01: There are so many great educational resources like this out there.
• 46:33
  SPEAKER_01: I would want them to get curious about okay, what are the things that I've been avoiding?
• 46:39
  SPEAKER_01: What are the basic things that because of fear and anxiety, I've been avoiding?
• 46:43
  SPEAKER_01: And what small steps could I take towards that today?
• 46:46
  SPEAKER_01: It doesn't necessarily need to be this highly structured, highly formatted, highly curated exposure hierarchy.
• 46:53
  SPEAKER_01: That would be great.
• 46:54
  SPEAKER_01: And some people need that, but it can also be as simple as what do I avoid on a day-to-day basis?
• 47:00
  SPEAKER_01: What are the ways that OCD and anxiety gets in the way of my life that I don't want it in the way of my life anymore?
• 47:05
  SPEAKER_01: And how could you start to defy that a little bit?
• 47:08
  SPEAKER_01: How could you start to push yourself outside of your comfort zone, even just a little bit?
• 47:12
  SPEAKER_00: Mm-hmm.
• 47:13
  SPEAKER_03: What are the biggest mistakes that you see people make when they are doing self-directed ERP that keep OCD going?
• 47:20
  SPEAKER_01: One of the biggest mistakes that I see people make is that they do the exposure piece.
• 47:23
  SPEAKER_01: They challenge themselves to do the anxiety-provoking thing, but then they don't do the ritual prevention before, during, or after.
• 47:30
  SPEAKER_01: Another big piece that people miss is they might resist the obvious compulsions like, okay, I'm not going to ask for reassurance or I'm not going to check that stove or I'm not going to take pictures of my hair straightener to make sure that it's turned off, but they do all the mental compulsions.
• 47:47
  SPEAKER_01: So if somebody, for instance, is really having a hard time leaving their house because they have to make sure the stove's off and the sink is off and the hair straightener's off, okay, they're leaving and they didn't check and they didn't take pictures of everything to refer back to, but they're still reviewing it their entire drive to work.
• 48:02
  SPEAKER_01: And okay, did I really make sure that I turned that off?
• 48:05
  SPEAKER_01: And what did that look like?
• 48:06
  SPEAKER_01: And did I hear it turn off?
• 48:08
  SPEAKER_01: And I'm sure I'm fine.
• 48:09
  SPEAKER_01: I've never done it before.
• 48:11
  SPEAKER_01: I've never left it on before.
• 48:12
  SPEAKER_01: Everything is fine.
• 48:13
  SPEAKER_01: It's still a compulsion to be doing that.
• 48:15
  SPEAKER_01: And it's just as reinforcing as driving back home and checking it.
• 48:19
  SPEAKER_01: And so it's really important to do the anxiety-provoking thing, not answer the questions.
• 48:24
  SPEAKER_01: Maybe I did, maybe I didn't is a really big common go-to response for people that I would recommend.
• 48:30
  SPEAKER_01: Maybe, maybe not.
• 48:32
  SPEAKER_01: I don't know.
• 48:32
  SPEAKER_01: And I'm not going to try to figure it out.
• 48:34
  SPEAKER_01: Ultimately, letting some of that uncertainty be there is really, really important.
• 48:37
  SPEAKER_01: I think another really big mistake that I see people make is that they try to do their worst-case scenario, their 10 out of 10 exposure.
• 48:46
  SPEAKER_01: They think I'm afraid of flying, so I'm just going to book a flight.
• 48:49
  SPEAKER_01: It doesn't necessarily have to be that.
• 48:51
  SPEAKER_01: Let's say that somebody is really struggling with harm-intrusive thoughts or false memory OCD.
• 48:56
  SPEAKER_01: They really struggle with this concept that, oh my gosh, I might have done something really bad.
• 49:00
  SPEAKER_01: They might think that they have to do a 10 out of 10 level exposure.
• 49:03
  SPEAKER_01: They might think that they need to watch a Jeffrey Dahmer documentary and just go all in and watch it and just be all in it.
• 49:10
  SPEAKER_01: If that's a 10 out of 10 for them, they don't need to do that right off the bat.
• 49:13
  SPEAKER_01: They can start by, okay, instead of using plastic silverware to cut up your dinner at night, why don't you use like a real butter knife?
• 49:20
  SPEAKER_01: Why don't you use an actual sharp knife that's more functional?
• 49:23
  SPEAKER_01: What are some more manageable ways that you could do the things that you're avoiding?
• 49:28
  SPEAKER_01: You don't necessarily need to jump right to the 10 out of 10.
• 49:30
  SPEAKER_01: That's not what this work is about.
• 49:32
  SPEAKER_03: So, in that example, if they're using a butter knife, and I'm not really aware of why that would be so different than the plastic.
• 49:38
  SPEAKER_03: So they have to fill me in on that too.
• 49:40
  SPEAKER_03: But if they, if it really is too much, they went too far too fast, what do you recommend then?
• 49:46
  SPEAKER_01: If somebody went too far too fast with an exposure, my first go-to is okay, I don't want to do any rituals right off the bat.
• 49:53
  SPEAKER_01: Like let's just sit here, let's sit with it.
• 49:54
  SPEAKER_01: You're really anxious right now.
• 49:56
  SPEAKER_01: I'm not going to give you permission to just go all for it and give OCD exactly what it wants when it wants it.
• 50:01
  SPEAKER_01: That would be so reinforcing.
• 50:03
  SPEAKER_01: And so what we can do instead is okay, you're really anxious right now and I get it.
• 50:07
  SPEAKER_01: Instead of going and doing your ritual exactly the way that OCD wants it, as soon as OCD wants it, can we postpone it a little bit?
• 50:14
  SPEAKER_03: Got it.
• 50:15
  SPEAKER_01: Can we wait a minute?
• 50:16
  SPEAKER_01: Can we wait two minutes, three minutes, five minutes, whatever that is?
• 50:19
  SPEAKER_01: Can we just postpone it?
• 50:21
  SPEAKER_01: It's kind of like when you teach a dog to sit.
• 50:24
  SPEAKER_01: When he sits right away, you want to give him the bone right away.
• 50:27
  SPEAKER_01: You don't wait five minutes because it's the learning gets kind of messy.
• 50:31
  SPEAKER_01: And so when you do a compulsion right away, as soon as you get anxious, that's like giving a dog a bone as soon as he sits.
• 50:38
  SPEAKER_01: Okay.
• 50:38
  SPEAKER_01: It learns that learning really quickly.
• 50:40
  SPEAKER_01: And so what we want to do, an exposure and response prevention, we want to do the opposite of that.
• 50:44
  SPEAKER_01: We want the learning to get a little bit muddled.
• 50:46
  SPEAKER_01: And so we will feel that heightened anxiety as much as you want to do that compulsion right away.
• 50:52
  SPEAKER_01: Can you postpone it?
• 50:53
  SPEAKER_01: A minute, two minutes, three minutes.
• 50:55
  SPEAKER_01: Okay, let's say, like it's you've postponed it, you've let anxiety ride out a little bit, that's good.
• 51:01
  SPEAKER_01: Now instead of doing it exactly the way that OCD wants you to do it, can we reduce it somehow?
• 51:06
  SPEAKER_01: So let's say that you want to call your doctor right away.
• 51:09
  SPEAKER_01: Instead of calling your doctor right away, can you maybe send a message online, a non-urgent message online that you might have to wait a couple of days for?
• 51:17
  SPEAKER_01: Interesting.
• 51:17
  SPEAKER_01: You know, can in what ways can I actively not do what OCD and anxiety wants me to do?
• 51:23
  SPEAKER_01: That's a really good strategic question and attitude and mindset for people to get into.
• 51:28
  SPEAKER_01: How can I not give OCD exactly what it wants?
• 51:31
  SPEAKER_01: Because we're so used to doing exactly what it wants.
• 51:33
  SPEAKER_01: How can I do actually not what it wants?
• 51:36
  SPEAKER_01: How can I actively defy it a little bit?
• 51:38
  SPEAKER_01: How can I be a little bit defiant with it?
• 51:40
  SPEAKER_03: And what did the cutlery thing mean?
• 51:42
  SPEAKER_01: Somebody could have a hard time using cutlery, for instance, if they are struggling with harm-intrusive thoughts.
• 51:47
  SPEAKER_01: Maybe that, oh my gosh, a knife could mean that I could hurt myself or that I could hurt somebody else.
• 51:51
  SPEAKER_01: And so I've worked with so many people who actually will lock up all their knives, the scissors and everything in the garage or in the basement.
• 51:58
  SPEAKER_01: Okay.
• 51:58
  SPEAKER_01: And they'll literally cut steak with a plastic knife because they're afraid of using actual knives.
• 52:03
  SPEAKER_03: Okay.
• 52:03
  SPEAKER_03: Understood now.
• 52:04
  SPEAKER_03: What credentials or training should someone look for and what red flags that a therapist isn't actually doing ERP if they're interested in exploring this?
• 52:13
  SPEAKER_01: I would want to make sure that that therapist says that they have experience with exposure and response prevention.
• 52:18
  SPEAKER_01: That's really important.
• 52:19
  SPEAKER_01: Not just cognitive behavioral therapy, not just experience treating OCD, but I should have them mention, they should mention exposure and response prevention specifically.
• 52:28
  SPEAKER_01: So that would be really great.
• 52:30
  SPEAKER_01: Bonus if they say that they also use acceptance and commitment therapy.
• 52:34
  SPEAKER_01: That's another one that is a really good adjunct to exposure and response prevention.
• 52:38
  SPEAKER_01: That's all about learning to incorporate values into your life.
• 52:41
  SPEAKER_01: That's uh really about accepting discomfort, having a willingness to tolerate discomfort.
• 52:46
  SPEAKER_01: And you can imagine that they work really well together.
• 52:49
  SPEAKER_01: I would also want to know how long have they been treating obsessive-compulsive disorder?
• 52:53
  SPEAKER_01: Is this just something that they say that they treat and they've never actually treated it?
• 52:57
  SPEAKER_01: And so that would be something that I would want them to be aware of too.
• 53:01
  SPEAKER_01: You can ask your therapist, you know, what is your experience treating OCD?
• 53:04
  SPEAKER_01: If I were to tell you some of these scary, intrusive, kind of shameful thoughts that I have, how might you address that?
• 53:10
  SPEAKER_01: Because a lot of times people say that they treat OCD, but then someone comes in with a really shameful or taboo intrusive thought and they get really freaked out.
• 53:19
  SPEAKER_01: And they are like, wait, does that mean that you actually want to do that?
• 53:23
  SPEAKER_01: Should I call the cops?
• 53:24
  SPEAKER_01: I've worked with so many people who, in fact, their therapists have called the cops on them or who have filed reports on them because they relayed these unwanted intrusive thoughts that are very much OCD, but they didn't know that.
• 53:35
  SPEAKER_01: Um, and so some green flags, some signs that you're actually working with the right person would be that they're able to talk to you about exposure and response prevention.
• 53:44
  SPEAKER_01: They're able to talk to you about some unwanted or some more taboo and less frequently talked about subtypes or themes of OCD.
• 53:50
  SPEAKER_01: They're able to identify the importance of response prevention.
• 53:54
  SPEAKER_01: They're not just talking about exposures, they're talking to you about things like mental compulsions and rumination and avoidance and some of those more subtle things.
• 54:01
  SPEAKER_01: I would also want them to talk to you about what they see exposure work looking for you like in the long term.
• 54:08
  SPEAKER_01: So again, I don't want therapists to be doing this fear for the sake of fear type of exposures.
• 54:14
  SPEAKER_01: It should not be an episode of fear factor.
• 54:17
  SPEAKER_01: It should not be like licking a dumpster or touching the floor with your face or anything like that.
• 54:24
  SPEAKER_01: It's it's how do we get you to live your life again?
• 54:26
  SPEAKER_01: How do we get you to do things that 80 to 90% of the people around you are doing in a more normalized fashion without OCD being part of the equation?
• 54:33
  SPEAKER_03: Before we close this episode, I want to make sure you talk about a couple of the less common or less well-known compulsions because I don't want someone who's been listening thinking, oh, I must not have OCD because I didn't even mention it.
• 54:47
  SPEAKER_03: Yeah.
• 54:47
  SPEAKER_03: So what are some that we haven't talked about?
• 54:49
  SPEAKER_03: You said false memory, you said relationship.
• 54:52
  SPEAKER_01: So I also don't want anybody to say, oh my gosh, well, she didn't say this.
• 54:56
  SPEAKER_01: And so she she didn't mention this obsession.
• 54:58
  SPEAKER_01: So I must not have it.
• 54:59
  SPEAKER_01: OCD can latch onto anything.
• 55:01
  SPEAKER_01: It is truly only limited to your imagination.
• 55:03
  SPEAKER_01: And so you might find some comfort in typical OCD subtypes, or there are some lists out there that exist, but five years ago, we didn't know or talk much about relationship OCD.
• 55:15
  SPEAKER_01: Five or 10 years ago, we didn't talk much about false memory OCD or real event OCD.
• 55:20
  SPEAKER_01: This is only the result of people talking about it more on social media and being more open in their experiences.
• 55:28
  SPEAKER_01: I was just seeing the other day something about optimization OCD, this experience where people have OCD and they have to optimize everything and they're constantly obsessing and compulsing about how to optimize every little aspect of their life.
• 55:40
  SPEAKER_01: That could be a thing.
• 55:42
  SPEAKER_01: I don't like getting too into the subtypes because I think for that reason, people overly identify with them.
• 55:48
  SPEAKER_01: And then when they don't see themselves in it, they get really upset.
• 55:51
  SPEAKER_01: They think, okay, I must not have OCD.
• 55:53
  SPEAKER_01: So it's just really important that people understand OCD can latch on to anything.
• 55:58
  SPEAKER_01: It can latch on to absolutely anything.
• 56:00
  SPEAKER_01: This is more so about you becoming obsessive and compulsive and overly involved and overly controlling something that you can't control, shouldn't control, or just don't have to control.
• 56:11
  SPEAKER_01: Um, but some other commonly experienced subtypes that we perhaps didn't talk enough about, one of which is false memory OCD.
• 56:18
  SPEAKER_01: So this is an example of someone who experienced this whoosh of, oh my gosh, could I have done something that I don't remember?
• 56:26
  SPEAKER_01: Could I have been, you know, in this situation that I don't remember.
• 56:31
  SPEAKER_01: A lot of times people struggle with this, maybe if they've been drinking or if they have been using drugs or in some situation where they're not with it 100%.
• 56:39
  SPEAKER_01: I can speak from personal experience when I had my son back in 2018.
• 56:44
  SPEAKER_01: Anyone out there as a new parent knows that you are very tired and you don't sleep very much.
• 56:48
  SPEAKER_01: And it messes with your cognition so much.
• 56:51
  SPEAKER_01: One of my big issues at the time was am I so sleep deprived that I could have left him somewhere?
• 56:58
  SPEAKER_01: I was worried that I could be so sleep deprived that I could have forgot to leave him somewhere because I am naturally a very forgetful person.
• 57:05
  SPEAKER_01: I lose my phone all the time.
• 57:06
  SPEAKER_01: I lose my driver's license multiple times in a day.
• 57:09
  SPEAKER_01: I'm known for forgetting things.
• 57:11
  SPEAKER_01: And so when it came to my son, I would go to the park with him or go to the grocery store with him.
• 57:16
  SPEAKER_01: And I would think to myself, oh my gosh, am I so forgetful?
• 57:20
  SPEAKER_01: Am I so tired that I could have forgotten him?
• 57:22
  SPEAKER_01: And so I would actually have to look visually for him in the rearview mirror to make sure he was there.
• 57:28
  SPEAKER_01: And that was good for a little bit.
• 57:29
  SPEAKER_01: That helped for a little bit.
• 57:30
  SPEAKER_01: But as it does with OCD, it's just never enough.
• 57:33
  SPEAKER_01: It's always raising the stakes.
• 57:35
  SPEAKER_01: And so I needed to look at him in the rearview mirror to engage my eyesight.
• 57:38
  SPEAKER_01: But then I also needed to hear him because I was like, oh my gosh, am I so tired that I can't trust my visual senses, that I can't trust what I'm seeing.
• 57:47
  SPEAKER_01: And so I would have to talk to him and hear him.
• 57:49
  SPEAKER_01: That wasn't enough.
• 57:50
  SPEAKER_01: I had to reach back and touch him.
• 57:52
  SPEAKER_01: And it got so bad that eventually I was pulling over on the side of the highway to unbuckle him from his multi-point car seat and actually hold him in my arms to try to feel the weight of him because I felt like if I could do that, then I'd know for sure that I wasn't sleeping or that I wasn't disoriented in some fashion.
• 58:08
  SPEAKER_00: Wow.
• 58:08
  SPEAKER_01: And so it's this false memory that oh my gosh, could I have done something that I'm not aware of?
• 58:13
  SPEAKER_01: And that can be so debilitating for people.
• 58:15
  SPEAKER_01: There's also real event OCD, which is kind of the flip side, which is that something quote unquote bad or something egregious might have actually happened, a mistake might have been made.
• 58:25
  SPEAKER_01: It could be something as small as, you know, just offending someone or saying something, quote unquote, rude in conversation.
• 58:32
  SPEAKER_01: It could also be as egregious as actually breaking a law or bullying or something like that.
• 58:37
  SPEAKER_01: But the idea is that someone becomes so obsessive and so compulsive about this, they're not giving themselves compassion.
• 58:44
  SPEAKER_01: They're not actually problem solving through that.
• 58:47
  SPEAKER_01: They're not actually letting themselves off the hook or trying to accept it and move on.
• 58:50
  SPEAKER_01: They're just obsessing over it.
• 58:52
  SPEAKER_01: They're mulling it over, they're doing compulsions about it.
• 58:55
  SPEAKER_01: It's usually rooted in more of a moral obligation and kind of this responsibility.
• 58:59
  SPEAKER_01: I just need to know.
• 59:00
  SPEAKER_01: I just need to know that I'm not a good, that I'm a good person.
• 59:03
  SPEAKER_01: I need to know that I'm okay, that I didn't make a mistake.
• 59:05
  SPEAKER_01: There's relationship OCD where you can be obsessive and compulsive about your relationship.
• 59:10
  SPEAKER_01: You can be obsessive and compulsive about the person, just the person.
• 59:14
  SPEAKER_01: Uh, you can also be obsessive and compulsive about the relationship in general and the integrity of your relationship, or you can be obsessive and compulsive about both.
• 59:21
  SPEAKER_01: I'm a really big believer.
• 59:23
  SPEAKER_01: A lot of times people think that you could only have relationship OCD in a romantic sense.
• 59:28
  SPEAKER_01: I say, why not?
• 59:29
  SPEAKER_01: I say, why wouldn't you be able to be obsessive and compulsive about your relationship with your sister or with your child?
• 59:35
  SPEAKER_01: Or certainly become obsessive and compulsive about my relationship and the integrity of my relationship with my son.
• 59:41
  SPEAKER_01: I've become obsessive and compulsive about is he gonna want to have dinner with us when he's older?
• 59:46
  SPEAKER_01: Is he?
• 59:46
  SPEAKER_01: I remember one time he had one of those little Tamagotchis and one of those little gigapets.
• 59:51
  SPEAKER_01: Uh, for people who don't know, it's just this little little electronic toy where you take care of it.
• 59:56
  SPEAKER_01: And he was three or four, he got frustrated with it and he threw it across the room.
• 1:00:00
  SPEAKER_01: I was obsessing and compulsive.
• 1:00:01
  SPEAKER_01: Oh my gosh, is he gonna be a sociopath because he can't handle taking care of this thing?
• 1:00:06
  SPEAKER_01: And he threw it across the room.
• 1:00:07
  SPEAKER_01: Did I teach him that?
• 1:00:08
  SPEAKER_01: What's wrong with him?
• 1:00:10
  SPEAKER_01: It's really just these intrusive thoughts and these what ifs that are relentless and go nowhere.
• 1:00:16
  SPEAKER_01: And so I promise you, if I didn't say your exact situation, if I didn't say exactly your compulsion, but you still resonate with everything else, there's a place for you.
• 1:00:26
  SPEAKER_01: You are not alone.
• 1:00:27
  SPEAKER_01: This only is limited to your imagination.
• 1:00:29
  SPEAKER_03: Thank you for that.
• 1:00:30
  SPEAKER_03: Because I do think it's important to hear because if somebody's trying to figure out what is wrong and they don't hear something that they identify with, they can think, well, it's not that, but uh, you did a great job with that.
• 1:00:41
  SPEAKER_03: So if there is a single takeaway from this discussion about ERP today, what are you hoping it is?
• 1:00:47
  SPEAKER_01: Exposure and response prevention gets a bad rep.
• 1:00:50
  SPEAKER_01: And I really hope that people take away from this that it's not about doing their worst case scenario.
• 1:00:56
  SPEAKER_01: It's not about pushing them to do the 10 out of 10 level exposure.
• 1:00:59
  SPEAKER_01: It is about getting you to live your life again.
• 1:01:02
  SPEAKER_01: It can be, even dare I say, fun.
• 1:01:04
  SPEAKER_01: Some of the best exposure work that I've done with people is getting them to do art again because God told them that they couldn't enjoy anything.
• 1:01:12
  SPEAKER_01: And so it's actively having them get involved in art again, even though they feel really bad for experiencing joy.
• 1:01:19
  SPEAKER_01: So much of my work has been the fun exposures of, you know, wearing that really amazing t-shirt that you wanted to wear, even though it was the same year that your dad died, right?
• 1:01:29
  SPEAKER_01: Like you really love that shirt because it's associated with good memories, but it's emotionally contaminated because it's the same year that your dad, you got it the same year that your dad died.
• 1:01:38
  SPEAKER_01: And it's just about being able to do the small, medium, and big things in your life that you need and want to do again without anxiety driving the ship.
• 1:01:48
  SPEAKER_01: It's all about reconnecting with your values, reconnecting with what it is that you want to do, reconnecting with what it is that you need to do without fear running the show.
• 1:01:57
  SPEAKER_01: And so, as scary as it feels like it might be, a good exposure and response prevention therapist isn't gonna force you to do anything.
• 1:02:05
  SPEAKER_01: They're not gonna have any expectations that you do these crazy outlandish exposures.
• 1:02:10
  SPEAKER_01: They just wanna help you live your life again in a way that works for you and you guide the ship when it comes to exposure and response prevention so much more than you probably think.
• 1:02:18
  SPEAKER_03: Good.
• 1:02:19
  SPEAKER_03: Thank you.
• 1:02:19
  SPEAKER_03: I really appreciate that.
• 1:02:20
  SPEAKER_03: Jenna Overbach, you were wonderful.
• 1:02:22
  SPEAKER_01: Thank you so much.
• 1:02:23
  SPEAKER_03: I appreciate you sharing both your personal experience and your professional experience.
• 1:02:27
  SPEAKER_03: And we will be back again next week with another dive into a behavioral health topic.
• 1:02:31
  SPEAKER_03: Please join us.