ERP and ACT: evidence-Based Treatment for OCD and Anxiety

 

Transcript

ANNOUNCER:  This is Curious Incident, a podcast for special needs families, and your window into the world of special education. Special needs parenting can be challenging, and we want to make it easier by providing you with the resources you need to help your child. Step deep into the world of learning differently with your host, special education attorney Adam Dayan. 

ADAM:  I’m pleased to welcome our next guest on the Curious Incident podcast, Lisa Abbrecht. Lisa is a clinical psychologist and has her own private practice called New Orleans Anxiety and OCD LLC. She works with individuals who are struggling to cope with uncertainty, helping them to understand how they can respond more productively to fears of the unknown. She has a passion for OCD and anxiety work as well as learning about the underlying theories and implementation of therapy for OCD, including exposure therapy with response prevention, also known as ERP and components of acceptance and commitment therapy, also known as ACT, which we’ll talk more about. Lisa worked in health psychology at the Tulane Cancer Center and continued seeing individuals with OCD at the behavioral health clinic. She continues to work as an adjunct professor in the psychiatry department at Tulane, providing the OCD didactics for residents. Welcome Lisa. Thanks for having me. It’s great to have you here. You specialize exclusively in adults with OCD and anxiety disorders. What led you to focus your entire practice in this space? 

LISA:  When I was in graduate school, every year we had to do clinical training. We would do practicums, year-long practicums, and then we would see clients in our departmental clinic as well. For every client we saw we would be supervised. We would meet with someone an hour a week. I had the opportunity to join a specialty supervision group in exposure therapy. This was mainly for anxiety and OCD. I continued in that group second year, third year, fourth year, so all the way until the end. During this time, I asked my supervisor how to get more training in anxiety and OCD because there weren’t a lot of year-long practicums offered in that area. He recommended going to different conferences, and one he had recommended was the Anxiety Disorder Association of America conference. It’s now Anxiety and Depression Association of America. That conference had a big impact on me. I remember two specific sessions, one being on indecision and anxiety, and one being on OCD with Jonathan Grayson, who I’ll talk about later in an exercise I learned there. During the conference, I remember the indecision session in terms of just simple daily stuff we deal with. This is more a first-world problem example, but I remember him talking about someone planning a vacation, and they were going through all these what-if questions. Should I go to Rome? Should I go to Paris? What if it rains in Rome? Oh, no. But what if it’s nice here? Oh, no. But what if it snows here? You know, all that kind of stuff. And it just kind of resonated with me because it made me think I’m just even, although that’s obviously more of a privilege, but daily decisions that we deal with and the what-if questions that come up. And it made me wonder how people cope or be more intrigued about how people cope with uncertainty. 

ADAM:  Just interject. Do you associate the what-if questions with anxiety or OCD or both? 

LISA:  I would say both for sure. At that time, I remember that session really stood out to me on what-if questions around generalized anxiety and decision-making. I left there really thinking, how can I specialize in this? And the way it works in psychology and graduate school and getting your degrees, you, after graduate school, you do a year-long internship where you match somewhere. And you obviously need a certain number of clinical hours and you have a better chance of matching somewhere with more hours in that area. And so I didn’t, aside from doing this group for a few years, didn’t have any of those year-long hours and anxiety and OCD. So I had matched for my internship in health psychology, which I was very interested in. But I made sure to keep up my training and anxiety and OCD. As you had mentioned in the intro, I also worked in the behavioral health clinic in the psychiatry department. And that’s where I was able to continue seeing people dealing with OCD and anxiety and also continue doing a lot of that work also in the cancer center. And then I went as soon as I was able to open a private practice, I knew that that’s what I wanted to specialize in. 

ADAM:  Nice. So how did your early work in health and oncology shape the way you understand anxiety today? 

LISA:  So there’s definitely a lot of overlap between those areas, especially in terms of acceptance work. This comes up in oncology in all different stages. So whether someone’s about to receive a diagnosis or waiting to receive a diagnosis and did some testing, they’re deciding on treatment, whether waiting to find out what treatment they need or their in treatment or they’re, for example, doing chemo. They don’t know if it’s going to work, how it’s going to work, if adjustments will need to be made or their post treatment and they’re in remission, but then they’re worried about fears of recurrence. And so definitely a lot of acceptance work comes up around, you know, just anxiety provoking thoughts about their future and, you know, will this work or will this come back with my current work in anxiety and OCD, I definitely approach it. Primarily in terms of health, anxiety and working in oncology and health psychology is really, although there was some adjustment to illness work, of course, and supporting families. Most of the work is focused on health, anxiety and coping with uncertainties, predominantly what I saw when I was in that setting. And then as well as other medical settings, I had worked in just that fear of the unknown. And then also what if questions would come up a lot? So what if I never get better? What if this recurs so that you can see a theme there that cuts across generalized anxiety, health anxiety, OCD as well, all those what if questions that come up. Also a lot of what I’ll talk about in terms of safety behaviors. So for example, with breast cancer, someone might be worried about a fear of recurrence. So say they’re obviously in remission, they’re worried it’ll come back and they start to physically check themselves. But then they’re checking themselves daily. And so at that point, there’s this anxiety sensitivity where they can’t relate, they may actually feel more symptoms or sensations than they would otherwise if they were checking less frequently. And then at this point, they can’t really tell if it’s going to come up. And then they also get wrapped up in checking or reassurance seeking. And so we talk a lot about not knowing if your cancer will return, like let’s say it were to return in 10 years or 20 years. You want to have spent those 10, 20 years wrapped up in checking and worrying that the cancer will return. And so this applies to my work now where we talk a lot about quality of life and how you want to spend your time. 

ADAM:  I see a lot of parallels in what you’re saying between health, psychology and anxiety slash OCD. And it’s interesting because in the health scenario, there’s rationality to the fear in the sense that the person is or has been ill. And so they’ve experienced something really traumatic health wise. And so there’s that fear that it could come back. Whereas in my experience, both professionally and personally with OCD, there’s a lot of irrational fear. And we’ll talk more about this, but your person is finding themselves afraid of things that have no basis in reality. So that is one interesting distinction, I think. 

LISA:  I was just thinking that it brings up for me the idea of one might be more low probability. With OCD or some of the intrusive thoughts, there might be it’s not even necessarily that it’s irrational. It’s just it might be a low probability chance of that happening. So someone might think, oh, I just had an image of harming someone or, you know, I had a thought and if I don’t do X, Y or Z, it’s going to cause my fear to happen. And you know, that’s something we obviously can’t prove or we don’t know. On one hand, we’re not saying, oh, that will never happen. That will definitely never happen. Or I’ll definitely never do that. But we can definitely say or most likely say it’s a low probability chance. Whereas with cancer, you might have, you know, more statistics and whatnot to actually back up the chance that you your cancer could recur. 

ADAM:  Right. The irrationality is in the compulsions, the behaviors that some people come up with to address the underlying fear. 

LISA:  Right. Exactly. 

ADAM:  And the other thing I was thinking more to just flag it because I want to come back to it, what you said about if the thing that you’re worried about comes to fruition or if it doesn’t, do you want to look back and see that you spend all that time worrying about it, which affects your quality of life? And I think to have that as a goal of, no, I don’t want to spend that time worrying. I just want to have good quality of life. And if it happens, it happens. And if it doesn’t, it doesn’t, that’s a great goal. I want to discuss how does a person accomplish that? Right. So it’s a good idea to have in mind, but how do you actually go about executing that so you’re worrying less and having a better quality of life? 

LISA:  When I talk about acceptance work, I’m definitely going to talk more about how we get there and how you get to that point where I really just factor in the quality of life piece and value. So a quick summary would be to give you a little preview would be what we want to talk about first is the behaviors that someone is engaging in to try to cope with their worries and fears or the fear that the cancer will return. How is that negatively impacting them? So how is this affecting their time with their family? Are they not feeling present in their daily life, whether that be family work, just things that are important to them or people they want to spend time with because they’re just so wrapped up in the anxiety. And so that’s really like, what is the long term effect of the way they deal with the worry? Just some quick anxiety education and they use the word term safety behaviors before is someone worries about something like their cancer coming back and then they do something they engage in some behavior to try to deal with that worry. So those are those safety behaviors like checking, reassurance-seeking, going on Google, and that can be self-reassurance too. Like, oh no, here’s why it’s unlikely or here’s why it might happen. In the short term, those behaviors might bring some relief to the person, so they check and they feel maybe a little better. But those behaviors in the long run are keeping them wrapped up in the anxiety. So we really want to highlight how those behaviors are negatively impacting them and that they can see that this is affecting their quality of life and then those become their reasons to even change those behaviors so that we can really highlight those values and what’s important to them. Then once they start to change those behaviors and they go through exposure and do change those checking and reassurance-seeking safety behaviors, the anxiety is not eliminated. I mean, they’re probably always going to have those fears of recurrence. They learn that it’s almost not realistic to not have those fears and they learn over time that they can function and they can be happy and present in their life even with the fears of uncertainty. They just don’t feel so wrapped up in them. 

ADAM:  That’s a great summary. Thank you. 

ANNOUNCER:  If you like what you are hearing, please let us know by subscribing to the Curious Incident Podcast and letting other special needs parents know about it too. If you have thoughts, questions, comments, or would like to suggest ideas for a future episode, we’d love to hear it. So email your feedback to podcast@dayanlawfirm.com. 

ADAM:  Many of the people you work with come in with a blend of health anxiety, social anxiety, generalized anxiety, and OCD. How do you help someone begin untangling those threads so treatment can move forward? 

LISA:  First, when people contact me, it’s usually via email. What often happens is someone will say, hi, I’m looking for treatment for OCD or for social anxiety or health anxiety. And whether via email or via phone, as we’ll generally do a phone screen if I have availability, that’s the next step is I’ll say I need to hear more about what you mean when you say OCD and what does that look like for you or what does social anxiety look like. So basically first, I want to get a really good understanding of all the different anxiety that they’re experiencing. Part of that can be done in a phone screen. But then when we, in the phone screen, it’s to determine fit as well to some extent. And then obviously we can better determine that in person. And then once we start meeting, we really go through all the different areas of anxiety, including OCD that they’re experiencing. And I will say people are, I don’t necessarily rely on this, but pretty good about bringing up different areas of anxiety. And so they might contact me for OCD. And then pretty quickly, for example, in the first session, they’ll bring up, oh, I also deal with social anxiety. I worry that I’m offending people or I send texts to apologize to people or I review situations. So this does come up naturally, but I certainly make a point to go through all any different area of anxiety. 

ADAM:  Social anxiety is fascinating to me. 

LISA:  Yeah, I would say most people I see end up bringing up some aspect of social anxiety. And I really feel like a lot of people deal with that. 

ADAM:  Do you want to go a little deeper with it, talk about how it can affect the person day to day? 

LISA:  I would say, especially nowadays, because I hear this a lot, I mentioned text messages. I mean, obviously conversations, but I will say people are constantly telling me they’re worried they upset someone or someone’s mad at them. And a lot of this is just even reading into the lack of emotion and tone that can come through text messages. So they’re worried someone’s upset with them or they offended them. And that person responding to them doesn’t use exclamation marks or just anything that would or send an emoji or smiley face that would really dictate to the person how they’re feeling and then the person on the receiving end takes that as a conclusion of their fears, basically. But it can come up in day to day conversation and then reviewing someone’s affect because you’re trying to determine, are they upset with me? Did I offend them? Do they think I’m unintelligent? And then it can take it a step further where people often deal with that by apologizing to the person or, you know, and then usually the friends will say, what are you talking about? You know, so you take it a step further and say, how does that usually work for you? So with social anxiety, and I know moving into the treatment aspect, but we can talk more about this not really functional to basically the best thing is to learn to deal with the not knowing and the uncertainty because it’s not really functional on a day to day to constantly be apologizing to people or asking if they’re upset with them for that reassurance. 

ADAM:  And when we were talking about acceptance work earlier, did you mean accepting the uncertainty or were you referring to something different? 

LISA:  Definitely accepting the uncertainty. So in terms of social anxiety, when someone has a fear of offending someone or just worrying what the person thinks about them or did I seem unapproachable to that person, the reality is even if we ask someone, we can never really know what they’re thinking. So we can’t guarantee that their answer is the answer that we want or is the truth. It’s just we can’t really know what someone’s thinking. So it’s definitely uncertainty based that you can’t have that answer. And then also, yes, we link together the different disorders is that basically the treatment is the same for all these diagnoses. And I personally don’t really in the way I was trained is it’s not as much about focusing on what diagnosis did I have, although I understand that can give some people comfort to know oh, I diagnosed with OCD or social anxiety. But I feel like people can often get stuck on those labels too. So for me, it’s really more about what are they experiencing? So what behaviors, what types of worries are they having and what behaviors are they engaging in to try to cope with the worries? But really, the treatment is very similar for all of these different diagnoses and they’re all about uncertainty no matter which one it is. 

ADAM:  Okay. So let’s talk about treatment for listeners who may be new to OCD treatment. Can you explain ERP exposure and response prevention and acceptance work, which we’ve talked a little bit about and how the two work together in treating OCD and anxiety? 

LISA:  ERP is really based in behavioral therapy. It’s really based in what we call learning theory. Basically what this involves is understanding someone’s history and in context. So in the context of the environment and how behaviors get maintained, it involves conditioning and reinforcement. So how people respond to certain triggers and stimuli and over time again, how that becomes maintained. So in terms of anxiety and ERP and ACT, we really talk about what I first like to do is I always give someone, I start treatment with anxiety education and that’s really talking about how behaviors get maintained. I reference this how just a quick review is in the short term, someone feels anxious about something and engages in a behavior to try to reduce their anxiety, whether that’s get an answer or try to prevent something, they think it’s preventing something from happening and they realize we talk about how in the long run, that’s really not working for them for various reasons. Included in that education, we also talk about stuff like safety behavior. So a lot of those behaviors people engage in are reassurance seeking and that could be with yourself, things you say to yourself, asking other people, looking online, checking, so that could be checking yourself for something, checking physically checking something like a door, mental internal review, avoidance and escape are big ones as well. If I remove myself from this situation, then I have to get out of here, it’s too crowded, that kind of thing. Or I’m not even going to go do that altogether because then I won’t even need to do that and now I don’t even need to deal with the anxiety. And then behind this is those, I’m sure you remember, back in school, those fight or flight reactions that we’ve all learned about. So your body reacts to various triggers and stimuli as potential danger signals. So these behaviors are adaptive for us. So we’re taught fear certain things. So it’s actually adaptive to fear a tiger or a lion. So you see the lion or tiger and you have this reaction to productively get out of there, right? Or a bear. And although some people say you’re not supposed to run from bears, but nonetheless, you have this productive reaction in response to get yourself out of there because that is actually dangerous. And then there’s fears that we pay for. We pay to ride roller coasters, to watch horror films. We actually want to be afraid in these situations. But then there’s the situations in terms of anxiety and OCD and intrusive thoughts where I mentioned maybe that first time that person has that harm intrusive thought, what if I stabbed someone in my family? What if I stabbed my child? And obviously that is alarming to them. Now someone might have that thought and think, oh, that was odd and go about their day. Someone else might have that thought and it might, they then respond with danger and they are reactive to it. And then they start to respond by avoiding knives or avoiding cooking. And this is something that they were doing before for their family. And so you can obviously see that effect over time. But basically what happens is the person is responding to the danger and these alarm bells go off. This is dangerous. I can’t have this happen. And then that leads to this maintenance over time. And the person starts to listen to their thoughts on, I can prevent this. No, I can’t have that happen. So the exposure involves slowly exposing yourself to what you fear. And the response prevention is key. So it’s not just exposure therapy, but it’s exposure therapy with response prevention for a reason. What that means is when you’re doing exposure therapy, it’s imperative that you actually don’t engage in those safety behaviors I mentioned, such as checking. 

ADAM:  And the longer the safety behaviors have been going on, the harder the ERP exercise is going to be. If a person has been avoiding knives for three decades, it’s going to be a lot of work for them to undo that, correct? 

LISA:  Oh, definitely. I will also say the longer it’s been going on, that’s one side. I’ll also say sometimes with people where it’s a newer diagnosis or newer experience of OCD, it’s not necessarily hard in the same way because they haven’t developed all those behaviors yet, but they’re not, for lack of a better term, used to having OCD. So there’s this hump that they have to get over, I’ll call it where they need to get used to the fact that this is even happening to them. Or even having these bothersome thoughts altogether. 

ADAM:  I’ve never heard it put that way before. Can you say a little more? 

LISA:  I’ve obviously noticed this over time in working with people. And I’d say actually this happens a lot. And I can even think back in the last year, probably most people that I’ve been working with where people come in and they developed OCD at a later age. So meaning they just haven’t been experiencing it since childhood or they were a teen. So maybe they’re in their 30s, for example. And everything was going fine for them as they feel. And then they started developing these intrusive thoughts. So it could be about self-harm, a word that they’re going to harm themselves, a word that they’re going to harm someone else. It could be dwelling on things that they’ve done. It could be obviously a number of things. And obviously they’re probably engaging in behaviors to try to prevent those fears from happening like those safety behaviors like we were talking about. And you just asked about, but they’re also stuck on the fact that they’re even having these thoughts. So what will happen a lot is people will say, I was going about my day and I was having a great day or a great time with my family. And then the thoughts showed up. And they just can’t get past the fact that these thoughts are showing up at all. And thinking, well, maybe I can get there’s something I can do in anxiety, OCD treatment that will get me back to a time where basically before OCD started. 

ADAM:  Which is inaccurate, right? The point of treatment is to help the individual tolerate those intrusive thoughts or anxieties. 

LISA:  Definitely. And it’s also working towards acceptance of the fact that this is happening. Is that this is part of your life now that you are having these thoughts. We can’t control what thoughts come into our mind. And as you said, it’s unrealistic to go back to the time before these thoughts were showing up and you’ll continue to suffer with it if we look at it. 

ANNOUNCER:  If you like what you are hearing, please let us know by subscribing to our podcast and letting others know about it too. If you have thoughts, questions, comments or would like to suggest ideas for a future episode, we’d love to hear it. So email your feedback to podcast@dayanlawfirm.com. 

LISA:  In terms of ACT, so ACT has various components to it. ACT stands for acceptance and commitment therapy. And ACT is a therapy that can obviously be done on its own, but I really use components of ACT to enhance the exposure work. And actually when I was in graduate school, I did my dissertation specifically on using ACT to enhance exposure work for intolerance of uncertainty. So I’ve always been very interested in this. So I’ll give a little summary. So one of the components of ACT is willingness. And we’ll talk about this in terms of readiness for treatment too. But basically someone needs to be fully committed to doing exposure work. So we talk a lot about, as I mentioned, how are these behaviors negatively impacting me and what’s the cost to them? And why would I be willing to even do this exposure work? So why would I be willing to stand next to a knife in the kitchen near my child? Why would I be willing to not check the door and have the discomfort that comes with that? So that response prevention. 

ADAM:  It sounds like that piece comes back to values. 

LISA:  Definitely. So that’s my next thing is values. So we talk certainly about values in terms of what is important to someone. And so oftentimes people will say something like, well, my family, my love for my family is my main value. And we talk about, well, okay, how are you, are you involving your family in your rituals? Are you asking them constantly for reassurance? And so skip to the end is the answers. Yes, the person is very much involving their family and their rituals or just the behaviors the person is engaging in are affecting their time with their family. And so I’ll highlight that discrepancy. Like, will you say you really value and love your family the most? But actually this is all really negatively impacting them and that doesn’t match. So we absolutely talk about that as a part of treatment and willingness and readiness to engage in treatment. 

ADAM:  Can you put yourself in the shoes of the patient? What is that moment like for them where their values come in conflict? They think that they’re prioritizing their family and hopefully through therapy realizing that the OCD or the anxiety or the safety behaviors are butting heads with positive quality time with family. And then, you know, what is it like for them when they have that realization? Or do they have that realization? 

LISA:  I will say most people do. I really feel like we can’t move on. They’re not really ready for treatment unless they do. So some people will react somewhat defensively in terms of what do you mean? Of course, I love my family. As if, you know, we’re saying you don’t love your family. But I will kind of harshly, you know, although there’s empathizing harshly pointed out in the sense of like, but this really isn’t aligning. So if you, if this is really, it’s not about do you love your family or not necessarily, but it’s about if this is really what’s important to you, let’s really look at the effects of your behavior. So then we’ll go through these various examples so they can realize, oh, wow, this is really affecting them that I’m calling them all the time where I’m making them return back to the house. I’m going to check something or I’m asking them, I’m constantly asking them for reassurance, whether that’s in person or via phone or maybe they’ll ask their family members, maybe they haven’t even asked them before and they’ll be surprised by their answer of how it’s affecting them as well. And I should note that oftentimes I end up giving family education as well about these accommodating behaviors. So family accommodation is a thing and OCD, whereas sometimes the family doesn’t even realize that they’re contributing to the problem as well. 

ADAM:  I just think it’s really interesting, you know, people having that compulsion of I have to do these things. My family is the most important thing to me, but I have to do these things and then they’re my number one. And that moment when you realize, wait a second, all this stuff that I feel I have to do is getting in the way of what really matters to me. 

LISA:  Definitely. And something I was going to talk about with ACT is this language component. There’s this getting stuck on the language and that getting reinforced. And what I mean by that is the person will have the thought, literally, I have to do this. I can’t go to sleep until I won’t be able to sleep unless I do this or I can’t leave the house until I do this. People say those have to need to can’t wording to me all the time. And that terminology and what I say, I really empathize with that is like, I believe you in that it truly feels that you have to do these things. And so I really, it’s important to me not to dismiss that, but at the same time to highlight. I know it feels like you have to do that, but physically you actually don’t have to. We talk about this with depression and the main treatment for depression is behavioral activation. So someone might say, I can’t shower. I can’t get out of bed. And so again, I empathize with I know it really feels that way that you can’t get out of bed, but the more you listen to those thoughts and don’t get out of bed and don’t make yourself shower or commit to doing that, the more that gets reinforced, that belief that I can’t do that. So with exposure work, what’s really important is committing. So this is where the willingness comes in and the understanding of language. We only do things in exposure that someone’s committed to doing and not something that they’re going to try to do because the problem is they’ll try it and they’ll say, no, no, that’s too hard for me. And then they’ll reinforce the belief that they can’t do that. The language component of act is huge. People get very stuck on listening to their thoughts as we just talked about. And then there’s also the making meaning out of their thoughts. So they’ll get stuck on this means something that I had that thought and then they’ll base their behavior and their responses off of that meaning. 

ADAM:  Something about their character, you mean? 

LISA:  Yeah. So it could be this means something about my character that I had that thought. So there’s this also thought action fusion in OCD. So having the thought is basically to them just as bad as having acted on the thought. And so that then means something about their character. Or it could just be the reading into the distressing thoughts they’re having. And then they’re then, oh, I can’t have that happen. And then they’re then engaging in those behaviors that keep them stuck because they’re thinking they’re preventing something from happening. 

ADAM:  Yeah. I think challenging that idea of I can’t enjoy the time with the people I’m with if these thoughts are interfering. It’s too distracting. It it it taints the experience. Stitching back against that and reminding yourself that both can be true. The thoughts can be there and you can enjoy the time with the people you’re with. Definitely. So we’ve emphasized that an individual needs to be ready before starting ERP or act work. What does it look like when someone is ready for treatment, particularly when their compulsions are internal and may not be apparent to an outside observer? 

LISA:  First, I want to say, I’ll mention, I know we’re going to talk a bit about the conference, but I’ve been fortunate to be unofficially mentored by Jonathan Grayson, who I love 

ADAM:  Jonathan Grayson. 

LISA:  He’s the best. 

ADAM:  He was a highlight of that conference. 

LISA:  Absolutely. I will say he got me hooked hooked as well early on. And I look forward to that every year. I would say, especially because of him. I call him the uncertainty guru. I don’t know if he knows that, but I do call him that. And he has these exposure and response prevention ERP motivator sheets. What he does is he talks through, he has talking points and these are categories of the way that you handle your worries, OCD or anxiety. How are these negatively impacting you and basically what are the costs to your behavior? So we need to go through these. So the person is really clear that there’s a negative impact on them and they have strong reasons to want to change these behaviors and do exposure. So some examples of the categories he uses are lost and wasted time. So obviously internal compulsions can be being stuck in your thoughts, trying to figure something out in your mind. You can obviously get really stuck in that and say, Oh, wow, an hour just went by and I didn’t even realize. And then they’re, you know, it’s affecting their work, their family life, all of that, losing out on things, missing out on things, being late for things because you’re stuck. 

ADAM:  What’s a telltale sign that a person is stuck in thought as opposed to just thinking? 

LISA:  I determined that by asking, I ask a lot of questions about, okay, what was the worry? Okay, then what thought did you have? And then what? And then, and I really can training the person in a sense to be attentive to this. So I can then tell and look for any subtle reassurance seeking behaviors. I look for the difference between worrying versus problem solving. And a lot of people think that when they’re worrying that they’re just functionally problem 

SPEAKER_03:  solving. 

LISA:  Well said. Another aspect would also be relationship effects. And he has a whole sheet where that is just geared towards the effects on your relationship, such as involving someone in your rituals. And that can be a partner, friends, family, really any kind of relationship. And so in terms of internal compulsions, it could also just be the effect that this has on your relationship of just not feeling present. So you can see how all these different categories in a sense relate to each other. I mentioned some examples before of like suicidal OCD. You’re worried you’re going to harm yourself. Someone could easily get stuck in, well, no, I don’t want to do that. Why would I have that thought? But does that mean something about me that I had that thought? And they’re just obviously very distressed by this and stuck in it. And then they can’t feel present in their relationship. And then I will also say with that aspect of OCD, there’s a lot of embarrassment, but worry of telling other people, whether that be your partner or even your psychologist, your therapist, because you’re worried that they’ll commit you or they’re going to have to report me or call 911 or that kind of thing as well. The point being with all these different categories is you go through them and you can really see how it’s negatively impacting you. And this usually makes someone ready to engage in and willing to engage in exposure work. And that really has to be on board. 

ADAM:  What do you say to those people who are feeling shame or fear that they’ll be committed if they share this with someone? 

LISA:  Well, I’m glad you asked that and that I think it’s important to say at first, I do always give someone education that this is OCD. And I won’t keep giving that down the road because, and they know this too, that this is reassurance. So people will often, the reason I’m kind of laughing is people will later down the road in a sense laugh because they know they’re asking me for reassurance. And they’ll say, okay, I know you can’t answer that. But at first, most importantly is I always give the education that this is OCD. So what OCD looks like, for example, in terms of suicidal OCD is you have a fear, you have an image or thought about harming yourself, but that’s very different from wanting to harm yourself or having the feeling that you don’t want to be here anymore. Or things would be better off if there’s called what’s called passive suicidal ideation is, and this would come up in oncology is, you know what, things would be, this would be so much easier if I wasn’t here anymore, which is passive because they’re not necessarily wanting to harm themselves. But what’s very different in OCD is the person has a worry or fear that they will harm themselves without any desire to actually do so. And it’s so bothersome to them that that would even cross their mind. 

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ADAM:  I know we’ve talked about the idea of an OCD demon. We’ve also discussed sabotage in the context of OCD. And so I’m wondering if you can say a little bit about those ideas and also about the internal dialogue that’s always happening within somebody who has OCD or maybe needs to be happening in someone who’s struggling with OCD. 

LISA:  A lot of exposure isn’t necessarily physical, even though we might be when we’re in the office or outside the office because we want it to generalize to different contexts is can be physical. But even if you’re doing an exposure that is more physical, meaning like doing so physically, not checking the door or purposely contaminating yourself, you’re constantly dealing with, even during that exposure, you’re dealing with the fears you have. So, oh no, I’m definitely going to get sick from touching that. I’m definitely going to get sick from doing that. And so during the week when they’re not at their session, that that’s what their life looks like is they’re constantly dealing with these what if thoughts, even if the actual worry is something more seemingly physical in nature. And then you mentioned the OCD man. So really what happens with people with OCD is the mind likes to sabotage. So they’ll be maybe productively doing an exposure and I really like to try to prepare people for this and let them know that this is what happens. They’ll be doing this exposure and then this, the sabotaging thoughts come up. Well, no, but I don’t think you really check the door. No, no, I committed to not checking the door. Let someone might break in and then it’s definitely going to be your fault. No, no, no, I’m not going to. No, I committed to it. I’m not listening to that thought. It basically what happens is the sabotaging thoughts provide, they’re almost like arguments as to why the person should engage in some sort of safety behavior. And so I like to tell the person that these thoughts will come up and the mind likes to challenge them and it’s their job to recognize that and not listen to that. And something else in that context that I talk about a lot is the difference between discomfort, so the thoughts being uncomfortable and the thoughts being a problem. So we talk about the fact that these thoughts are going to come up and it will be uncomfortable, but that’s not a problem because people will often say to me, almost as an argument for why they feel they had to give into the thought is like, oh, but the problem is I started thinking about this. Again, you can’t control your thoughts and they’re going to come up. So it’s not a problem, but it’s uncomfortable. 

ADAM:  Yeah, that’s good. So for those people who are feeling angry or frustrated about the thoughts that they’re having, how do you help clients move toward acceptance of uncertainty and tolerating distressing thoughts and talk about fantasy versus reality in this context? 

LISA:  So as we talked about, people definitely get stuck on the fact that these thoughts are occurring and it can be major roadblock in therapy that we really need to work towards that acceptance before we can in the sense move on with therapy. And so early on, I’ll talk a lot about and actually, Jonathan Grayson uses this term as the wishing ritual. So basically someone gets stuck on wishing this wasn’t happening. So they’ll say things like, if only this wasn’t happening, or I tell them if your thought has the ring to it of if only this wasn’t happening. And again, we don’t get that luxury. So we talk about how there’s a difference between wishing or being a little frustrated or bothered at first that the thoughts that are uncomfortable versus dwelling on it. And then we talk about, as you brought up, the fantasy versus reality. So this will come up a lot with decisions that people made. So they’ll, in a sense, berate themselves for the decision and say if they don’t have the outcome that they wanted, or they’re worried about the way something turned out, they’ll, it’s like this hindsight, you know, bias and fantasy world of, oh, if only I made this other decision that I was thinking of, things would have turned out. Okay. Or I should have known that and they’ll come up with this evidence as though they should have known something. 

ADAM:  Lisa, we met at the International OCD Foundation Annual Conference. Do you want to say a few words about the conference and how it can be a resource for those suffering from anxiety and OCD? 

LISA:  I will start by saying this is by far my favorite conference. I attend sometimes three conferences a year, somewhat similar areas. So anxiety related or treatment that applies to anxiety and OCD. The reason this is my favorite conference and I is that I find it to be the most valuable. It’s really the only conference that I know of, not even just the anxiety, OCD world, but in psychology and that psychology world where it’s both providers and people with OCD that come to the conference. And I’ve found it extremely valuable because you can attend sessions that are just for therapists, you can attend sessions that are for individuals with OCD families. And I’ve really enjoyed the sessions for individuals with OCD in the sense that you’ll often have these panels. You might have a therapist who’s obviously provided or providing treatment. And then there might be people on the panel, obviously who are individuals with OCD. And I remember one panel on relationship OCD that I found extremely helpful and to bring back to my patients to talk about where, I mean, and that’s a really hard one for couples to go through and to hear these couples who’ve gone through the treatment. And then especially what it was like for the partner of someone with relationship OCD and how treatment helped them as well. I found that just to be extremely helpful and meaningful. And then at the conference every year, as you know, I do the road to recovery tour with Jonathan Grayson. And what we do is we, it’s a pretty large group, but we take the large group out. He does a little speech at first and he uses a lot of his basically motivational components of why would you take these risks and we go and we do exposures for different areas of OCD. And although sometimes people will tell me the next day I do a support group or a debrief about the tour and people have told me at times, oh, my area of OCD wasn’t highlighted in the tour, but they found it extremely supportive or helpful. Or we talk about the fact that although it’s not always feasible to do smaller groups and touch on every area that there’s a supportive component in it for everyone or for other people who are dealing with that aspect of OCD. 

ADAM:  Do you want to give some examples of the exposures that happen on the road to recovery tour and what the purpose or intended effect is? 

LISA:  So we go through examples for an I give you more specific, but harm OCD contamination work worrying that your thoughts are causal. We do. There’s a hoarding component. So for the harm component, we do. He asks who struggles with harm OCD. And so he brings a bunch of knives and we make two lines facing each other that are narrow and you know, where it feels like there’s some risk and they run through the lines with their knives. And although there’s some, I can say this humor aspect to it and that even the people who struggle with this, although they do find it hard, some of them will have some humor about it. They still do report that they’ll find that effective or it’s somewhat touches on their daily experience. When we were talking a little bit about the crash and burn exercise, so for people that worry that their thoughts are causal. Or if I don’t do X, Y and Z or if I if I say this, it’s going to make it come true. We’ll say, who worries that their thoughts are causal? And so we do this exercise together where we stand if possible, a busier road or at least a road where we know cars are going to come by and we say, we all yell and this could be like 200 people yelling, crash and burn, crash and burn, crash and burn. And so that’s one of the examples of those internal, let’s say, compulsion or thought based exercises that we do. And then we also do contamination. So we’ll this we usually end it by going back into the hotel and and everyone does this, whether they struggle with it or not again, just the support. But where we go in and rub our hands on the toilet and grab a ticktack and eat the ticktack without washing our hands. And we talk about not washing our hands when we go back to our hotel room. 

ADAM:  Yeah, it was a powerful experience. Speaking of Jonathan Grayson, I know he’s got that prompt about writing down that a loved one will die painfully. I’ll let you describe it. But do you want to talk about why that exercise is effective and what it teaches about thought control and acceptance? 

LISA:  So at that first conference, I went to that really got me hooked on anxiety and OCD work. This is where I went to a session and Jonathan Grayson did this exercise where he said, right down and this is at the time where everyone was using paper and pens and other phones, but write down the name of a loved one or someone you love very much. And then he’ll pause and say, now, right down, they’re going to die a horrible and painful death. And then obviously pauses. The quick version is he’ll start to point out, I saw you rip up your paper. I saw you erase that and people will quickly admit I erased that. No way I was writing that down. And I do this with psychiatry residents now as well. And it’s really to give someone who doesn’t have OCD the experience of having OCD. So so with the psychiatry residents, I’ve found it really impactful. And for instance, last year when I it stands out to me when I did it with them, they, you know, they’re writing it on their phones and they immediately said, oh, I erased that. Or there’s no way I was writing that down. So this is what I was going to write down and there’s no way I was writing that down. And so we talk about the fact that people with OCD don’t have that luxury. So it gives them that insight into how uncomfortable it would be. So imagine if you couldn’t erase that. And that’s what it’s like for people with OCD is they don’t get the choice to not have the thoughts. 

ADAM:  Mm hmm. Well, I know there are people out there who are feeling alone with their intrusive thoughts. I’m wondering if there’s any words of wisdom that you want to give them or any other final takeaway messages that you want to leave our listeners with. 

LISA:  I really would want them to know that there are so many people out there who struggle in the same way and basically struggle with these thoughts and intrusive thoughts. And with OCD, for example, and that there’s so many resources out there, whether that’s an abundance of them are through the International OCD Foundation, but whether that’s attending conferences or you can attend the conference virtually now, which is obviously much more accessible to a lot of people. There’s online OCD conferences that are just solely online. There’s live streams. I mean, they have live streams every week on their website, on Facebook that you can watch them later. It doesn’t have to be live. There’s an abundance of podcasts out there. So that by listening to these things, you can really get a lot of support. And there’s actual support groups too and virtual support groups for people and families so that they also don’t feel alone in terms of dealing with OCD and how there’s just a lot of support embedded with hearing these stories and also the treatment success stories as well. Where can people learn more about your work? The main place where people can learn more about me is on my website at New Orleans Anxiety and OCD.com. I don’t have social media set up at the moment. Something I’ve been thinking of, but I would say on my website would be the main place. They can always contact me there. They can so they can read a bio more information about me there. They can contact me through the website. They can email me New Orleans OCD at gmail.com. And I’ll generally respond pretty quickly in any questions that they have to learn more about me that way as well. 

ADAM:  Amazing. Well, I want to thank you so much for this conversation. You’ve given so much valuable information to our listeners. You’re doing wonderful work in this space. I know that you have helped so many people already. And I wish you lots of success as you continue working with people who have anxiety and OCD. And I look forward to being in touch. 

LISA:  Thank you and thanks so much again for having me. 

ADAM:  It was a pleasure. 

 

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