Alison Dotson's Blog, page 6

Treating OCD With Brass Knuckles: Steven Phillipson

[image error]Today’s Q&A might read a little different to you, a little more casual—that’s because Dr. Steven Phillipson and I had a long phone call, and I didn’t follow my prepared questions to a tee. The conversation flowed as it needed to, and I learned just how dedicated he is to helping people with obsessive-compulsive disorder, and how little he cares about what others think of him as long as he’s doing right by people who are suffering. Based in New York, Dr. Phillipson treats patients in person as well as via teletherapy, and his clinic uses a sliding fee scale.

Feel free to jump into the Q&A now or familiarize yourself with Dr. Phillipson by reading his article “Choice” first. Yes, it’s 47 pages, but you can listen to an audio version as well.

How long have you treated OCD? Why did you choose to focus your practice on OCD?

It’s been about 30 years now that I’ve been an OCD specialist. I fell into it quite by accident. I was doing an internship at a location where one of the senior staff was a very known expert in the area of OCD. He was a behavioral psychologist and I had done an internship at Johns Hopkins in behavioral psychology, and I really liked the way he looked at the condition, at the way he treated the condition. It was what we call empirically based treatment, very, very scientifically based, and I asked him if he would consider sending me patients that couldn’t afford his fee, perhaps supervising me on those cases so I could learn what was going on, what to do, and he agreed to that.

After about six months one of my patients asked me if I knew of any support groups in the city, and I thought, “Oh, surely, there has to be one,” and in doing a lot of research discovered that there was not an OCD support group, so I spoke to this mentor and we agreed we would start the first behavior therapy and support group for OCD in the city, perhaps even the country. During that time we combined about eight to ten patients and started the group. I took copious notes about what was going on and started to develop a fascination with the condition: It didn’t make sense to me that our own brain would produce such a self-destructive pattern, so I went back to my learning about neurophysiology and basically constructed a treatment model for the Pure O population based on what was already being offered to the observable ritualizing OCD types like handwashing and light checking. I applied the principles that already existed very successfully in the treatment of OCD toward the Pure O population and wrote about it. I got a very resounding positive response across the country because my article appeared in the International OCD Foundation (IOCDF) newsletter, and that’s basically where my career started as being a well-known entity in the world of OCD.

What year was that?

My article came out about 1989, 1990 , and then in 1991 they started doing video broadcasts of specialists with OCD and that video broadcast is actually on my website based on my writing an article title back then, “Thinking the Unthinkable.” That video is on OCDOnline.com. And I haven’t changed a bit, by the way, I look exactly the same as that 1991 video.

You mentioned Pure O. Is it true that you coined that term?

It is true, that was me. That term was coined in my article “Thinking the Unthinkable,” so I’ve got a time stamp on that.

Why did you use that term? What does it mean?

Back then many patients were still exposed to a tremendous amount of ignorance, both in the media and amongst people who were calling themselves therapists qualified to treat OCD, despite how little knowledge there was and how much misinformation there was. Persons were misidentifying the diagnosis because there weren’t observable rituals. In a way it’s a misnomer but in a way it reflects that both the intrusive thoughts—or what I refer to as a spike—and the undoing response, the ritual, were both obsessional in nature, meaning that they were conducted both as a thought, so the brain produced an intrusive thought (that’s the obsessional spike), and then the person would engage in an obsessional ritual to “undo” the intrusive thought. So that’s why I called it Pure O, because the initiating intrusive thought and the undoing response were both obsessional in nature. All persons with OCD engage in the ritualization to escape the intrusive thought, so in that regard that is the compulsion, but back in the early ’90s people were looking at compulsions as only observable phenomena rather than obsessive phenomena, so that’s why I coined that term. I think that it has been from the client population a very welcomed term because people who have been so misunderstood, or those who suffer from that form of OCD, really appreciate a differential term that delineates them from the more widely known aspects of OCD.

“I’m an outspoken, controversial person. I don’t mind being a controversial spokesperson.”

If you’ve gotten any pushback or someone arguing with you has it normally been a therapist, a practitioner?

Well, believe it or not, the greatest pushback has been from the IOCDF in recent years. They don’t like the term because they believe that it misleads and confuses the population, and I disagree. I see it as a nickname for a certain subtype of OCD. There has been that ongoing differential, and persons like Chrissie Hodges or Aaron Harvey who are big advocates of the concept of intrusive thoughts and the obsessional nature of undoing those thoughts definitely understand it as being a positive addition to the clinical vocabulary in understanding OCD.

Right. Just my personal take on it is that it was helpful for me. It was kind of labeling what was going on, and then with that label I knew where to look for more resources and more support. I still have a hard time differentiating what’s considered a mental compulsion and what’s considered an obsession, so just knowing “You still have OCD even if you can’t always identify it as obviously a compulsion” helps.

Right, the compulsion is generally speaking, but not always, the gatekeeper’s effort to undo, escape, neutralize the intrusive thought, so in that regard it’s generally the conscious, voluntary effort to reduce the anxiety or reduce the perceived problem as it were.

Can you give an example of how someone might confuse an intrusive thought, an obsession, with a mental compulsion? Mine were probably praying, but for the most part I didn’t have a lot of obvious compulsions—I learned later that staying in my house and avoiding the grocery store was a compulsion, but it took a long time to get to that point where I realized that.

Sure. So you’re saying that in your case you’d use prayer as a means of undoing the sinful intrusive thought.

Yeah.

Generally speaking, I think occasionally people confuse whether the thought is coming from their machine brain, meaning it happens spontaneously and without our voluntary choice, versus whether or not they are voluntarily engaging in an intrusive thought or trying to undo the intrusive thought. That occasionally is confused, but generally where there’s a question I encourage people to write it off as the spontaneity of the brain rather than it being volitional.[image error]

I’ve heard some therapists say their patient will come in and say, “I have HOCD, or I have ROCD, can you treat that?” and the therapist will be like, “I don’t know what you’re talking about, I’ve never heard of that, I just treat OCD.” So should therapists be following their patients’ lead more and looking into more of what the community is talking about, and still getting out the message that OCD is OCD and we’re going to treat it with the same research-based therapies, but to get more of a grasp of what we talk about in our support groups and in our community?

If you are a specialist in understanding and treatment of OCD, whether you know the letters or not, you certainly would be familiar with what the letters stand for. I think a true specialist also would want to understand that if someone has HOCD it really is important to look into the potential that this person also qualifies for a condition I refer to as perfectionism—although it’s still referred to as obsessive-compulsive personality disorder—which means a higher degree of attachment to trying to find the answers. One of the other things I’ve done in my work is really examine how certain subtypes of OCD correspond very significantly with certain personality styles, and I think a true expert would want to be aware that a female patient with body dysmorphic disorder is likely to also have features of borderline personality disorder and a man would have features of narcissistic personality disorder. This is a level of expertise that I think unfortunately very few clinicians across the country are up to speed with, so in that regard, the differentiation of the subsets of OCD are clinically very relevant.

One of the reasons I waited so long to get professional help was that I was afraid I’d be reported to the authorities if I shared my sexual intrusive thoughts with anyone. Do you hear this yourself? What would you tell someone with this same fear?

It’s understandable that they’re very afraid that they might disclose information to a clinician and if that clinician is not an expert, they may be misdiagnosed, or the clinician may develop an unreasonable or unnecessary concern about the patient’s safety or safety to others. I would interview any clinician before I opened up about any of the specific content of an intrusive thought to see what level of expertise they have and to say, “If I disclose the content of my intrusive thoughts and they involve topics that might seem dangerous or paranoid, are you aware that we’re talking about an anxiety disorder and not an actual threat?”

I didn’t know I had OCD, so I wouldn’t have known to ask a therapist that question, because I thought I might be a threat, so how do you go about that? Maybe that’s an unanswerable question…

Well, I think the answer lies in what you probably did, which was go online and unfortunately have to use your own judgment to find resources that determined what was going on in your world. Thank goodness that exists, and for you to be able to develop your own database, knowledge base, to be able to have an intelligent interview with a potential clinician who was claiming to be a specialist with OCD.

In some ways I’m glad I waited so long because when I finally went in it was the right person. He recommended The Imp of the Mind. I didn’t have to say much to him for him to know, which was great, because I was really afraid “I’m not going to be able to tell this person my awful thoughts—”

Hey, don’t judge your brain’s creative thoughts.

Super creative.

Yeah, super creative. I really am a strong advocate that we not judge our brains’ creativity. My brain has had a great deal of creativity in many different departments in life. I don’t have OCD, so I can’t fully comprehend the pairing of what is exactly my brain’s creativity as it would be for yourself, because when my brain shares these creative thoughts it doesn’t pair it with a tsunami of emotional distress, and that’s really the only difference between your brain and mine, is that there’s probably a malfunction in your amygdala that pairs an “I’m about to die” signal with these creative thoughts. But most humans report having these associations of one kind or another—without OCD they don’t have that paired distress signal, so it’s literally a three-second “Oh, thanks for sharing, brain” and it’s over event.

I get the other kind, the three years and it might be over event.

Right, but with the proper remediation you could definitely show your brain that you’re not going to be fragile about its creativity. I’ve seen people really put their OCD into a dormant state like a volcano that hasn’t erupted in years. I think there’s wonderful hope in aggressive treatment of OCD.

So if you’re saying that some people can put their OCD into a dormant state, do you think that means that it will explode like a volcano and that a dormant state is bad?

Not at all. I think a dormant state is wonderful. Many of my patients, after a successful treatment, have had their OCD go into a dormant state for years. Some contact me to say that their brain is kind of recharging on its signals and energy on some topics, and no big deal—usually it’s a four-session booster process of putting the monster back in the cage, and we’re the helpful best friends I sometimes like to say, and putting the cap on it again. All of our brains are capable of malfunctioning in this way—I’ve had about 27 panic attacks, not that I’m counting, in my life, and they’re very powerful and very overwhelming, but they’re very survivable. My relationship with my panic attacks is to say to my brain, “Come and get me, I’m here, I’m ready, and I’m not going to go to the hospital even though it feels like I’m about to die of a heart attack.” Anxiety is a very manageable entity.

Sometimes people will say to me that they’re afraid of going back to square one, but do you think that once someone has had therapy, and even medication, they never really will be at square one again, even if the volcano does erupt, so to speak?

Yes, absolutely. I don’t agree that people do go back to square one. I tell my patients when they have a bit of a setback that you’ve already blazed the recovery trail, you’ve already kind of gone through the process of recovery and therefore the likelihood of you doing it again is very great. I think that with behavior therapy; I wouldn’t necessarily say that with medication because medication doesn’t teach skills—it offers the potential for relief without developing a skill set to manage one’s brain’s creativity and diversity.

And could you tell them that there’s anything about their brain that’s actually changed with therapy and that it would take longer—I mean, I’m totally throwing this out there—but what would be the scientific answer for that, to be like, “Look, you actually reconfigured some parts of your brain and it will take more time than that to undo it all”?

Exactly, that’s very well put. The wonderful term is neuroplasticity, and, yeah, you do reconfigure the brain, you reconfigure the neural pathways and the speed with which they connect and you demonstrate the irrelevance of the alarm system, so yes, one cannot relapse in a single day. I tell my patients when they’re kind of signing the goodbye contract, “Look, if your brain is challenging you in a way you’re not managing well for two weeks, definitely give me a call and don’t let it go beyond that” because you can kind of reconstitute those more anxious neuropathways by giving in for a longer stretch of time.

So don’t call after one day, but two weeks is a reasonable amount of time.

Exactly.

A common question I get from individuals with OCD is whether ERP can help with sexual, violent, and religious intrusive thoughts. How does ERP work in these cases?

All of behavior therapy for OCD is predicated on exposure therapy, so you can basically do exposure therapy for any aspect of OCD: if you have a thought about God, you could write it down, as I have patients do on an index card, and carry that index card around with the statements of your own brain in terms of what the nature of the intrusive thought is and expose yourself to that topic ten times a day without engaging in an undoing response.

I’m a fan of what’s called repeated exposure. I always tell my staff—the center I work at and am a director at is a training facility—to think of exposures as something that could be done ten times a day. Exposures are based on the premise of facilitating what’s called habituation. It’s a scientific concept of how our brain stops reacting to stimuli that are redundant and voluntary, so that’s the beauty of behavior therapy, that it really takes advantage of neurophysiology, which is what’s responsible for the condition, so that’s why the treatment is so potent. I have done what are referred to as in vivo exposure exercises where I walked on the street with patients and we might walk close to an oncoming pedestrian and create the idea that maybe that pedestrian just injected you with an AIDS needle, or maybe that pedestrian looked at you and realized that you are gay.

What’s funny is a very well-known specialist named Jonathan Grayson used to do weekend camping trips with a gang of patients and they would go dumpster diving, and there were no showers permitted for the entire weekend, so that’s a form of flooding, which I certainly am a fan of, but I’ve never gone on a weekend camping expedition with contamination patients. But I certainly salute him for doing so.

What’s a misconception about OCD you’d like to clear up for the general public or even for people with OCD?

The biggest misconception, basically, I think from bad media sources like As Good As It Gets or The Aviator, is that OCD is often mistaken for perfectionism, you know people who are, say, lining their shoes up in a nice straight line, they’ll be like, “Oh, I’m so OCD about the way I put away my shoes.” OCD is not about perfectionism—that’s an entirely different diagnosis. OCD is about very threatening intrusive thoughts that are paired with a tsunami of distress and emotions and I think that the public is turning the term OCD into an adjective rather than a diagnosis and most of my patients who have OCD, when they hear that from the lay population, are pretty offended. They recognize right away that the person is not OCD, they’re just being a little bit quirky, and I think a lot of my patients feel very alienated and misunderstood when they hear people use that phrase “I’m so OCD about X” in a way that so clearly is a misdiagnosis.

That actually reminds me of another question I have. I grew up in a town that definitely did not have an OCD therapist. That sounds smart, obviously, to say, “Don’t go to just anyone, don’t rely on just reading about it,” but what does a person do when they’re in a rural community or maybe a different country where they’re just desperate for help, they don’t have someone within driving distance or they don’t have insurance. What do they do?

My very long answer—as I’ve been giving you very long answers—to that question, is that when I first wrote that article on thinking the unthinkable and it was distributed across the country by the IOCDF, I got a lot of phone calls in 1992 through the ’90s asking to work with people over the phone (because Skype hadn’t been invented yet). In fact, I used to say to patients, “Fly to New York, I want to meet you first, I want to see if we can develop a good working rapport, and then I’ll work with you over the phone.” So that started in 1992, I worked with patients over the phone, and for about ten years I noticed something very peculiar, because I’m a scientist and I keep track of a lot of things. I noticed the patients I worked with over the phone—guess what, Alison, got better quicker, got better the same, or got better slower than patients I worked with face to face. What would be your guess?

Well, I mean, my guess would be—ugh, now you’re making me—I’m gonna say they got better faster because that seems like the opposite…

That’s correct. Fifteen percent of my patients improved faster and had better outcomes than patients I worked with face to face. I thought about that, and it’s not because being in the same room with me and seeing my ugly face is a distraction: I guessed that patients who called me from across the country had had in local treatment failure done extensive research, and when they reached out to me they were very ready and willing to do very aggressive therapy, and that is obviously the ingredient for success, to be willing to engage in no-nonsense, brass knuckles exposure therapy. That’s where my national, and what’s now become my international, career launched, working with people such as yourself who live in a rural community where there aren’t experts but they wanted to work with an expert. The center provides, at this point, video therapy with VSee or Skype or Facetime. We work with people all around the world at this point, exactly to the reason you mentioned, that many patients who reach out to us don’t have access within a hundred miles of qualified experts.

What about a workbook that actually guides you through a hierarchy—obviously they’re not going to be held as accountable as they would with a therapist—but would you consider that a good first step, or a last resort, or a complement to therapy?

No, I never recommend people substitute bibliotherapy for face-to-face therapy. I think bibliotherapy is great as a learning instrument to say, okay, when I meet an expert these are the things they’re going to recommend that I do, but, no, I would never substitute reading, as I said before, in any way, for working with a qualified expert, because OCD is a complicated condition. My latest article is on how resentment is a form of ritualizing, and in this article I say I worked with many patients who are very treatment compliant and yet in the final stages of treatment are still not crossing the line into recovery because they’re expecting their brain to stop sending these cognitive signals. That expectation produces resentment and frustration and anger, and all those emotions are a form of ritualizing that perpetuates the condition. If you’re not working with an expert you’re not going to be aware of those nuances of treatment and recovery, and, you know, you won’t read about that in a book.

If you could share just one piece of advice with someone who has OCD, what would it be—to read your 45-page paper?

Forty-seven pages! Sure, I would start there, but I would also say never think therapy can be done through reading or through working with someone who has taken a weekend course in the understanding and treatment of OCD. OCD is a complex condition that ultimately benefits from working with an expert, someone who really knows the ins and outs of the condition, because working with someone who doesn’t understand OCD can be more detrimental than beneficial. My Choice article is a wonderful manual on how to be successful in therapy, but in no way is it a substitution for therapy. It just basically says to patients who read it, “These are the characteristics of people who get better in the treatment of OCD and this is why they derive improvement and this is a level of understanding of the condition that I want you to look for in any clinician who calls themselves an expert.”

Treating OCD with brass knuckles: Steven Phillipson

[image error]Steven Phillipson during an interview for IntrusiveThoughts.org

Today’s Q&A might read a little different to you, a little more casual—that’s because Dr. Steven Phillipson and I had a long phone call, and I didn’t follow my prepared questions to a tee. The conversation flowed as it needed to, and I learned just how dedicated he is to helping people with obsessive-compulsive disorder, and how little he cares about what others think of him as long as he’s doing right by people who are suffering. Based in New York, Dr. Phillipson treats patients in person as well as via teletherapy, and his clinic uses a sliding fee scale.

Feel free to jump into the Q&A now or familiarize yourself with Dr. Phillipson by reading his article “Choice” first. Yes, it’s 47 pages, but you can listen to an audio version as well.

How long have you treated OCD? Why did you choose to focus your practice on OCD?

It’s been about 30 years now that I’ve been an OCD specialist. I fell into it quite by accident. I was doing an internship at a location where one of the senior staff was a very known expert in the area of OCD. He was a behavioral psychologist and I had done an internship at Johns Hopkins in behavioral psychology, and I really liked the way he looked at the condition, at the way he treated the condition. It was what we call empirically based treatment, very, very scientifically based, and I asked him if he would consider sending me patients that couldn’t afford his fee, perhaps supervising me on those cases so I could learn what was going on, what to do, and he agreed to that.

After about six months one of my patients asked me if I knew of any support groups in the city, and I thought, “Oh, surely, there has to be one,” and in doing a lot of research discovered that there was not an OCD support group, so I spoke to this mentor and we agreed we would start the first behavior therapy and support group for OCD in the city, perhaps even the country. During that time we combined about eight to ten patients and started the group. I took copious notes about what was going on and started to develop a fascination with the condition: It didn’t make sense to me that our own brain would produce such a self-destructive pattern, so I went back to my learning about neurophysiology and basically constructed a treatment model for the Pure O population based on what was already being offered to the observable ritualizing OCD types like handwashing and light checking. I applied the principles that already existed very successfully in the treatment of OCD toward the Pure O population and wrote about it. I got a very resounding positive response across the country because my article appeared in the International OCD Foundation (IOCDF) newsletter, and that’s basically where my career started as being a well-known entity in the world of OCD.

What year was that?

My article came out about 1989, 1990 , and then in 1991 they started doing video broadcasts of specialists with OCD and that video broadcast is actually on my website based on my writing an article title back then, “Thinking the Unthinkable.” That video is on OCDOnline.com. And I haven’t changed a bit, by the way, I look exactly the same as that 1991 video.

You mentioned Pure O. Is it true that you coined that term?

It is true, that was me. That term was coined in my article “Thinking the Unthinkable,” so I’ve got a time stamp on that.

Why did you use that term? What does it mean?

Back then many patients were still exposed to a tremendous amount of ignorance, both in the media and amongst people who were calling themselves therapists qualified to treat OCD, despite how little knowledge there was and how much misinformation there was. Persons were misidentifying the diagnosis because there weren’t observable rituals. In a way it’s a misnomer but in a way it reflects that both the intrusive thoughts—or what I refer to as a spike—and the undoing response, the ritual, were both obsessional in nature, meaning that they were conducted both as a thought, so the brain produced an intrusive thought (that’s the obsessional spike), and then the person would engage in an obsessional ritual to “undo” the intrusive thought. So that’s why I called it Pure O, because the initiating intrusive thought and the undoing response were both obsessional in nature. All persons with OCD engage in the ritualization to escape the intrusive thought, so in that regard that is the compulsion, but back in the early ’90s people were looking at compulsions as only observable phenomena rather than obsessive phenomena, so that’s why I coined that term. I think that it has been from the client population a very welcomed term because people who have been so misunderstood, or those who suffer from that form of OCD, really appreciate a differential term that delineates them from the more widely known aspects of OCD.

“I’m an outspoken, controversial person. I don’t mind being a controversial spokesperson.”

If you’ve gotten any pushback or someone arguing with you has it normally been a therapist, a practitioner?

Well, believe it or not, the greatest pushback has been from the IOCDF in recent years. They don’t like the term because they believe that it misleads and confuses the population, and I disagree. I see it as a nickname for a certain subtype of OCD. There has been that ongoing differential, and persons like Chrissie Hodges or Aaron Harvey who are big advocates of the concept of intrusive thoughts and the obsessional nature of undoing those thoughts definitely understand it as being a positive addition to the clinical vocabulary in understanding OCD.

Right. Just my personal take on it is that it was helpful for me. It was kind of labeling what was going on, and then with that label I knew where to look for more resources and more support. I still have a hard time differentiating what’s considered a mental compulsion and what’s considered an obsession, so just knowing “You still have OCD even if you can’t always identify it as obviously a compulsion” helps.

Right, the compulsion is generally speaking, but not always, the gatekeeper’s effort to undo, escape, neutralize the intrusive thought, so in that regard it’s generally the conscious, voluntary effort to reduce the anxiety or reduce the perceived problem as it were.

Can you give an example of how someone might confuse an intrusive thought, an obsession, with a mental compulsion? Mine were probably praying, but for the most part I didn’t have a lot of obvious compulsions—I learned later that staying in my house and avoiding the grocery store was a compulsion, but it took a long time to get to that point where I realized that.

Sure. So you’re saying that in your case you’d use prayer as a means of undoing the sinful intrusive thought.

Yeah.                                                                                   

Generally speaking, I think occasionally people confuse whether the thought is coming from their machine brain, meaning it happens spontaneously and without our voluntary choice, versus whether or not they are voluntarily engaging in an intrusive thought or trying to undo the intrusive thought. That occasionally is confused, but generally where there’s a question I encourage people to write it off as the spontaneity of the brain rather than it being volitional.[image error]

I’ve heard some therapists say their patient will come in and say, “I have HOCD, or I have ROCD, can you treat that?” and the therapist will be like, “I don’t know what you’re talking about, I’ve never heard of that, I just treat OCD.” So should therapists be following their patients’ lead more and looking into more of what the community is talking about, and still getting out the message that OCD is OCD and we’re going to treat it with the same research-based therapies, but to get more of a grasp of what we talk about in our support groups and in our community?

If you are a specialist in understanding and treatment of OCD, whether you know the letters or not, you certainly would be familiar with what the letters stand for. I think a true specialist also would want to understand that if someone has HOCD it really is important to look into the potential that this person also qualifies for a condition I refer to as perfectionism—although it’s still referred to as obsessive-compulsive personality disorder—which means a higher degree of attachment to trying to find the answers. One of the other things I’ve done in my work is really examine how certain subtypes of OCD correspond very significantly with certain personality styles, and I think a true expert would want to be aware that a female patient with body dysmorphic disorder is likely to also have features of borderline personality disorder and a man would have features of narcissistic personality disorder. This is a level of expertise that I think unfortunately very few clinicians across the country are up to speed with, so in that regard, the differentiation of the subsets of OCD are clinically very relevant.

One of the reasons I waited so long to get professional help was that I was afraid I’d be reported to the authorities if I shared my sexual intrusive thoughts with anyone. Do you hear this yourself? What would you tell someone with this same fear?

It’s understandable that they’re very afraid that they might disclose information to a clinician and if that clinician is not an expert, they may be misdiagnosed, or the clinician may develop an unreasonable or unnecessary concern about the patient’s safety or safety to others. I would interview any clinician before I opened up about any of the specific content of an intrusive thought to see what level of expertise they have and to say, “If I disclose the content of my intrusive thoughts and they involve topics that might seem dangerous or paranoid, are you aware that we’re talking about an anxiety disorder and not an actual threat?”

I didn’t know I had OCD, so I wouldn’t have known to ask a therapist that question, because I thought I might be a threat, so how do you go about that? Maybe that’s an unanswerable question…

Well, I think the answer lies in what you probably did, which was go online and unfortunately have to use your own judgment to find resources that determined what was going on in your world. Thank goodness that exists, and for you to be able to develop your own database, knowledge base, to be able to have an intelligent interview with a potential clinician who was claiming to be a specialist with OCD.

In some ways I’m glad I waited so long because when I finally went in it was the right person. He recommended The Imp of the Mind. I didn’t have to say much to him for him to know, which was great, because I was really afraid “I’m not going to be able to tell this person my awful thoughts—”

Hey, don’t judge your brain’s creative thoughts.

Super creative.

Yeah, super creative. I really am a strong advocate that we not judge our brains’ creativity. My brain has had a great deal of creativity in many different departments in life. I don’t have OCD, so I can’t fully comprehend the pairing of what is exactly my brain’s creativity as it would be for yourself, because when my brain shares these creative thoughts it doesn’t pair it with a tsunami of emotional distress, and that’s really the only difference between your brain and mine, is that there’s probably a malfunction in your amygdala that pairs an “I’m about to die” signal with these creative thoughts. But most humans report having these associations of one kind or another—without OCD they don’t have that paired distress signal, so it’s literally a three-second “Oh, thanks for sharing, brain” and it’s over event.

I get the other kind, the three years and it might be over event.

Right, but with the proper remediation you could definitely show your brain that you’re not going to be fragile about its creativity. I’ve seen people really put their OCD into a dormant state like a volcano that hasn’t erupted in years. I think there’s wonderful hope in aggressive treatment of OCD.

So if you’re saying that some people can put their OCD into a dormant state, do you think that means that it will explode like a volcano and that a dormant state is bad?

Not at all. I think a dormant state is wonderful. Many of my patients, after a successful treatment, have had their OCD go into a dormant state for years. Some contact me to say that their brain is kind of recharging on its signals and energy on some topics, and no big deal—usually it’s a four-session booster process of putting the monster back in the cage, and we’re the helpful best friends I sometimes like to say, and putting the cap on it again. All of our brains are capable of malfunctioning in this way—I’ve had about 27 panic attacks, not that I’m counting, in my life, and they’re very powerful and very overwhelming, but they’re very survivable. My relationship with my panic attacks is to say to my brain, “Come and get me, I’m here, I’m ready, and I’m not going to go to the hospital even though it feels like I’m about to die of a heart attack.” Anxiety is a very manageable entity.

Sometimes people will say to me that they’re afraid of going back to square one, but do you think that once someone has had therapy, and even medication, they never really will be at square one again, even if the volcano does erupt, so to speak?

Yes, absolutely. I don’t agree that people do go back to square one. I tell my patients when they have a bit of a setback that you’ve already blazed the recovery trail, you’ve already kind of gone through the process of recovery and therefore the likelihood of you doing it again is very great. I think that with behavior therapy; I wouldn’t necessarily say that with medication because medication doesn’t teach skills—it offers the potential for relief without developing a skill set to manage one’s brain’s creativity and diversity.

And could you tell them that there’s anything about their brain that’s actually changed with therapy and that it would take longer—I mean, I’m totally throwing this out there—but what would be the scientific answer for that, to be like, “Look, you actually reconfigured some parts of your brain and it will take more time than that to undo it all”?

Exactly, that’s very well put. The wonderful term is neuroplasticity, and, yeah, you do reconfigure the brain, you reconfigure the neural pathways and the speed with which they connect and you demonstrate the irrelevance of the alarm system, so yes, one cannot relapse in a single day. I tell my patients when they’re kind of signing the goodbye contract, “Look, if your brain is challenging you in a way you’re not managing well for two weeks, definitely give me a call and don’t let it go beyond that” because you can kind of reconstitute those more anxious neuropathways by giving in for a longer stretch of time.

So don’t call after one day, but two weeks is a reasonable amount of time.

Exactly.

A common question I get from individuals with OCD is whether ERP can help with sexual, violent, and religious intrusive thoughts. How does ERP work in these cases?

All of behavior therapy for OCD is predicated on exposure therapy, so you can basically do exposure therapy for any aspect of OCD: if you have a thought about God, you could write it down, as I have patients do on an index card, and carry that index card around with the statements of your own brain in terms of what the nature of the intrusive thought is and expose yourself to that topic ten times a day without engaging in an undoing response.

I’m a fan of what’s called repeated exposure. I always tell my staff—the center I work at and am a director at is a training facility—to think of exposures as something that could be done ten times a day. Exposures are based on the premise of facilitating what’s called habituation. It’s a scientific concept of how our brain stops reacting to stimuli that are redundant and voluntary, so that’s the beauty of behavior therapy, that it really takes advantage of neurophysiology, which is what’s responsible for the condition, so that’s why the treatment is so potent. I have done what are referred to as in vivo exposure exercises where I walked on the street with patients and we might walk close to an oncoming pedestrian and create the idea that maybe that pedestrian just injected you with an AIDS needle, or maybe that pedestrian looked at you and realized that you are gay.

What’s funny is a very well-known specialist named Jonathan Grayson used to do weekend camping trips with a gang of patients and they would go dumpster diving, and there were no showers permitted for the entire weekend, so that’s a form of flooding, which I certainly am a fan of, but I’ve never gone on a weekend camping expedition with contamination patients. But I certainly salute him for doing so.

What’s a misconception about OCD you’d like to clear up for the general public or even for people with OCD?

The biggest misconception, basically, I think from bad media sources like As Good As It Gets or The Aviator, is that OCD is often mistaken for perfectionism, you know people who are, say, lining their shoes up in a nice straight line, they’ll be like, “Oh, I’m so OCD about the way I put away my shoes.” OCD is not about perfectionism—that’s an entirely different diagnosis. OCD is about very threatening intrusive thoughts that are paired with a tsunami of distress and emotions and I think that the public is turning the term OCD into an adjective rather than a diagnosis and most of my patients who have OCD, when they hear that from the lay population, are pretty offended. They recognize right away that the person is not OCD, they’re just being a little bit quirky, and I think a lot of my patients feel very alienated and misunderstood when they hear people use that phrase “I’m so OCD about X” in a way that so clearly is a misdiagnosis.

That actually reminds me of another question I have. I grew up in a town that definitely did not have an OCD therapist. That sounds smart, obviously, to say, “Don’t go to just anyone, don’t rely on just reading about it,” but what does a person do when they’re in a rural community or maybe a different country where they’re just desperate for help, they don’t have someone within driving distance or they don’t have insurance. What do they do?

My very long answer—as I’ve been giving you very long answers—to that question, is that when I first wrote that article on thinking the unthinkable and it was distributed across the country by the IOCDF, I got a lot of phone calls in 1992 through the ’90s asking to work with people over the phone (because Skype hadn’t been invented yet). In fact, I used to say to patients, “Fly to New York, I want to meet you first, I want to see if we can develop a good working rapport, and then I’ll work with you over the phone.” So that started in 1992, I worked with patients over the phone, and for about ten years I noticed something very peculiar, because I’m a scientist and I keep track of a lot of things. I noticed the patients I worked with over the phone—guess what, Alison, got better quicker, got better the same, or got better slower than patients I worked with face to face. What would be your guess?

Well, I mean, my guess would be—ugh, now you’re making me—I’m gonna say they got better faster because that seems like the opposite…

That’s correct. Fifteen percent of my patients improved faster and had better outcomes than patients I worked with face to face. I thought about that, and it’s not because being in the same room with me and seeing my ugly face is a distraction: I guessed that patients who called me from across the country had had in local treatment failure done extensive research, and when they reached out to me they were very ready and willing to do very aggressive therapy, and that is obviously the ingredient for success, to be willing to engage in no-nonsense, brass knuckles exposure therapy. That’s where my national, and what’s now become my international, career launched, working with people such as yourself who live in a rural community where there aren’t experts but they wanted to work with an expert. The center provides, at this point, video therapy with VSee or Skype or Facetime. We work with people all around the world at this point, exactly to the reason you mentioned, that many patients who reach out to us don’t have access within a hundred miles of qualified experts.

What about a workbook that actually guides you through a hierarchy—obviously they’re not going to be held as accountable as they would with a therapist—but would you consider that a good first step, or a last resort, or a complement to therapy?

No, I never recommend people substitute bibliotherapy for face-to-face therapy. I think bibliotherapy is great as a learning instrument to say, okay, when I meet an expert these are the things they’re going to recommend that I do, but, no, I would never substitute reading, as I said before, in any way, for working with a qualified expert, because OCD is a complicated condition. My latest article is on how resentment is a form of ritualizing, and in this article I say I worked with many patients who are very treatment compliant and yet in the final stages of treatment are still not crossing the line into recovery because they’re expecting their brain to stop sending these cognitive signals. That expectation produces resentment and frustration and anger, and all those emotions are a form of ritualizing that perpetuates the condition. If you’re not working with an expert you’re not going to be aware of those nuances of treatment and recovery, and, you know, you won’t read about that in a book.

If you could share just one piece of advice with someone who has OCD, what would it be—to read your 45-page paper?

Forty-seven pages! Sure, I would start there, but I would also say never think therapy can be done through reading or through working with someone who has taken a weekend course in the understanding and treatment of OCD. OCD is a complex condition that ultimately benefits from working with an expert, someone who really knows the ins and outs of the condition, because working with someone who doesn’t understand OCD can be more detrimental than beneficial. My Choice article is a wonderful manual on how to be successful in therapy, but in no way is it a substitution for therapy. It just basically says to patients who read it, “These are the characteristics of people who get better in the treatment of OCD and this is why they derive improvement and this is a level of understanding of the condition that I want you to look for in any clinician who calls themselves an expert.”

Showing Up With OCD and Anxiety: Bryan Piatt

[image error]After a long hiatus, Tuesday Q&A is back! I couldn’t be more honored to share some insight from my latest guest, someone I’m so lucky to call my friend, Bryan Piatt. Bryan and I met four years ago when his employer, KARE 11, assigned him to a story about an “ugly Christmas sweater” Target was selling—it said, “OCD: Obsessive Christmas Disorder”—and Bryan reached out to me for an interview. (I agreed that the sweater was ugly, all right, but for very different reasons.)

After several years in his dream job as a TV reporter, Bryan decided to focus more time on some behind-the-scenes work, including his labor of love, Refresh Network, and sharing his experience with anxiety and obsessive-compulsive disorder (OCD) with his fans—and beyond.

Because you’ve been on TV for several years—and because you’re funny, engaging, and smart—you have a platform for spreading awareness of mental health. You’ve recently started to share your story. Why did you decide to open up? And what has the response been like?

Can you please keep going with the compliments? But for real—I have always had this deep sense that I wanted to use my platform from working on television to share my story and help other people who may be struggling with their mental health. My word for 2019 has been “action”—taking action toward all the things I’ve been talking about doing for years—and a big piece of that was opening up more about my own mental health journey. The response has been absolutely beautiful so far. So much love and support out there and so many people feeling safe to share their own mental health struggles with me too, which is such an honor. We all have things we’re struggling with and need safe spaces to be able to talk about them.[image error]

How did you realize what you’d been going through was OCD? Can you tell us about some of your obsessions?

Looking back I think there were a lot of signs of anxiety and OCD doing their thing when I was younger. I was always scared of throwing up in public, scared of fainting during choir recitals at school, very anxious about sleepovers with friends—those kinds of things.

In middle school I had a panic attack in the lunch room at school that literally shook me to my core. I got a huge wave of what I now understand to be depersonalization. My entire world become consumed by monitoring and checking whether or not I was feeling that super-detached, spacey feeling. “Is it there? What does this mean? Do I have a brain tumor? Am I safe?” Constantly. So scary.

As I grew up, health anxiety really started to take hold for me—I was often checking to see if I had any lumps on my body that might be cancer, noticing any fluttering of my heart and convincing myself that I was heaving a heart attack or that I had a heart condition.

I always identified more with the word “anxiety.” I was loosely diagnosed with OCD in college, but I never really identified with it very much, until later.

Into adulthood, I started noticing a trend when it came to me being in relationships. I would start to get close to someone, then start having doubt about that person, which would cause a lot of anxiety for me, and then I would push them away from me and break up with them to get that anxiety to go away. I remember thinking, “I literally don’t think I can function in any other area of my life if I keep dating this person—this is clearly the universe telling me that they aren’t the right person for me—and I need to end it.” Then I would eventually let them back in, because I missed them, only to break up with them again because I felt too anxious. This tortuous cycle is what eventually led me to start looking into why I’m behaving like this—and that led me to understanding my struggles with OCD.

OCD has taken on many different forms for me, including harm and sexual obsessions. When I would see awful events happening in the news, I would get consumed by, “Wait, am I actually that person who wants to do something like that too?” Being consumed with analyzing sexual attraction is a theme that I’ve struggled with a lot, too.[image error]

Once you knew it was OCD how did you go about tackling it? How did you know where to start?

I had talked with a couple of therapists about OCD—and then eventually heard about Dr. Steven Phillipson through reading Pure OCD: The Invisible Side of Obsessive Compulsive Disorder by Chrissie Hodges. I got on his waiting list and ended up working with him for about a year doing exposure and response prevention (ERP).

You’ve taken a holistic approach to your care, and yoga has been a huge part of the process. Tell us how it helps, and how you would respond to someone like me, who might say, “But I can’t even touch my toes! I can’t do yoga.”

I hear this all the time. And trust me—you don’t have to be able to touch your toes to do yoga. It isn’t about twisting yourself into a pretzel. Yoga has been a key piece in my mental health journey. I always say that yoga is truly a journey back to ourselves. It’s an amazing tool to quiet some of the noise in our minds and truly get into our bodies. There’s so much clarity that I find on my yoga mat.[image error]

Shame and guilt can wreak havoc on our recovery, making us feel unworthy of love, help, and healing. When you feel like you’re drowning in shame, how do you pull yourself out and move forward?

The shame is one of the toughest pieces for me. The things that our minds try to convince us of are so scary. And so isolating. Acceptance and commitment therapy (ACT) has been a beautiful tool for me to maneuver a lot of that shame. I tell myself often—the thoughts, the emotions, the shame, the sensations in my body—they all get to come along for the ride. I’m not going to push them away, but they don’t get to sit in the driver’s seat. I get to decide what my actions are going to be, and I do my best to make sure those actions are more in line with how I want to be living my life.

If you could offer just one piece of advice to others with OCD, what would it be?

It’s okay to step out into the world messy. You don’t have to always feel like you have it pulled together. Embrace the mess and show up for your life. One step at a time.

Showing up with OCD and anxiety: Bryan Piatt

[image error]After a long hiatus, Tuesday Q&A is back! I couldn’t be more honored to share some insight from my latest guest, someone I’m so lucky to call my friend, Bryan Piatt. Bryan and I met four years ago when his employer, KARE 11, assigned him to a story about an “ugly Christmas sweater” Target was selling—it said, “OCD: Obsessive Christmas Disorder”—and Bryan reached out to me for an interview. (I agreed that the sweater was ugly, all right, but for very different reasons.)

After several years in his dream job as a TV reporter, Bryan decided to focus more time on some behind-the-scenes work, including his labor of love, Refresh Network, and sharing his experience with anxiety and obsessive-compulsive disorder (OCD) with his fans—and beyond.

Because you’ve been on TV for several years—and because you’re funny, engaging, and smart—you have a platform for spreading awareness of mental health. You’ve recently started to share your story. Why did you decide to open up? And what has the response been like?

Can you please keep going with the compliments? But for real—I have always had this deep sense that I wanted to use my platform from working on television to share my story and help other people who may be struggling with their mental health. My word for 2019 has been “action”—taking action toward all the things I’ve been talking about doing for years—and a big piece of that was opening up more about my own mental health journey. The response has been absolutely beautiful so far. So much love and support out there and so many people feeling safe to share their own mental health struggles with me too, which is such an honor. We all have things we’re struggling with and need safe spaces to be able to talk about them.[image error]

How did you realize what you’d been going through was OCD? Can you tell us about some of your obsessions?

Looking back I think there were a lot of signs of anxiety and OCD doing their thing when I was younger. I was always scared of throwing up in public, scared of fainting during choir recitals at school, very anxious about sleepovers with friends—those kinds of things.

In middle school I had a panic attack in the lunch room at school that literally shook me to my core. I got a huge wave of what I now understand to be depersonalization. My entire world become consumed by monitoring and checking whether or not I was feeling that super-detached, spacey feeling. “Is it there? What does this mean? Do I have a brain tumor? Am I safe?” Constantly. So scary.

As I grew up, health anxiety really started to take hold for me—I was often checking to see if I had any lumps on my body that might be cancer, noticing any fluttering of my heart and convincing myself that I was heaving a heart attack or that I had a heart condition.

I always identified more with the word “anxiety.” I was loosely diagnosed with OCD in college, but I never really identified with it very much, until later.

Into adulthood, I started noticing a trend when it came to me being in relationships. I would start to get close to someone, then start having doubt about that person, which would cause a lot of anxiety for me, and then I would push them away from me and break up with them to get that anxiety to go away. I remember thinking, “I literally don’t think I can function in any other area of my life if I keep dating this person—this is clearly the universe telling me that they aren’t the right person for me—and I need to end it.” Then I would eventually let them back in, because I missed them, only to break up with them again because I felt too anxious. This tortuous cycle is what eventually led me to start looking into why I’m behaving like this—and that led me to understanding my struggles with OCD.

OCD has taken on many different forms for me, including harm and sexual obsessions. When I would see awful events happening in the news, I would get consumed by, “Wait, am I actually that person who wants to do something like that too?” Being consumed with analyzing sexual attraction is a theme that I’ve struggled with a lot, too.[image error]

Once you knew it was OCD how did you go about tackling it? How did you know where to start?

I had talked with a couple of therapists about OCD—and then eventually heard about Dr. Steven Phillipson through reading Pure OCD: The Invisible Side of Obsessive Compulsive Disorder by Chrissie Hodges. I got on his waiting list and ended up working with him for about a year doing exposure and response prevention (ERP).

You’ve taken a holistic approach to your care, and yoga has been a huge part of the process. Tell us how it helps, and how you would respond to someone like me, who might say, “But I can’t even touch my toes! I can’t do yoga.”

I hear this all the time. And trust me—you don’t have to be able to touch your toes to do yoga. It isn’t about twisting yourself into a pretzel. Yoga has been a key piece in my mental health journey. I always say that yoga is truly a journey back to ourselves. It’s an amazing tool to quiet some of the noise in our minds and truly get into our bodies. There’s so much clarity that I find on my yoga mat.[image error]

Shame and guilt can wreak havoc on our recovery, making us feel unworthy of love, help, and healing. When you feel like you’re drowning in shame, how do you pull yourself out and move forward?

The shame is one of the toughest pieces for me. The things that our minds try to convince us of are so scary. And so isolating. Acceptance and commitment therapy (ACT) has been a beautiful tool for me to maneuver a lot of that shame. I tell myself often—the thoughts, the emotions, the shame, the sensations in my body—they all get to come along for the ride. I’m not going to push them away, but they don’t get to sit in the driver’s seat. I get to decide what my actions are going to be, and I do my best to make sure those actions are more in line with how I want to be living my life.

If you could offer just one piece of advice to others with OCD, what would it be?

It’s okay to step out into the world messy. You don’t have to always feel like you have it pulled together. Embrace the mess and show up for your life. One step at a time.

Residential Treatment for OCD: Anna Wetrosky

[image error]Happy Tuesday! Today we’re hearing from Anna Wetrosky, who’s graciously shared her experience with multiple diagnoses and residential treatment for obsessive-compulsive disorder (OCD) and anorexia. Anna is a generous volunteer with a local nonprofit and a strong person with a lot of insight to offer. Thank you, Anna!

How long have you had OCD? And how long did you experience symptoms before you were diagnosed?

I’ve had some symptoms for as long as I can remember—they weren’t anything obvious when I was younger unless you were a specialist probably. I was diagnosed with an anorexia when I was 12 years old, but that wasn’t considered an off-shoot of OCD in 1997. I received an actual diagnosis in 2000.

Once you were diagnosed, how did you go about treating it?

I was diagnosed after being hospitalized, so I had 24/7 care for two weeks when I was 15. Then I was moved to outpatient once a week, then once every two weeks until I was 18. I went back into outpatient therapy a few years later in college and have been in more inpatient, partial programs, and outpatient during various times since then.

You went through residential treatment at Rogers Behavioral Health in Wisconsin. Why did you decide to commit to that level of treatment?

I researched centers and contacted Rogers after I had been in multiple treatments for seven years without the success in lowering my OCD symptoms that I was looking for. I hadn’t received much information on proven treatments for OCD even though I had been diagnosed with it years before. I had been bounced around in general treatments and was feeling frustrated and angry. My age and growing independence were factors in making a big change without the okay of anyone else.

[image error]

Tell us what a typical day was like at Rogers.

I was there about ten years ago, so things may be different now. The staff woke people up to get their medications before breakfast if you took them along with your weight and vitals. You might not get weight and vitals taken in a non-eating-disorder track, I’m not sure. After that was a buffet-style breakfast. Some people had different dietary requirements. Your exposures happen all throughout the day and vary depending on your specific fears and hierarchy. One of my exposures was to eat varying amounts of my food—between 75 and 100 percent. I struggled with wanting to eat nothing or “having” to eat a certain amount. Everyone in my house also had at least one exposure dealing with food. After that was morning hygiene. I had trouble brushing my teeth in a reasonable amount of time, so I would time myself—not brushing my teeth for more than two minutes.

Then we sat in a group with our therapists and other clients and checked in with how our exposures were going. We carried around small black books with our symptoms and checked about how many times we did them during the day. This was also dedicated time to practice our specific exposures and rate them as our anxiety went up and down—there are staff members present during this time who can be helpful for support. I had exposures to do on the internet surrounding Facebook, using the phone, and in general conversing with people in different ways. Everyone had certain staff members that they got along with well or didn’t like to be around—that was something I didn’t like because of my avoidance surrounding interpersonal issues.

Lunch was similar to breakfast, and then we did some cognitive restructuring and thought challenging. I had a pretty constant thought (still do sometimes) of “everyone hates me.” I labeled it as mind-reading, listing the reasons that led to me thinking it was true, then writing only the things I knew to be accurate.

Experiential therapy in the afternoon was usually an outing for clients who had the okay from their therapist to do exposures and practice outside of the center. One day we went to the mall where I practiced trying on clothes and making small purchases (something I had avoided more and more over the years). Other outings went to Hobby Lobby and the local library. Making clients behave outside was a challenge for the therapists—don’t waste your time trying to bend the rules with the cool kids. You’re paying to be in treatment!

Supervised assignment work happened in the afternoon. Since every person has a different background, we worked on some of the same things but also had individualized goals. A friend of mine had experienced sexual trauma, so her assignment was to write down what happened to her since she could barely talk about it. As she became more comfortable, she told her therapist and courageously eventually read the story to the entire group.

Since I was in a house that worked with eating disorders along with any other OCD issues, we sometimes split up for meals as we progressed in our treatment. Toward the end of my stay I ate dinner in the hospital cafeteria (all by myself!). Not having to be watched while you eat is pretty exciting when you’ve been in eating disorder treatment for months. Once you progress in your treatment if you are working on an eating disorder, you also get to go out to eat with a few people, by yourself, or with your therapist.

After dinner we would all get together to review our goals, then have some more supervised assignment work where we’d spread out around the building if we wanted. Finally, we had a short group activity or took care of chores, laundry, and so on. Weekends were more lax with more free time. We spent a lot of time sharing music (pirating also—which is funny to think about now) and talking about our lives. Someone had a guitar, so we’d play that—someone else had a board game. There are TVs to watch movies, cable, and computers to use the internet. It’s like jail, but a lot better.

[image error]

How did you adjust to daily life after residential treatment? Did you experience any hiccups without 24/7 access to care?

I had a little different experience after leaving. It was recommended I go to another inpatient program since I couldn’t do the partial program at Rogers (I was still having suicidal thoughts at that time). I honestly don’t know what the reasoning for that was, but that was what happened. The hardest thing for me to deal with when getting out of residential treatment was dealing with relationships issues. I’ve always had the hardest time dealing with those, so not having someone to talk to right away when starting out was hard. But it is also freeing, because you can get really sick of constantly being monitored.

You have also been diagnosed with an eating disorder, bipolar disorder, and borderline personality disorder. Has treatment for one disorder informed how you approach another? What challenges do co-morbid diagnoses present?

I haven’t changed anything in particular regarding treatment due to one disorder, but they have influenced each other subconsciously for better or worse. When I try to eat well to deal with the eating disorder, that raises my anxiety and can lead to more borderline and OCD symptoms. It can also help, because eating regularly is better for blood sugar and helps with depressive swings. There are general things I try to follow that helps everything—getting enough sleep, eating well, and exercising that typically apply all around.

You volunteer with OCD Twin Cities. Why did you decide to give back in this way?

I decided to volunteer because I had been through enough treatment that I felt I had extra knowledge that wasn’t necessarily being used by me. It was also a good chance to meet people and get involved. There is something satisfying about hoping what what you’ve learned from your negative experiences could help others not make the same mistakes.

If you could give just one piece of advice to others with OCD, what would it be?

Probably to remember that there’s no silver bullet. As shiny as that idea can be it’s just not realistic in 99 percent or more of cases. People who aren’t diagnosed with psychiatric disorders fall into this trap all the time as we can see—just look at the diet industry. In a way it seems more overwhelming that there’s no silver bullet—so many things to think about. You may have to start small and take one step at a time if necessary.

I know this is two things, but continuing exposure therapy on my own has been insanely helpful. It’s so easy to get out of treatment and be like, “Okay, I’m better now. Don’t have to think about that stuff anymore.” But again, unfortunately, for 99+ percent of people your OCD/other disorder won’t go away. It will just need to be managed. I had to use some exposure therapy to write these answers—I honestly avoided it for two months, as Alison can attest to, even though I was glad to share my experience. But finally I had to sit down, start an Excel spreadsheet, start setting goals and rating my anxiety as I went along. Here I am doing similar exposures around social media and putting myself in the spotlight ten years later. But it’s done, so go me!

Residential treatment for OCD: Anna Wetrosky

[image error]Happy Tuesday! Today we’re hearing from Anna Wetrosky, who’s graciously shared her experience with multiple diagnoses and residential treatment for obsessive-compulsive disorder (OCD) and anorexia. Anna is a generous volunteer with a local nonprofit and a strong person with a lot of insight to offer. Thank you, Anna!

How long have you had OCD? And how long did you experience symptoms before you were diagnosed?

I’ve had some symptoms for as long as I can remember—they weren’t anything obvious when I was younger unless you were a specialist probably. I was diagnosed with an anorexia when I was 12 years old, but that wasn’t considered an off-shoot of OCD in 1997. I received an actual diagnosis in 2000.

Once you were diagnosed, how did you go about treating it?

I was diagnosed after being hospitalized, so I had 24/7 care for two weeks when I was 15. Then I was moved to outpatient once a week, then once every two weeks until I was 18. I went back into outpatient therapy a few years later in college and have been in more inpatient, partial programs, and outpatient during various times since then.

You went through residential treatment at Rogers Behavioral Health in Wisconsin. Why did you decide to commit to that level of treatment?

I researched centers and contacted Rogers after I had been in multiple treatments for seven years without the success in lowering my OCD symptoms that I was looking for. I hadn’t received much information on proven treatments for OCD even though I had been diagnosed with it years before. I had been bounced around in general treatments and was feeling frustrated and angry. My age and growing independence were factors in making a big change without the okay of anyone else.

[image error]

Tell us what a typical day was like at Rogers.

I was there about ten years ago, so things may be different now. The staff woke people up to get their medications before breakfast if you took them along with your weight and vitals. You might not get weight and vitals taken in a non-eating-disorder track, I’m not sure. After that was a buffet-style breakfast. Some people had different dietary requirements. Your exposures happen all throughout the day and vary depending on your specific fears and hierarchy. One of my exposures was to eat varying amounts of my food—between 75 and 100 percent. I struggled with wanting to eat nothing or “having” to eat a certain amount. Everyone in my house also had at least one exposure dealing with food. After that was morning hygiene. I had trouble brushing my teeth in a reasonable amount of time, so I would time myself—not brushing my teeth for more than two minutes.

Then we sat in a group with our therapists and other clients and checked in with how our exposures were going. We carried around small black books with our symptoms and checked about how many times we did them during the day. This was also dedicated time to practice our specific exposures and rate them as our anxiety went up and down—there are staff members present during this time who can be helpful for support. I had exposures to do on the internet surrounding Facebook, using the phone, and in general conversing with people in different ways. Everyone had certain staff members that they got along with well or didn’t like to be around—that was something I didn’t like because of my avoidance surrounding interpersonal issues.

Lunch was similar to breakfast, and then we did some cognitive restructuring and thought challenging. I had a pretty constant thought (still do sometimes) of “everyone hates me.” I labeled it as mind-reading, listing the reasons that led to me thinking it was true, then writing only the things I knew to be accurate.

Experiential therapy in the afternoon was usually an outing for clients who had the okay from their therapist to do exposures and practice outside of the center. One day we went to the mall where I practiced trying on clothes and making small purchases (something I had avoided more and more over the years). Other outings went to Hobby Lobby and the local library. Making clients behave outside was a challenge for the therapists—don’t waste your time trying to bend the rules with the cool kids. You’re paying to be in treatment!

Supervised assignment work happened in the afternoon. Since every person has a different background, we worked on some of the same things but also had individualized goals. A friend of mine had experienced sexual trauma, so her assignment was to write down what happened to her since she could barely talk about it. As she became more comfortable, she told her therapist and courageously eventually read the story to the entire group.

Since I was in a house that worked with eating disorders along with any other OCD issues, we sometimes split up for meals as we progressed in our treatment. Toward the end of my stay I ate dinner in the hospital cafeteria (all by myself!). Not having to be watched while you eat is pretty exciting when you’ve been in eating disorder treatment for months. Once you progress in your treatment if you are working on an eating disorder, you also get to go out to eat with a few people, by yourself, or with your therapist.

After dinner we would all get together to review our goals, then have some more supervised assignment work where we’d spread out around the building if we wanted. Finally, we had a short group activity or took care of chores, laundry, and so on. Weekends were more lax with more free time. We spent a lot of time sharing music (pirating also—which is funny to think about now) and talking about our lives. Someone had a guitar, so we’d play that—someone else had a board game. There are TVs to watch movies, cable, and computers to use the internet. It’s like jail, but a lot better.

[image error]

How did you adjust to daily life after residential treatment? Did you experience any hiccups without 24/7 access to care?

I had a little different experience after leaving. It was recommended I go to another inpatient program since I couldn’t do the partial program at Rogers (I was still having suicidal thoughts at that time). I honestly don’t know what the reasoning for that was, but that was what happened. The hardest thing for me to deal with when getting out of residential treatment was dealing with relationships issues. I’ve always had the hardest time dealing with those, so not having someone to talk to right away when starting out was hard. But it is also freeing, because you can get really sick of constantly being monitored.

You have also been diagnosed with an eating disorder, bipolar disorder, and borderline personality disorder. Has treatment for one disorder informed how you approach another? What challenges do co-morbid diagnoses present?

I haven’t changed anything in particular regarding treatment due to one disorder, but they have influenced each other subconsciously for better or worse. When I try to eat well to deal with the eating disorder, that raises my anxiety and can lead to more borderline and OCD symptoms. It can also help, because eating regularly is better for blood sugar and helps with depressive swings. There are general things I try to follow that helps everything—getting enough sleep, eating well, and exercising that typically apply all around.

You volunteer with OCD Twin Cities. Why did you decide to give back in this way?

I decided to volunteer because I had been through enough treatment that I felt I had extra knowledge that wasn’t necessarily being used by me. It was also a good chance to meet people and get involved. There is something satisfying about hoping what what you’ve learned from your negative experiences could help others not make the same mistakes.

If you could give just one piece of advice to others with OCD, what would it be?

Probably to remember that there’s no silver bullet. As shiny as that idea can be it’s just not realistic in 99 percent or more of cases. People who aren’t diagnosed with psychiatric disorders fall into this trap all the time as we can see—just look at the diet industry. In a way it seems more overwhelming that there’s no silver bullet—so many things to think about. You may have to start small and take one step at a time if necessary.

I know this is two things, but continuing exposure therapy on my own has been insanely helpful. It’s so easy to get out of treatment and be like, “Okay, I’m better now. Don’t have to think about that stuff anymore.” But again, unfortunately, for 99+ percent of people your OCD/other disorder won’t go away. It will just need to be managed. I had to use some exposure therapy to write these answers—I honestly avoided it for two months, as Alison can attest to, even though I was glad to share my experience. But finally I had to sit down, start an Excel spreadsheet, start setting goals and rating my anxiety as I went along. Here I am doing similar exposures around social media and putting myself in the spotlight ten years later. But it’s done, so go me!

Tuesday Q&A: Anna Wetrosky

[image error]Happy Tuesday! Today we’re hearing from Anna Wetrosky, who’s graciously shared her experience with multiple diagnoses and residential treatment for obsessive-compulsive disorder (OCD) and anorexia. Anna is a generous volunteer with a local nonprofit and a strong person with a lot of insight to offer. Thank you, Anna!

How long have you had OCD? And how long did you experience symptoms before you were diagnosed?

I’ve had some symptoms for as long as I can remember—they weren’t anything obvious when I was younger unless you were a specialist probably. I was diagnosed with an anorexia when I was 12 years old, but that wasn’t considered an off-shoot of OCD in 1997. I received an actual diagnosis in 2000.

Once you were diagnosed, how did you go about treating it?

I was diagnosed after being hospitalized, so I had 24/7 care for two weeks when I was 15. Then I was moved to outpatient once a week, then once every two weeks until I was 18. I went back into outpatient therapy a few years later in college and have been in more inpatient, partial programs, and outpatient during various times since then.

You went through residential treatment at Rogers Behavioral Health in Wisconsin. Why did you decide to commit to that level of treatment?

I researched centers and contacted Rogers after I had been in multiple treatments for seven years without the success in lowering my OCD symptoms that I was looking for. I hadn’t received much information on proven treatments for OCD even though I had been diagnosed with it years before. I had been bounced around in general treatments and was feeling frustrated and angry. My age and growing independence were factors in making a big change without the okay of anyone else.

[image error]

Tell us what a typical day was like at Rogers.

I was there about ten years ago, so things may be different now. The staff woke people up to get their medications before breakfast if you took them along with your weight and vitals. You might not get weight and vitals taken in a non-eating-disorder track, I’m not sure. After that was a buffet-style breakfast. Some people had different dietary requirements. Your exposures happen all throughout the day and vary depending on your specific fears and hierarchy. One of my exposures was to eat varying amounts of my food—between 75 and 100 percent. I struggled with wanting to eat nothing or “having” to eat a certain amount. Everyone in my house also had at least one exposure dealing with food. After that was morning hygiene. I had trouble brushing my teeth in a reasonable amount of time, so I would time myself—not brushing my teeth for more than two minutes.

Then we sat in a group with our therapists and other clients and checked in with how our exposures were going. We carried around small black books with our symptoms and checked about how many times we did them during the day. This was also dedicated time to practice our specific exposures and rate them as our anxiety went up and down—there are staff members present during this time who can be helpful for support. I had exposures to do on the internet surrounding Facebook, using the phone, and in general conversing with people in different ways. Everyone had certain staff members that they got along with well or didn’t like to be around—that was something I didn’t like because of my avoidance surrounding interpersonal issues.

Lunch was similar to breakfast, and then we did something cognitive restructuring and thought challenging. I had a pretty constant thought (still do sometimes) of “everyone hates me.” I challenged with labeling it as mind-reading, listing the reasons that led to me thinking it was true, then writing only the things I knew to be accurate.

Experiential therapy in the afternoon was usually an outing for clients who had the okay from their therapist to do exposures and practice outside of the center. One day we went to the mall where I practiced trying on clothes and making small purchases (something I had avoided more and more over the years). Other outings went to Hobby Lobby and the local library. Making clients behave outside was a challenge for the therapists—don’t waste your time trying to bend the rules with the cool kids. You’re paying to be in treatment!

Supervised assignment work happened in the afternoon. Since every person has a different background, we worked on some of the same things but also had individualized goals. A friend of mine had experienced sexual trauma, so her assignment was to write down what happened to her since she could barely talk about it. As she became more comfortable, she told her therapist and courageously eventually read the story to the entire group.

Since I was in a house that worked with eating disorders along with any other OCD issues, we sometimes split up for meals as we progressed in our treatment. Toward the end of my stay I ate dinner in the hospital cafeteria (all by myself!). Not having to be watched while you eat is pretty exciting when you’ve been in eating disorder treatment for months. Once you progress in your treatment if you are working on an eating disorder, you also get to go out to eat with a few people, yourself, or your therapist.

After dinner we would all get together to review our goals, then have some more supervised assignment work where we’d spread out around the building if we wanted. Finally, we had a short group activity or took care of chores, laundry, and so on. Weekends were more lax with more free time. We spent a lot of time sharing music (pirating also—which is funny to think about now) and talking about our lives. Someone had a guitar, so we’d play that—someone else had a board game. There are TVs to watch movies, cable, and computers to use the internet. It’s like jail, but a lot better.

[image error]

How did you adjust to daily life after residential treatment? Did you experience any hiccups without 24/7 access to care?

I had a little different experience after leaving. It was recommended I go to another inpatient program since I couldn’t do the partial program at Rogers (I was still having suicidal thoughts at that time). I honestly don’t know what the reasoning for that was, but that was what happened. The hardest thing for me to deal with when getting out of residential treatment was dealing with relationships issues. I’ve always had the hardest time dealing with those, so not having someone to talk to right away when starting out was hard. But it is also freeing, because you can get really sick of constantly being monitored.

You have also been diagnosed with an eating disorder, bipolar disorder, and borderline personality disorder. Has treatment for one disorder informed how you approach another? What challenges do co-morbid diagnoses present?

I haven’t changed anything in particular regarding treatment due to one disorder, but they have influenced each other subconsciously for better or worse. When I try to eat well to deal with the eating disorder, that raises my anxiety and can lead to more borderline and OCD symptoms. It can also help, because eating regularly is better for blood sugar and helps with depressive swings. There are general things I try to follow that helps everything—getting enough sleep, eating well, and exercising that typically apply all around.

You volunteer with OCD Twin Cities. Why did you decide to give back in this way?

I decided to volunteer because I had been through enough treatment that I felt I had extra knowledge that wasn’t necessarily being used by me. It was also a good chance to meet people and get involved. There is something satisfying about hoping what what you’ve learned from your negative experiences could help others not make the same mistakes.

If you could give just one piece of advice to others with OCD, what would it be?

Probably to remember that there’s no silver bullet. As shiny as that idea can be it’s just not realistic in 99 percent or more of cases. People who aren’t diagnosed with psychiatric disorders fall into this trap all the time as we can see—just look at the diet industry. In a way it seems more overwhelming that there’s no silver bullet—so many things to think about. You may have to start small and take one step at a time if necessary.

I know this is two things, but continuing exposure therapy on my own has been insanely helpful. It’s so easy to get out of treatment and be like, “Okay, I’m better now. Don’t have to think about that stuff anymore.” But again, unfortunately, for 99+ percent of people your OCD/other disorder won’t go away. It will just need to be managed. I had to use some exposure therapy to write these answers—I honestly avoided it for two months, as Alison can attest to, even though I was glad to share my experience. But finally I had to sit down, start an Excel spreadsheet, start setting goals and rating my anxiety as I went along. Here I am doing similar exposures around social media and putting myself in the spotlight ten years later. But it’s done, so go me!

What Have You Been Up To, Jon Hershfield?

[image error]I first hosted Jon Hershfield in a Tuesday Q&A in 2015 and he’s done so much since then it’s time to have him back! With four books under his belt, he puts authors like me to shame, so I don’t know why I’m continuing to promote him. But, really, he has a wealth of practical advice to offer and always does so with humor and compassion. We’re lucky to have him in the OCD community.

A lot has happened since we last chatted! You may be the most ambitious person I know: You just published your fourth book, Overcoming Harm OCD. One of the most common questions I hear about harm-related intrusive thoughts is “How will ERP work for me? It’s not like I can walk around with a sharp knife.” How would you answer that question as a therapist?

Well, you can literally walk around with a sharp knife. Normally we do this when we’re on our way to divide a sandwich. But the question has to do with concern about causing actual harm in the course of doing exposure to a fear of causing harm. In ERP we do a lot of scary things, but what we don’t do is actually hurt people. In OCD there’s been some problematic training of the brain to assign “danger” to uncertainty about harm thoughts. So if I see a knife and I have an intrusive thought of causing harm with it, my brain may believe we are in danger. ERP works by getting in the ring with that uncertainty, resisting compulsions and other safety behaviors, and retraining the brain to have a different association with the uncertainty. So actually, yeah, handling a sharp knife in the presence of unwanted thoughts and other triggers can be really good ERP. I think it’s easy to get confused here because one might think we don’t have people stab strangers as exposure simply because it’s wrong. It is wrong, but that’s not really why we don’t do it. We don’t do it because that would fail to actually teach the brain how to handle uncertainty. For exposures where handling a knife may be complicated (e.g., you can’t bring one on an airplane), we have imaginal exposure where we use writing as a strategy to trick the brain into thinking we could be in danger. In this state, we practice resisting compulsions and we create new learning about being uncertain. People with harm OCD are not the ticking time bombs they think they are, but no amount of me telling them this will actually touch the OCD. They have to experience the exposure without the compulsions to truly understand this.

We know that getting the right diagnosis and proper treatment can take years, and I’ve always wondered if it takes longer for folks with harm obsessions. When I was worried I’d hurt a child, I was afraid to tell anyone, even a therapist, because I thought they’d deem me a risk to society and call the police. In your experience, are individuals with harm obsessions less likely to seek help than those with, say, a germ phobia? Or is their fear that they’ll hurt somebody so strong they feel they must be stopped before it’s too late?

Both of these things are very common in unwanted violent obsessions. A person with harm OCD may avoid treatment because of the concern that the treatment provider will have them hospitalized or arrested, or that disclosure of these thoughts will bring shame and scorn to them and their families. In more severe cases, anxiety can be so high and insight so low that a belief develops in the mind of the person with OCD that they must be defective at the core. Essentially, they imagine that going to treatment will reveal this defect and the borrowed time they’re living with before hurting someone will come to a sudden end. We can largely blame external stigma about mental health issues, especially as it relates to intrusive thoughts, for inhibiting people from seeking help. But self-stigma is even more powerful and the belief that having these thoughts makes us immoral or bad keeps a lot of people from asking for help.

[image error] We know reassurance seeking is a compulsion, and giving reassurance only adds roadblocks to the recovery process, so what is the best way to help a loved one with these upsetting intrusive thoughts?

Loved ones can educate themselves about the disorder. Knowing your loved one without OCD understands that you have OCD is reassuring in the best possible way. If the sufferer and the family member (or partner, etc.) can work together with compassion and an educated understanding of the disorder, navigating reassurance becomes easier. Collaborating on non-reassuring, but compassionate, responses makes a huge difference. So rather than constantly telling a person with harm OCD that they’ll never hurt anyone, they can find appropriate ways of telling them that they understand OCD is really painful, that they are proud of and support the work that’s being done to overcome it, and that there are several shows on Netflix right now that demand more attention than the question on the table at the moment. Of course, none of this type of interaction is possible without empathy and kindness. Helping them access treatment when possible, supporting that treatment, and never confusing the symptoms with who the person really is are all instrumental.

Speaking of not giving in to compulsions, let’s talk about your book When a Family Member Has OCD. It must be hard for parents to resist the urge to act as a therapist themselves, and to instead support their child through the recovery process. What would you tell a parent who is at his wit’s end and just wants to make life easier for his child, even if that means doing the “wrong” thing?

In writing When a Family Member Has OCD, I really kept in mind two audiences: one is the family member who wants to better understand a loved one with OCD and the other is the OCD sufferer who wants to be understood. Families operate as systems. There is no such thing as a child with OCD that exists in a vacuum where the child just gets fixed by the therapist and life goes back to normal. A child with OCD does hard work with CBT/ERP to master the disorder. The parent of that child must also be willing to do exposure to their own fear that they aren’t doing enough to relieve their child’s suffering. It’s excruciating, but when parents sabotage the treatment by providing reassurance and accommodating rituals, they just set the stage for more pain for everyone later. Reassurance actually doesn’t make life easier for the child because it sends the message to the child’s brain that there was something dangerous to reassure about and that they could not have coped without your intervention. Confronting the discomfort over withholding reassurance means sitting with uncertainty about how much pain you and your child can withstand in the face of OCD. It’s not easy. But parents who overcome this fear get a better understanding of what it’s like for their child to overcome fear and when the child improves, the parent’s relationship to anxiety changes too, and the whole system improves.

[image error] You co-authored Everyday Mindfulness for OCD with Shala Nicely, an inspiring read about how to enhance ERP with mindfulness techniques. I’ll admit that I always thought sitting in silence with my horrific thoughts felt a little like torture—and many people can’t believe we’re supposed to accept those thoughts.

It’s an interesting way we often put it—“to sit in silence with horrific thoughts.” There are some inherent problems in framing it this way. First, it implies that in the absence of distraction, it’s just the self and the thoughts alone in space. But this isn’t true. In the absence of distraction, we see things as they really are, which includes input from all five senses and, yes, thoughts. So it’s really being in the company of six streams of information and treating them all as such. Sound, touch, thoughts, and so on are all just objects of attention being projected onto the screen of the mind, so if we learn how to pay attention, there’s a lot more to look at than just sitting with obsessions. This highlights the other problem, that word “horrific.” We get so used to categorizing thoughts like movie genres that we easily forget how thoughts are just words and pictures. They don’t really have positive or negative qualities unless we decide that they do. Yes, the thought of harming my children abhors me. But if I write “harming my children” in red marker on a piece of paper, the only thing that’s changed about the paper is that it has red ink on it. The same is true of us. When we think a thought, the thought is just words scribbled on the mind. It doesn’t change who we are.

Tell us how mindfulness can help, and explain why it’s a myth that meditation means completely clearing our minds of all thoughts.

Two problems occur in the way the OCD mind operates that can both be addressed with mindfulness, which simply means watching the mind objectively. First, the mind wanders from the present, as it should, no different than a puppy sniffing things on a walk around the block. But we often fail to notice that it’s wandered and then, in a way, we find the puppy pooping on the neighbor’s porch. In other words, we get lost in our obsessive thoughts because we have trouble paying attention to where the mind is in any given moment. Then, when we discover that we’ve been pulled away by an obsession, the disorder sets a precondition for returning to the present. We feel obliged to neutralize the obsession (i.e., get certainty that it isn’t true), to do a compulsion, and then we get permission to return to wherever we were before we got distracted. If, on the other hand, we had the capacity to notice early on when the mind has been pulled away by an obsession and could simply start over in that moment as if it never happened, without permission from the OCD, we’d be much more in command. Meditation is an exercise that targets these two strengths, of recognizing where the mind is in each moment, and starting over when we see the mind distracted. By definition, this requires the mind to not be clear, but to see it clearly. Have all the thoughts, but know that they are thoughts and don’t try to fix them.

What’s next for you?

It’s been brought to my attention that I’ve written four books in the past five years or so. I’m hoping that Overcoming Harm OCD helps more than just the kind, gentle, and creative people I’ve encountered in my clinical work, but harm OCD sufferers everywhere. I also hope it serves as an excuse for me to slow down before I find myself writing something about sexual obsessions. So what’s really “next” for me is just continuing to build my practice and doing the best I can to help empower the most people in their OCD recovery.

Catching up with author and therapist Jon Hershfield

[image error]I first hosted Jon Hershfield in a Tuesday Q&A in 2015 and he’s done so much since then it’s time to have him back! With four books under his belt, he puts authors like me to shame, so I don’t know why I’m continuing to promote him. But, really, he has a wealth of practical advice to offer and always does so with humor and compassion. We’re lucky to have him in the OCD community.

A lot has happened since we last chatted! You may be the most ambitious person I know: You just published your fourth book, Overcoming Harm OCD. One of the most common questions I hear about harm-related intrusive thoughts is “How will ERP work for me? It’s not like I can walk around with a sharp knife.” How would you answer that question as a therapist?

Well, you can literally walk around with a sharp knife. Normally we do this when we’re on our way to divide a sandwich. But the question has to do with concern about causing actual harm in the course of doing exposure to a fear of causing harm. In ERP we do a lot of scary things, but what we don’t do is actually hurt people. In OCD there’s been some problematic training of the brain to assign “danger” to uncertainty about harm thoughts. So if I see a knife and I have an intrusive thought of causing harm with it, my brain may believe we are in danger. ERP works by getting in the ring with that uncertainty, resisting compulsions and other safety behaviors, and retraining the brain to have a different association with the uncertainty. So actually, yeah, handling a sharp knife in the presence of unwanted thoughts and other triggers can be really good ERP. I think it’s easy to get confused here because one might think we don’t have people stab strangers as exposure simply because it’s wrong. It is wrong, but that’s not really why we don’t do it. We don’t do it because that would fail to actually teach the brain how to handle uncertainty. For exposures where handling a knife may be complicated (e.g., you can’t bring one on an airplane), we have imaginal exposure where we use writing as a strategy to trick the brain into thinking we could be in danger. In this state, we practice resisting compulsions and we create new learning about being uncertain. People with harm OCD are not the ticking time bombs they think they are, but no amount of me telling them this will actually touch the OCD. They have to experience the exposure without the compulsions to truly understand this.

We know that getting the right diagnosis and proper treatment can take years, and I’ve always wondered if it takes longer for folks with harm obsessions. When I was worried I’d hurt a child, I was afraid to tell anyone, even a therapist, because I thought they’d deem me a risk to society and call the police. In your experience, are individuals with harm obsessions less likely to seek help than those with, say, a germ phobia? Or is their fear that they’ll hurt somebody so strong they feel they must be stopped before it’s too late?

Both of these things are very common in unwanted violent obsessions. A person with harm OCD may avoid treatment because of the concern that the treatment provider will have them hospitalized or arrested, or that disclosure of these thoughts will bring shame and scorn to them and their families. In more severe cases, anxiety can be so high and insight so low that a belief develops in the mind of the person with OCD that they must be defective at the core. Essentially, they imagine that going to treatment will reveal this defect and the borrowed time they’re living with before hurting someone will come to a sudden end. We can largely blame external stigma about mental health issues, especially as it relates to intrusive thoughts, for inhibiting people from seeking help. But self-stigma is even more powerful and the belief that having these thoughts makes us immoral or bad keeps a lot of people from asking for help.

[image error] We know reassurance seeking is a compulsion, and giving reassurance only adds roadblocks to the recovery process, so what is the best way to help a loved one with these upsetting intrusive thoughts?

Loved ones can educate themselves about the disorder. Knowing your loved one without OCD understands that you have OCD is reassuring in the best possible way. If the sufferer and the family member (or partner, etc.) can work together with compassion and an educated understanding of the disorder, navigating reassurance becomes easier. Collaborating on non-reassuring, but compassionate, responses makes a huge difference. So rather than constantly telling a person with harm OCD that they’ll never hurt anyone, they can find appropriate ways of telling them that they understand OCD is really painful, that they are proud of and support the work that’s being done to overcome it, and that there are several shows on Netflix right now that demand more attention than the question on the table at the moment. Of course, none of this type of interaction is possible without empathy and kindness. Helping them access treatment when possible, supporting that treatment, and never confusing the symptoms with who the person really is are all instrumental.

Speaking of not giving in to compulsions, let’s talk about your book When a Family Member Has OCD. It must be hard for parents to resist the urge to act as a therapist themselves, and to instead support their child through the recovery process. What would you tell a parent who is at his wit’s end and just wants to make life easier for his child, even if that means doing the “wrong” thing?

In writing When a Family Member Has OCD, I really kept in mind two audiences: one is the family member who wants to better understand a loved one with OCD and the other is the OCD sufferer who wants to be understood. Families operate as systems. There is no such thing as a child with OCD that exists in a vacuum where the child just gets fixed by the therapist and life goes back to normal. A child with OCD does hard work with CBT/ERP to master the disorder. The parent of that child must also be willing to do exposure to their own fear that they aren’t doing enough to relieve their child’s suffering. It’s excruciating, but when parents sabotage the treatment by providing reassurance and accommodating rituals, they just set the stage for more pain for everyone later. Reassurance actually doesn’t make life easier for the child because it sends the message to the child’s brain that there was something dangerous to reassure about and that they could not have coped without your intervention. Confronting the discomfort over withholding reassurance means sitting with uncertainty about how much pain you and your child can withstand in the face of OCD. It’s not easy. But parents who overcome this fear get a better understanding of what it’s like for their child to overcome fear and when the child improves, the parent’s relationship to anxiety changes too, and the whole system improves.

[image error] You co-authored Everyday Mindfulness for OCD with Shala Nicely, an inspiring read about how to enhance ERP with mindfulness techniques. I’ll admit that I always thought sitting in silence with my horrific thoughts felt a little like torture—and many people can’t believe we’re supposed to accept those thoughts.

It’s an interesting way we often put it—“to sit in silence with horrific thoughts.” There are some inherent problems in framing it this way. First, it implies that in the absence of distraction, it’s just the self and the thoughts alone in space. But this isn’t true. In the absence of distraction, we see things as they really are, which includes input from all five senses and, yes, thoughts. So it’s really being in the company of six streams of information and treating them all as such. Sound, touch, thoughts, and so on are all just objects of attention being projected onto the screen of the mind, so if we learn how to pay attention, there’s a lot more to look at than just sitting with obsessions. This highlights the other problem, that word “horrific.” We get so used to categorizing thoughts like movie genres that we easily forget how thoughts are just words and pictures. They don’t really have positive or negative qualities unless we decide that they do. Yes, the thought of harming my children abhors me. But if I write “harming my children” in red marker on a piece of paper, the only thing that’s changed about the paper is that it has red ink on it. The same is true of us. When we think a thought, the thought is just words scribbled on the mind. It doesn’t change who we are.

Tell us how mindfulness can help, and explain why it’s a myth that meditation means completely clearing our minds of all thoughts.

Two problems occur in the way the OCD mind operates that can both be addressed with mindfulness, which simply means watching the mind objectively. First, the mind wanders from the present, as it should, no different than a puppy sniffing things on a walk around the block. But we often fail to notice that it’s wandered and then, in a way, we find the puppy pooping on the neighbor’s porch. In other words, we get lost in our obsessive thoughts because we have trouble paying attention to where the mind is in any given moment. Then, when we discover that we’ve been pulled away by an obsession, the disorder sets a precondition for returning to the present. We feel obliged to neutralize the obsession (i.e., get certainty that it isn’t true), to do a compulsion, and then we get permission to return to wherever we were before we got distracted. If, on the other hand, we had the capacity to notice early on when the mind has been pulled away by an obsession and could simply start over in that moment as if it never happened, without permission from the OCD, we’d be much more in command. Meditation is an exercise that targets these two strengths, of recognizing where the mind is in each moment, and starting over when we see the mind distracted. By definition, this requires the mind to not be clear, but to see it clearly. Have all the thoughts, but know that they are thoughts and don’t try to fix them.

What’s next for you?

It’s been brought to my attention that I’ve written four books in the past five years or so. I’m hoping that Overcoming Harm OCD helps more than just the kind, gentle, and creative people I’ve encountered in my clinical work, but harm OCD sufferers everywhere. I also hope it serves as an excuse for me to slow down before I find myself writing something about sexual obsessions. So what’s really “next” for me is just continuing to build my practice and doing the best I can to help empower the most people in their OCD recovery.

Catching Up With Jon Hershfield

[image error]I first hosted Jon Hershfield in a Tuesday Q&A in 2015 and he’s done so much since then it’s time to have him back! With four books under his belt, he puts authors like me to shame, so I don’t know why I’m continuing to promote him. But, really, he has a wealth of practical advice to offer and always does so with humor and compassion. We’re lucky to have him in the OCD community.

A lot has happened since we last chatted! You may be the most ambitious person I know: You just published your fourth book, Overcoming Harm OCD. One of the most common questions I hear about harm-related intrusive thoughts is “How will ERP work for me? It’s not like I can walk around with a sharp knife.” How would you answer that question as a therapist?

Well, you can literally walk around with a sharp knife. Normally we do this when we’re on our way to divide a sandwich. But the question has to do with concern about causing actual harm in the course of doing exposure to a fear of causing harm. In ERP we do a lot of scary things, but what we don’t do is actually hurt people. In OCD there’s been some problematic training of the brain to assign “danger” to uncertainty about harm thoughts. So if I see a knife and I have an intrusive thought of causing harm with it, my brain may believe we are in danger. ERP works by getting in the ring with that uncertainty, resisting compulsions and other safety behaviors, and retraining the brain to have a different association with the uncertainty. So actually, yeah, handling a sharp knife in the presence of unwanted thoughts and other triggers can be really good ERP. I think it’s easy to get confused here because one might think we don’t have people stab strangers as exposure simply because it’s wrong. It is wrong, but that’s not really why we don’t do it. We don’t do it because that would fail to actually teach the brain how to handle uncertainty. For exposures where handling a knife may be complicated (e.g., you can’t bring one on an airplane), we have imaginal exposure where we use writing as a strategy to trick the brain into thinking we could be in danger. In this state, we practice resisting compulsions and we create new learning about being uncertain. People with harm OCD are not the ticking time bombs they think they are, but no amount of me telling them this will actually touch the OCD. They have to experience the exposure without the compulsions to truly understand this.

We know that getting the right diagnosis and proper treatment can take years, and I’ve always wondered if it takes longer for folks with harm obsessions. When I was worried I’d hurt a child, I was afraid to tell anyone, even a therapist, because I thought they’d deem me a risk to society and call the police. In your experience, are individuals with harm obsessions less likely to seek help than those with, say, a germ phobia? Or is their fear that they’ll hurt somebody so strong they feel they must be stopped before it’s too late?

Both of these things are very common in unwanted violent obsessions. A person with harm OCD may avoid treatment because of the concern that the treatment provider will have them hospitalized or arrested, or that disclosure of these thoughts will bring shame and scorn to them and their families. In more severe cases, anxiety can be so high and insight so low that a belief develops in the mind of the person with OCD that they must be defective at the core. Essentially, they imagine that going to treatment will reveal this defect and the borrowed time they’re living with before hurting someone will come to a sudden end. We can largely blame external stigma about mental health issues, especially as it relates to intrusive thoughts, for inhibiting people from seeking help. But self-stigma is even more powerful and the belief that having these thoughts makes us immoral or bad keeps a lot of people from asking for help.

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We know reassurance seeking is a compulsion, and giving reassurance only adds roadblocks to the recovery process, so what is the best way to help a loved one with these upsetting intrusive thoughts?

Loved ones can educate themselves about the disorder. Knowing your loved one without OCD understands that you have OCD is reassuring in the best possible way. If the sufferer and the family member (or partner, etc.) can work together with compassion and an educated understanding of the disorder, navigating reassurance becomes easier. Collaborating on non-reassuring, but compassionate, responses makes a huge difference. So rather than constantly telling a person with harm OCD that they’ll never hurt anyone, they can find appropriate ways of telling them that they understand OCD is really painful, that they are proud of and support the work that’s being done to overcome it, and that there are several shows on Netflix right now that demand more attention than the question on the table at the moment. Of course, none of this type of interaction is possible without empathy and kindness. Helping them access treatment when possible, supporting that treatment, and never confusing the symptoms with who the person really is are all instrumental.

Speaking of not giving in to compulsions, let’s talk about your book When a Family Member Has OCD. It must be hard for parents to resist the urge to act as a therapist themselves, and to instead support their child through the recovery process. What would you tell a parent who is at his wit’s end and just wants to make life easier for his child, even if that means doing the “wrong” thing?

In writing When a Family Member Has OCD, I really kept in mind two audiences: one is the family member who wants to better understand a loved one with OCD and the other is the OCD sufferer who wants to be understood. Families operate as systems. There is no such thing as a child with OCD that exists in a vacuum where the child just gets fixed by the therapist and life goes back to normal. A child with OCD does hard work with CBT/ERP to master the disorder. The parent of that child must also be willing to do exposure to their own fear that they aren’t doing enough to relieve their child’s suffering. It’s excruciating, but when parents sabotage the treatment by providing reassurance and accommodating rituals, they just set the stage for more pain for everyone later. Reassurance actually doesn’t make life easier for the child because it sends the message to the child’s brain that there was something dangerous to reassure about and that they could not have coped without your intervention. Confronting the discomfort over withholding reassurance means sitting with uncertainty about how much pain you and your child can withstand in the face of OCD. It’s not easy. But parents who overcome this fear get a better understanding of what it’s like for their child to overcome fear and when the child improves, the parent’s relationship to anxiety changes too, and the whole system improves.

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You co-authored Everyday Mindfulness for OCD with Shala Nicely, an inspiring read about how to enhance ERP with mindfulness techniques. I’ll admit that I always thought sitting in silence with my horrific thoughts felt a little like torture—and many people can’t believe we’re supposed to accept those thoughts.

It’s an interesting way we often put it—“to sit in silence with horrific thoughts.” There are some inherent problems in framing it this way. First, it implies that in the absence of distraction, it’s just the self and the thoughts alone in space. But this isn’t true. In the absence of distraction, we see things as they really are, which includes input from all five senses and, yes, thoughts. So it’s really being in the company of six streams of information and treating them all as such. Sound, touch, thoughts, and so on are all just objects of attention being projected onto the screen of the mind, so if we learn how to pay attention, there’s a lot more to look at than just sitting with obsessions. This highlights the other problem, that word “horrific.” We get so used to categorizing thoughts like movie genres that we easily forget how thoughts are just words and pictures. They don’t really have positive or negative qualities unless we decide that they do. Yes, the thought of harming my children abhors me. But if I write “harming my children” in red marker on a piece of paper, the only thing that’s changed about the paper is that it has red ink on it. The same is true of us. When we think a thought, the thought is just words scribbled on the mind. It doesn’t change who we are.

Tell us how mindfulness can help, and explain why it’s a myth that meditation means completely clearing our minds of all thoughts.

Two problems occur in the way the OCD mind operates that can both be addressed with mindfulness, which simply means watching the mind objectively. First, the mind wanders from the present, as it should, no different than a puppy sniffing things on a walk around the block. But we often fail to notice that it’s wandered and then, in a way, we find the puppy pooping on the neighbor’s porch. In other words, we get lost in our obsessive thoughts because we have trouble paying attention to where the mind is in any given moment. Then, when we discover that we’ve been pulled away by an obsession, the disorder sets a precondition for returning to the present. We feel obliged to neutralize the obsession (i.e., get certainty that it isn’t true), to do a compulsion, and then we get permission to return to wherever we were before we got distracted. If, on the other hand, we had the capacity to notice early on when the mind has been pulled away by an obsession and could simply start over in that moment as if it never happened, without permission from the OCD, we’d be much more in command. Meditation is an exercise that targets these two strengths, of recognizing where the mind is in each moment, and starting over when we see the mind distracted. By definition, this requires the mind to not be clear, but to see it clearly. Have all the thoughts, but know that they are thoughts and don’t try to fix them.

What’s next for you?

It’s been brought to my attention that I’ve written four books in the past five years or so. I’m hoping that Overcoming Harm OCD helps more than just the kind, gentle, and creative people I’ve encountered in my clinical work, but harm OCD sufferers everywhere. I also hope it serves as an excuse for me to slow down before I find myself writing something about sexual obsessions. So what’s really “next” for me is just continuing to build my practice and doing the best I can to help empower the most people in their OCD recovery.