Podcast: Helping Your Patients Face Their Fears With ERP

Jenn talks to Dr. Elizabeth McIngvale about exposure and response prevention (ERP) therapy, including its effectiveness and why it’s a gold standard in obsessive compulsive disorder (OCD) treatment. Elizabeth provides guidance to clinicians about implementing ERP with patients diagnosed with OCD, debunks myths about the treatment, and answers audience questions.

Elizabeth McIngvale, PhD, LCSW, is the director of the McLean OCD Institute in Houston, founder of Peace of Mind, a nonprofit foundation dedicated to OCD, and manager of OCDChallenge.org, a self-help website for OCD. She was the first-ever national spokesperson for the IOCDF and now serves as a board member. Dr. McIngvale engages in clinical work, research, and advocacy aimed at improving OCD treatment and access to care.

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Episode Transcript

Jenn: Welcome to Mindful Things.

The Mindful Things podcast is brought to you by the Deconstructing Stigma team at McLean Hospital. You can help us change attitudes about mental health by visiting deconstructingstigma.org. Now on to the show.

Alright, so we’re just about ready to get started. First and foremost, just wanted to extend a note of thanks to all of you joining today. If you’re joining us live, for the recorded session, for the first time, for the 51st time, thank you for taking some time to spend with us.

So I’d like to introduce myself. I’m Jenn Kearney, I’m a digital communications manager for McLean Hospital. And if you’re joining us today, chances are you’ve heard about exposure with response prevention therapy, it’s otherwise known as ERP.

The long and short of it is that it helps break patients’ patterns of avoidance and fears, but there’s so much more to it than just that. How do you know what will work for each patient? How do you know if it’s going to work for you? And what do you do if it’s unsuccessful in your first or second attempt?

So, I’m not the expert here, but I’m very eager to introduce the expert Liz, so we can talk all things ERP. So, in our installment of the series, Dr. Liz McIngvale is going to talk all about ERP. She’s going to debunk myths about the therapy, talk about its efficacy and answer audience questions about OCD and ERP.

So, brief introduction of Liz before she takes it away from me. So Elizabeth McIngvale PhD, is the director of the McLean Houston OCD Program. She’s the founder of the Peace Of Mind Foundation, which is a nonprofit foundation dedicated to OCD, and she also runs ocdchallenge.org, which is a self-help website for OCD.

She was the first ever national spokesperson for the IOCDF, where she now serves as a board member, and was diagnosed with OCD at the age of 12 and underwent both inpatient and outpatient therapy.

She engages in clinical work, research, and advocacy with the goal of improving access to care and OCD treatment. So Liz, thank you so much for joining us. I’m going to mute, please feel free to take it away.

Elizabeth: Thank you so much Jenn and to McLean for hosting this series, it’s been fun. We’ve been doing a couple of them, and so I think this is the third one where we’re really talking about OCD. And today I think we’re going to spend much more time getting into the nitty-gritty and details of ERP.

So before we do that, I just want to take a step back. I’m very keenly aware that some of you may treat OCD, you certainly probably come into counter with OCD. But many of you may not have a client caseload like ours that’s primarily OCD or anxiety disorders.

So let’s just take a second and define what OCD is. For many of you, you may already know, and it may be very clear, but for some of us I think there’s some confusion, and sometimes there’s misunderstanding of what OCD really is, versus is not.

And so let’s start with the basics. OCD, obsessive compulsive disorder, is comprised of two things, right? So obsessions and compulsions. When we think of these obsessions, we really need to define them appropriately, which is that they are unwanted, intrusive thoughts.

So these are thoughts that the individual doesn’t want. They don’t find pleasure in them and they’re very bothersome and they would frankly do anything to get rid of them. The compulsions, or the behaviors or actions that they do, physical or mental, to relieve the anxiety associated with the obsession.

What happens is every time an individual gets an unwanted intrusive thought and they engage in whatever the behavior might be to feel better, they actually reinforce their OCD. Because, in turn, what they’re doing is they’re teaching themselves that in order to get rid of this uncomfortable feeling, this anxiety, this unwanted thought, I need to engage in a behavior. I need to do something to make it go away.

And we teach ourselves that we actually should be afraid of the thoughts, that the thoughts are scary, they’re dangerous, and there needs to be an action taken. I want to dispel a really quick myth that’s really important, and actually got brought up a lot in the past couple of weeks, which is that this kind of understanding of compulsions as being outward ritual.

So a hand wash, using hand sanitizer, going back and forth through a doorway, re-reading a book because you get stuck and you’re worried you didn’t read it correctly. Compulsions don’t stop there.

There is very, very strong evidence that many individuals, if not most, but that many individuals with OCD live with what we call mental compulsions. Mental compulsions can be mentally reviewing, trying to remember a situation, make sure we remember it correctly, we know that we didn’t do something wrong.

It could be something like giving ourselves mental reassurance. Yeah, but I know I’m not really a bad person. Or, but I really do love them so I wouldn’t want something bad to happen. Or it could be something like rumination.

So just getting stuck, trying to understand, trying to be certain, trying to figure a situation out. Any of those behaviors, even if they’re done internally, feed OCD the same way as an external compulsion.

And it’s really important we understand that because a lot of times people think oh, well when we jump into treatment, we just start facing our fears and as long as the person is doing exposures and working through it, then they’re going to get better, but it’s not true. We have to remove the compulsions, physical and mental.

So before you can even think about doing ERP with a patient and start doing the true intervention that’s effective for OCD, you have to understand their symptomology. You have to spend time recognizing what are their obsessions, what are their intrusive thoughts? What are their core fears? And what are the rituals that they do that currently maintain these fears, both mental and physical rituals?

The more we understand these outward physical compulsions and the mental rituals, the better we can tailor ERP to appropriately help them. Remember, exposures have to be done with ritual prevention.

So ERP is the most effective treatment for OCD, as far as it being a behavioral intervention. So many individuals will engage in or do a treatment combination of ERP and medication. But we’re going to focus today on ERP.

So it’s called exposure with response prevention. It’s a specific form of cognitive behavioral therapy that was developed really specifically for OCD, and is the frontline, most beneficial validated treatment that exists.

So what is ERP? So ERP is what I just said, exposure with response prevention. And it’s very different than exposure therapy. Many of you may be keenly aware of exposure therapy. You think of somebody with social phobia, PTSD, different diagnoses, where we do exposure therapy in some level that’s really useful.

Exposure therapy, I want to make it very clear, does not work for OCD. If you are going to a practitioner, or somebody who lives with OCD, you’re going to a practitioner to treat your OCD, and they say I do exposure therapy, that is not going to help move you forward.

Because exposures in and of themselves, while it’s great if we’re not avoiding and we’re doing these things that scare us, if we aren’t removing the behaviors that actually keep the OCD there and that give power to OCD, then the exposures are not going to be beneficial.

So the best example I can give of this is that many patients with OCD, unless they live in a complete world of isolation where family members do everything for them, they do exposures every day. So if I’m in my office and I need to get out of my office, but my door knob is contaminated, I’d probably have to find a way to leave the office.

So I could avoid touching the doorknob, I could use a barrier like grab a tissue, touch the door knob, throw the tissue away. Or I could do an exposure by touching the doorknob. Touch the doorknob, do an exposure, open the door.

But if I touch the door knob and do that exposure, the work isn’t done there, because I could still choose to walk straight to my bathroom, which is in the hallway here at our Houston campus, and wash my hands.

And if I do that ritual, even though I did the exposure of touching the doorknob, it did not help reduce OCD, right? It actually gave OCD more power, because what I taught myself is that the door knob is scary and I need to engage in a behavior every time I touch it.

And so for OCD, exposure therapy doesn’t work alone because just doing the exposures, if the individual’s still ritualizing, is not going to help them, it’s actually going to reinforce their illness. And that’s why it’s really important we identify both the mental and physical rituals that they engage in. Because if somebody is doing a mental ritual, you might not see it.

So you might think oh they’re doing their exposure and they’re not ritualizing. But if they’re not telling you and talking about it and they actually are engaging in some type of mental compulsion or ritual, it’s feeding the OCD the same way as an external compulsion would.

So the only way we’re going to actually overcome the fear of the doorknob being contaminated is to touch the doorknob and cross-contaminate, so continue the exposure.

So I touch the doorknob, I touch my face, I touch my wallet, I cross-contaminate, and I prevent myself from engaging in that ritual. So relapse ritual prevention, so I don’t hand wash, right.

Now sometimes patients have to wash their hands, right? They use the bathroom, they take a shower, whatever might happen. But they can always cross-contaminate. So just because, it doesn’t mean you can never wash your hands again.

But what we don’t want to happen is okay, I touched the doorknob, I’m not going to hand wash until later when I use the restroom, but I’m going to avoid touching anything with my right hand, I’m going to keep it balled up and put it in my pocket, and only use my left hand.

Again, that avoidance feeds OCD the same way. So OCD gets stronger through avoidance or through rituals. We have to remove both and we have to engage in exposure with response prevention.

Now we don’t do flooding where we start with everything and just go for it, right? We slowly and systematically work our way up.

So we often will create what we call hierarchies, where we’ll list individuals’ fears from least anxiety-provoking exposures with response prevention, to most anxiety-provoking, and slowly work our way up to where individuals will engage in exposures that are at levels, maybe zero through five, and then slowly work their way up to higher level exposures.

As they do that, we have to make sure they’re engaging in response ritual prevention the whole time, so not engaging in their rituals, and that that anxiety subsides.

The most common phrase we look for is when a patient will say oh, Dr. McIngvale, I think I’m doing something wrong. And I’ll say, what’s going on, what do you mean? And they’ll say, well I’ve been doing this exposure but I’m bored. And that’s usually actually a perfect indicator for us.

If you’re bored that means it’s probably not anxiety-provoking for you anymore, and that you’re able to do this without it causing distress, and so we can move on to the next level exposure. And we slowly and systematically work our way up.

It’s really important when you do assessment for OCD that you’re not just looking at what are the rituals, how do we address them, but that we’re also understanding what’s their core fear, right. Is an individual’s core fear, from the surface it might look like oh the doorknob contamination’s their core fear, but maybe actually their core fear is not about them getting contaminated and dying.

Maybe that individual’s core fear is that I’m terrified I’m going to make someone else sick. And then I’m going to cause harm to someone I love. Maybe their core fear is actually about it being a chemical that could be on the doorknob that they could contaminate their dog later and kill them.

And so it can be so different, so make sure you don’t just take surface information of rituals or what individuals are avoiding and kind of assume, but instead really spend time in assessment, what is their core fear? Why is that critical? Because that’s how you’re going to build exposures later, right?

So if their core fear’s about contaminating other people, guess what, later on we want to intentionally try to contaminate other people, right? Not truly contaminate, but in an OCD world, push all these core fears that are really anxiety-provoking as much as we can.

So it’s kind of my basics of what is OCD? What is ERP? What does it kind of look like? Let’s jump into questions. So I want everyone to just start putting a million questions that you have. I will slowly go through them and answer them to the best of my ability.

So the first question, I have a nine-year-old patient who’s having sexual obsessions about seeing his mother naked and staring at her private parts. He also has obsessions about his grandmother dying. What kinds of exposures would be effective and appropriate? How do I engage with him as he’s embarrassed?

It’s a great question. Especially when we think about sexual intrusive thoughts with kiddos, right. There can be a lot of stigma, a lot of stereotypes.

So, the first thing I would do is really encourage them to watch some videos and content on iocdf.org and different places, where they can hear from other individuals their age that are going through similar struggles, to normalize it.

To normalize that these unwanted sexual intrusive thoughts are very common. And a lot of people with OCD, no matter their age, have them. And so when you think about exposures there’s a few rules I always want to stick by.

The first is that an exposure should never be something I wouldn’t be willing to do. So an exposure should be something, as a clinician, we’d be willing to do with our patients. We often do them on a daily basis without even knowing they’re exposures.

The second is that we should be willing to do them together. So often the first exposures need to be done together to build that confidence, before the patient goes and does them on their own.

And the third is that it should never be a surprise, right? So I would never want there to be a surprise exposure where it’s like, okay, Mom just decided to do this today and to trigger you, and you have to deal with it, right? The patient needs to know, be prepared, and be able to have appropriate tools.

And so when we think about the first exposure of kind of the fear of seeing Mom naked, right, really it’s what can we do with the patient, right? Like, what are some scripts, what are some uncertainty statements you can lean into around, you know, maybe I will see my mom naked. Maybe I have looked at her private parts before.

Maybe…and leaning into that uncertainty and anxiety of it. Would you have a child that’s nine-years-old actually view their mom when they’re naked? No, right, because that’s not something that you would probably do.

Now if Mom has gotten to the point where she has to shut the door, she can’t wear a robe at home, she can’t do anything that she would normally do in front of other kids, those are the things we want to re-introduce, right.

So what are the behaviors Mom would want to be doing and that she is comfortable doing, but that she’s no longer doing because of the triggers it can have. Eventually we’d want Mom to be able to sit in her pajamas, sit with a robe, whatever the triggers might be, with the child watching a movie together.

Is the child avoiding hugging Mom, being close to Mom because of these triggers? And those are the things we want to really push exposures around. But again, it’s not just the exposure of doing it, but it’s doing it and leaning into uncertainty, right.

So doing this exposure, being with Mom and thinking like, okay, I may or may not be attracted to Mom, or these thoughts are here and I’m not going to do anything to get rid of them. Maybe I am interested in her, right. Pushing that fear, ‘cause the fear, if we don’t push it all the way and we don’t push and lean into uncertainty around it, it will continue to be there.

I can’t remember the second piece of that question, here it is. Grandmother dying, same thing. So often we want to know what are behaviors you do if you have a fear that someone’s going to die.

So are you calling the grandparents over and over? Are you touching, tapping? Are you doing number rituals or different things because you have this superstitious or magical thinking as we call it with OCD belief, that if I do this, they’ll be safe. If I don’t do this harm could happen.

So it’s really about leaning into that uncertainty that like hey Grandma and Grandpa may or may not be okay, and we’re going to keep pushing through, we’re going to keep living life.

The core with OCD is often always centered around uncertainty, right. I want to be certain my grandparents are okay. I want to be certain I don’t have these thoughts about Mom. I want to be certain I’m not a bad person. The core is like, let’s lean into the fear that maybe they’re not okay, maybe we are a bad person, and we’re willing to live with that.

Jenn: Hey Liz, we did get a few questions in advance emailed to me.

Elizabeth: Okay.

Jenn: If you don’t mind just handling those, before we jump back in.

Elizabeth: Yeah, let’s hop into those. Perfect.

Jenn: So someone asked is ERP a one and done, or like a done and dusted form of therapy. Or is this something that you have to do as a refresher every so often?

Elizabeth: I think it’s both. I think that OCD, we do not have a cure for OCD. So for those of us who live with OCD, myself included, we have to engage in ERP for the rest of our life.

Now oftentimes it can, ERP can be done in treatment, in often an average of like 12 to 16 sessions, and patients can learn to manage their symptoms and they don’t necessarily have to come back to treatment.

However, they are still going to use their tools and skills every day of their life. So it’s not one and done of like, okay, you come to treatment, you move on, you’re done with it. But instead it’s about continuously doing it in your life.

In some patients like myself, I enjoy going to therapy, having accountability. Like that’s a part of my maintenance. For some people, they don’t need that. And so there’s not a right or wrong. But ERP should be done throughout our life.

Jenn: So if we care for a person, whether we’re the parent or guardian or even spouse of somebody who is struggling with OCD, should we engage in ERP as well? Is that a useful thing for us to be kind of like a bystander or witness to?

Elizabeth: I think it depends. So if it’s a child, the parents are going to be actively involved in ERP, right?

If someone is nine or 10-years-old, and they’re asking Mom and Dad a lot of reassurance questions, Mom and Dad need to be involved in that treatment process. They need to know what’s the plan, what do I respond with, how do I deal with this, to not enable them to not feed their illness. If they’re an adult, I think it really depends on the patient.

So I will say personally, ‘cause I can speak to that more easily and quickly, I don’t like people doing exposures with me. I view it as kind of like this is my work, I’m going to do it. It always, even as a kid, when my mom would try to like, let me help you, let’s do ‘em together, I never wanted that. It was my own work to do.

That being said, there’s many people that they feel comfort in like will you do this with me and we can do this together. And sometimes if it’s a higher level exposure that they’re doing at home, that support of someone else also doing it and saying like, yeah, I’ll do it too, like I’ll sit with you, can give them encouragement. But we don’t want it to be continuous, right.

So sometimes if I had a really big trigger maybe I might ask my husband like hey, will you do this too, and he’d say like yeah, ‘cause he doesn’t have OCD, it’s not triggering for him.

But long-term, if every single exposure I need him to do it with me, that becomes a bit of a crutch because he’s not always with me and that’s not feasible. And then I start to use him as reassurance. Like oh, well if he’s willing to do it then I should be willing to do it. And so sometimes.

Jenn: So I know you had actually like teed me up perfectly for the next question. Is ERP something that you could do like at home without a licensed professional?

Is this something that like your friend or parent or loved one could be, I don’t want to necessarily say trained in, because obviously this takes time. But is it something that you could do without the help of a psychologist?

Elizabeth: So I think my short answer is no. And my long answer is maybe. So when I say no, you need to get, you need to work with a clinician to get properly diagnosed, to develop a treatment plan and to understand what ERP would look like.

Those of us that do ERP work, we’ve been doing this for years, there’s extensive training. If it was super simple, people with OCD would never need to come to treatment, right. We would do it on our own.

Remember, they don’t like the intrusive thoughts. They don’t like the rituals. And so they wish they could just kind of get rid of it and do it independently.

I think usually when family members or friends are trying to like let me tell you how to do ERP, it usually doesn’t work out. It often results in conflict of like I don’t need you to tell me what to do, and then they’re like well why can’t you do this, it’s not that hard, let’s just, and I think it’s really important that it’s done with a licensed professional.

It’s a specific therapeutic modality, right? So it’s something we’re trained to do. Like peer support specialists, coaches should not be doing ERP. It is something that should be done with a licensed professional.

The reason I say maybe is that there are many people who can go to therapy but insurance runs out, right, or they can only go a few sessions or whatever the reason is, but they can kind of get the core and the basics of what it looks like.

And then maybe they have somebody that helps them engage in the treatment at home, as long as there was a clear treatment plan and understanding of what it looked like developed with the clinician.

Some individuals use self-help workbooks because it’s all they have access to and it’s all they can do, and sometimes other individuals can help them in that process. I would caution you because if it’s possible, I would always recommend a licensed clinician.

But if needed and if it was done appropriately with the right content, it could be done at home for sure. Remember, just because you work with us, you have to do the work at home, right.

And so you’re doing the work independently, you’re doing the work at home regardless. We’re not doing it all with you because then you become reliant. You have to really become your own clinician, regardless. But I would start with a clinician for sure.

Jenn: That’s like the equivalent of going to a trainer once a week and being like oh I don’t have to workout any other time, because I’m in shape.

Elizabeth: Exactly. Exactly. But at the same time, right, if you are having back problems, like you start with going to the doctor and getting a diagnosis and understanding what is the recommended treatment that you need to do to be able to get back to working out.

And then maybe you continue physical therapy on your own. Same with OCD, start with the clinician.

Jenn: Exactly. So how would we initiate the conversation with our loved one to suggest ERP? So, for example, if you think that like your child or your spouse would benefit from it, what’s a good way to break the ice?

Elizabeth: I always say we have to start with education and good content, but we have to get them with a great clinician. I really don’t think that a parent or a loved one is going to convince someone with OCD that they need to do ERP, because guess what, like it’s not your field, you’re not an expert.

That’s our job, as a clinician, to help them understand their diagnosis. To help them understand the treatment that works and the success that exists with ERP, for patients with OCD. I think it’s more important that you can help convince them to get to a clinician, right?

Like that’s really the important first step versus convincing them to do ERP, because ERP sounds scary, it’s terrifying and it’s hard for a loved one to explain it, compared to a clinician. And so I always say start with good content.

So iocdf.org, different resources and websites, podcasts, you name it, where they can hear from other individuals who have had a variety of severity and different types of OCD, who have done ERP and it’s changed their life, right? So that they can, it can be normalized and they can understand that ERP can give them a chance at managing these symptoms.

And then the second piece is getting them to an appropriate clinician. You have to get them with an OCD specialist. If you get them with a general clinician, they’re not going to believe in ERP. They’re not going to believe in treatment. Because they probably weren’t able to make progress.

But with an OCD specialist, it’s our job to help them understand why and how ERP works, to get them ready for ERP. When a patient comes to see us that’s seeing us for the first time, we don’t start with ERP.

We start with psychoeducation. We start with an assessment. We start with helping them understand the disorder, understand what feeds it and what makes it stronger, and why ERP would make sense, and how we’re going to do it slowly, right. So it’s a process.

Jenn: So what do you do when someone isn’t habituating and they’re just staying bothered at the same level after weeks or months of ERP. So the long and short of that question would be what do you do when someone’s unwilling to move to a more difficult ERP?

Elizabeth: So I think two things. I think a lot of people in the field are going away from the term of habituation because it doesn’t always look linear, right? It’s not always this perfect bell curve as we understood it to be originally, where it doesn’t always happen in this beautiful bubble.

So sometimes patients may not totally habituate and sometimes that’s okay. They can keep living their life and we can keep pushing them. However, I always want to know what’s going on.

So if a patient tells me that they’ve been doing this exposure and it’s still just as bothersome and it’s not getting better, I want to know why, because that’s usually an indicator for me that you’re doing some type of mental ritual or some type of compulsion that’s actually keeping that fear there.

If you are truly leaning into the uncertainty, while it’s anxiety-provoking at the beginning, you should start to see the fear and the anxiety dissipate because they’ve pushed it, right. They’ve done their most challenging thing.

And so it’s kind of like flying on a plane, right? If you have a phobia of planes, if you go on a plane enough and you’re not engaging in any sort of negative coping strategies, you shouldn’t be as scared to fly, go on a plane. Doesn’t mean you’re going to love flying and that you’re going to become a pilot, right. That may not be your thing.

But there’s a difference in being terrified versus like oh yeah, I can do that. But again, you can go on a flight 20 times, 30 times a year, but take a Xanax every time before or drink every time before, and guess what, it’s still going to be terrifying to fly because you’ve taught yourself that like I can’t actually deal with flying on my own, right. And you’ve taught yourself you should be scared.

And so I would want to know is there behaviors that are going on that is reinforcing why they’re not like overcoming or fully able to lean into this fear. And if there is, that needs to be addressed before we move up. We don’t want to move on to a next level exposure if a patient hasn’t really addressed the first level exposure.

Now if it’s the opposite, which is like they’ve leaned in and they’ve done it, but they just don’t want to do the higher level ones, that’s about engaging in some ACT in MI and different resources, to help pull some motivation of why these higher level ones are important.

Jenn: So a therapist wrote in saying that they always feel awkward during sessions while doing ERP with someone. Do you have any advice for what they could do right before, during and after these exposures?

Elizabeth: Yeah. I think it comes with practice. For those of us that do ERP work, we actually love it. So we love sitting with patients. We love them doing ERP. But it’s hard.

If you are not an ERP clinician, what’s really hard is that you’re sitting there and watching patients experience high levels of discomfort and you’re not doing anything to help them feel better. Right?

That’s the component and principle of ERP is that you struggle and we let you struggle, because that’s how you’re going to overcome this, versus doing anything or talking you through it. And so you have to be quiet, you have to sit. And so you have to do your own work.

If it’s anxiety-provoking for you to sit there while someone’s in distress and to not want to fix it, to not want to address it right away, then that’s kind of your work to do because it is a critical piece of ERP treatment.

Jenn: So another therapist wrote in saying that a client has contamination fears. So one of the fears would be being around people who sneeze or throw up in front of her. How would you do an exposure for that?

Elizabeth: Yeah. Great question. We do this all the time. So we’ll do YouTube videos of people sneezing. We’ll do YouTube videos of people throwing up. There’s actually entire websites for the fear of vomiting, that like have different exercises and tools and things that you can do.

Eventually maybe we mimic the sound. Maybe we sneeze in office. Go around people where there could be a sneeze. Go around places where people could, or there maybe has been vomit in the past, and lean into that. All sorts of different exposures that you can do around those fears.

Jenn: So what happens if you’re both a clinician and a family member of someone with OCD? Could you be the clinician for your relative using ERP?

Elizabeth: Definitely not. Right, no. So I think ethically, we wouldn’t want to do that. You shouldn’t be a family member’s clinician. But I also think just conflict-wise, I don’t see how that could work.

I have a nephew who definitely has some anxiety. He’s lived with anxiety throughout his life. I would never be his clinician. Does that mean I might not ever support him or tell my story or be an outlet for him?

Of course I would do that, right, and of course having the ability for him to have someone he could talk to, that he feels safe, that’s really important, right, to be this mentor and this safe family member.

But being their clinician I think would just be really difficult. You really, at the end of the day, you’re their aunt and you’re their mom. And I’ll never forget my mom telling my clinician, when they would say well you have to do this or you have to push Liz to do this, she finally looked at him and said you know, I love you and I love Liz, like you’ve changed her life.

I don’t know if she said I love you, but you know, I appreciate you, I love Liz. But I’m her mom, I’m not her therapist, I don’t want to be her therapist because I want to be her mom. And I think it’s really important you have the separation of roles because I want my mom to be able to support me and love me. I don’t need her being the person to tell me what to do for my exposures. So I think that would be tough.

Jenn: We had an individual write in saying that their 18-year-old son is suffering from intrusive thoughts and is currently in treatment at a residential center practicing ERP.

They’re curious about ways to support him when he comes home, both as a family as well as finding the proper practitioner, which might be even more challenging during COVID.

Elizabeth: Yeah. So it is challenging. So what I will say, and I’m telling my patients right now who arrive at our residential program here in Houston, is the day they arrive I want us to start thinking about who their aftercare clinician will be, because wait lists are really long right now.

And sometimes we need to get on it early on, right, versus getting on it the last week of treatment and there being a gap in services. So I think start researching right now and start getting on wait lists. And even if the wait list is long, get on it.

A lot of people say oh well their wait list was three months so I didn’t worry about it. Well, now it’s still three months, right, and now we’re two months later. So get on it at the beginning.

The second piece is how to support them. I think first the fact that you want to know how to support them and you care, you’re doing the right things, right? That’s step number one.

IOCDF, which you can go to their website at www.iocdf.org, has an amazing annual conference and amazing support for family members. We also do weekly webinars and live series that I recommend watching, to get more education and content.

But most centers, if they’re at a McLean centers at least, I don’t know about the other ones, do family therapy, and I highly recommend that you’re involved and integrated in that now. Because the clinical team, especially if the patient’s returning to your home, they should be working with you and with them of how they’re going to continue treatment when they get home, so that it is not a surprise to you, a surprise to them.

What you don’t want to happen is for you to think, oh they’ve overcome these fears and they come home and they’re struggling and you’re upset with them. Or for them to expect when they come home it’s going to go back to the way it was, when that’s not your thoughts. Like you want a clear plan and you want to be working together with the treatment team to prepare for their arrival home.

Jenn: I did have an individual write in saying they have a college age client that their OCD is actually fixated on her trying to analyze whether or not she’s making up her OCD. So some compulsions have been looking things up online and testing different variables, but they’ve been having a hard time coming up with exposures for her to do that stick. Do you have any suggestions?

Elizabeth: Yeah, right, it’s all uncertainty based, so it’s very, very common where we see individuals question is this OCD, is this real? Maybe this isn’t OCD, what’s going on? And so we want to lean into that fear, right.

So instead of it, yes, we want to reduce the rituals. So no more searching online, no more reassurance seeking, no more kind of making sure that it’s OCD or asking the clinician, but also we need to lean into the uncertainty.

So maybe it isn’t OCD and maybe I really have something else going on. A lot of patients have a fear of like having schizophrenia or another diagnosis. But leaning into that fear and doing scripts around that is really important because it also faces the whole fear versus just removing the rituals.

So we need to do exposures, what is the fear, plus the ritual prevention. So oftentimes for this it’s going to be scripts, it’s going to be imaginal statements. It’s going to be not avoiding the things they avoid, leaning in with the uncertainty and no longer engaging in rituals, whether it’s searching or whatever it might be.

Jenn: If a clinician has patients whose thoughts don’t seem to habituate during even prolonged ERP sessions, should they move to an expectancy violation model where the example they wrote in was they say you were able to sustain that for 90 minutes and nothing bad happened, and then repeat that exposure in the model.

Elizabeth: I would steer away from that with OCD, because I think that what that could cause is the patient to just hold on for the 90 minutes to make sure nothing bad happens. And what we actually want is we don’t want you to hold on to anything.

We want you to lean into something bad may or may not happen now and in the future, and I’m going to live with that, right. That’s what we want to lean into. And so I would really again want to say like what’s going on that sustaining the anxiety.

Are there any mental rituals? Are there any compulsions? Is there any sort of checking behaviors that they’re doing? So maybe they’re not doing a pass ritual but maybe in their mind they’re giving themselves some sort of simple reassurance. Like yeah, but this is actually the case or I’m not this type of person, or whatever it might be.

So how can they lean all the way in? The second piece is that if patients are really anxious and it’s not working, we may be doing too high of a level of exposure. So can we taper the exposures down?

Can we start with a lower level exposure around that same fear, that they can have success in where they work their way up, compared to doing higher level ones, if they’re engaging in any rituals that’s sustaining the anxiety at any level.

Jenn: What would you do if OCD is interfering with ERP? And the example that a clinician provided was that a client who has obsessions and related mental rituals and decides to do ERP, only to have her OCD say to her that’s not enough. You need to do something more extreme.

Elizabeth: Yeah, so it sounds like here actually we’re seeing OCD and perfectionism intertwined and we see that happen a lot, and it can be hard to tease apart. Like is this OCD, is this perfectionism. So we need to address both.

So yeah, like yeah, and maybe I didn’t do that exposure correctly and I didn’t do it all the way, and like it is what it is, right. So again, it’s about leaning into the uncertainty that like I’m probably not doing this perfectly and I probably am messing it up, but I might not ever get better. But like I’m going to take that risk.

Jenn: If a provider has a patient who does exposures but reports that they’re bored, though their anxiety is remaining high, do you have any thoughts about what this might indicate or how can they help reeducate their self-perception about the anxiety they’re experiencing?

Elizabeth: So again, if the anxiety is high, I still want to know are they doing any rituals to maintain that level of anxiety? Are they bored because they’re still mentally ritualizing, like they’re doing a mental ritual, and so maybe they’re bored.

But if it’s truly that they’re bored but their baseline anxiety is just high, then I don’t see why you wouldn’t move up to a higher level exposure.

Some patients have a higher level of baseline anxiety, and they may not actually be seeing their anxiety increase that much from the exposure anymore, but maybe just their baseline is high or the way they report it or understand it is high.

But if they’re bored and they’re not doing any rituals, I don’t see why you wouldn’t move up to a next level exposure.

Jenn: Can you provide a little bit of background into what scripts and imaginal statements are?

Elizabeth: Yeah, so I highly recommend purchasing the book “Freedom From OCD” by Dr. Jonathan Grayson. It’s a wonderful book that really kind of talks through uncertainty, OCD and the treatment.

It’s wonderful for clinicians. It’s really wonderful for patients and family members. And it has really great examples of scripts. So I would recommend that you check that out to get more details.

But the point is that we want to write scripts that are going to trigger our OCD. So the scripts become the exposure, right?

So if I have an intrusive thought that something bad may or may not happen to my mom and my rituals are usually to call her or to check on her or whatever it might be, the script might be something like yeah, because I’m not calling my mom and checking on her something bad could be happening right now and it’s my fault. Or, and there’s nothing I can do about it, right?

So it’s leaning into that overall fear and pushing what OCD usually wants us to do even further. But again, it’s really important when we write scripts we encourage patients to not search for certainty in their script.

So we don’t want them doing anything in a script that would make them feel better or that would give them certainty. So sometimes patients will say that script I just said, and then they’ll add at the end but like, but if something happened to her I probably would know by now.

Or, but I don’t actually want anything to happen, so it wouldn’t be my fault. Any of that kind of undoes this whole script and exposure. We need to fully lean in, not lean in but with hesitation.

Jenn: Is there a specific way to design a script in terms of like content and process of use that would be more effective?

Elizabeth: Absolutely, it’s all about their trigger, right? So it’s really about what is their current trigger, what are they worried about, and designing a script specifically around that? If it’s sexual intrusive thought, if it’s scrupulosity, if it’s harm OCD, the scripts are going to look drastically different.

But it’s based on what is their fear, right? So if their fear is if I don’t say my prayer correctly God’s going to be upset with me and I might not go to heaven, we’re going to design a script around that, compared to if their fear is I changed my child’s diaper and I’m worried that I’m a pedophile, right? Like very different script.

Jenn: So what role does medication play with OCD treatment? And particularly with exposure, because I know, as you mentioned earlier, you take Xanax or you have a drink before you go on a plane, you’re actually not mitigating any of your anxiety. You’re just kind of like stamping it down temporarily.

Elizabeth: Yeah, so I’m not going to get into medication specifically since I’m not a psychiatrist, but there are wonderful medications that are very useful. Most people, it’s a combination. I want to say two things.

There are OCD psychiatry specialists, and that always shocks a lot of our patients. They’ll come here, they’ll work with one of our psychiatrists who specialize in OCD, and they’re like oh my gosh, I didn’t know this existed.

It’s really important that someone is seeing a psychiatrist who understands OCD, to really address appropriate medication, versus just their GP or a general psychiatrist.

But the second piece is, if a patient were on medications like benzos, do we want them taking a benzo right before they come into session with us and do ERP? Of course not.

I also don’t want them smoking a cigarette. And I also don’t want them engaging in other activities that are going to reduce their anxiety level drastically where the exposures, we’re not going to be able to actually like get there and do the exposures.

With that being said, it’s not my job to taper them off medication, it’s the psychiatrist, so that’s why we want to work together. It should be a team effort to really think about how can we do these and make exposures be the most effective?

Jenn: Could you talk about obsessions that would start in one area? So, for example, contamination, and then once that’s been addressed, whether through ERP or not, moving into a different obsession. Is this something that’s common for OCD or does it mean that the core belief wasn’t adequately addressed at first?

Elizabeth: No, it’s absolutely common. The core belief can be completely addressed in this. And that just happens all the time, but it’s actually expected that it happens. So one of the core diagnostic criteria with OCD is that symptoms wax and wane.

And we see this all the time where someone’s worried about contamination, they actually lean in, they address it, and now all of a sudden scrupulosity pops up and they’ve never dealt with religious intrusive thoughts or OCD.

And so this is actually one of the biggest myths in treatment is that I find a lot of individuals leaving residential programs, they’ve addressed the OCD that they came there to address and then new symptoms pop up.

And they’ll say I’ve relapsed, I don’t know how to do this. Like I never got treatment for this. And the response is, well of course you did, right. Treatment hasn’t changed, treatment is the exact same. It just looks a little bit different because now the intrusive thoughts are different, the fears are different.

The obsessions are different. But it’s very common. The good news is ERP works the same way. So even if the theme changes, even if the core fear changes, even if OCD symptoms change, leaning into uncertainty and the way we do ERP is the same. It just varies depending on their current fears.

Jenn: Someone wrote in asking, that they were wondering what your clinical opinion is of the emerging use of TMS in conjunction with ERP for OCD. And I know there’s probably some folks on here who are unaware of what TMS is. If you have any insight, that would be fantastic. You’re going to be way better at explaining it than I am.

Elizabeth: Yeah, so I’m not an expert at TMS at all. I believe it’s transcranial magnetic stimulation. And it’s really a new kind of psychiatric treatment intervention for, that people use sometimes for depression and sometimes OCD.

I believe that there’s been a little bit more research potentially on like deep TMS for OCD. So a specific form that’s used for OCD. I don’t have enough out there to be able to say if I think it’s any more effective than ERP alone for OCD.

And I think the research is still very minimal and emerging. So I’m not, at this point we don’t use TMS here at the clinic. It doesn’t mean none of our patients have ever had TMS.

Jenn: The next question is actually quite lovely. An individual wrote in saying they have OCD and their experience with ERP has been so profound that they’re in the process of applying to a master’s in mental health counseling program so they can become a clinician and help others with OCD and anxiety, which I love.

So as a clinician with OCD, they wanted to know does your OCD ever interfere with your ability to successfully treat your patients? And if so, what strategies can you share to manage issues that might arise?

Elizabeth: Yeah, I mean I think I’d be lying if I said never. But I think that I would also be lying if I said like, yes, and who cares, right, because for me, the core of what I do, why I do what I do, is to be able to give people a chance at managing their symptoms and having a successful life.

If my OCD were ever interfering with my ability to treat patients, I would stop and do my own work to be able to move forward. I think that there’s a difference in me being triggered and me interfering with patients in a negative way.

Triggered happens all the time, right? If some patient has similar OCD fears, I’m pushing them, I’m doing ERP with them, like it could be a little bit challenging for me too. They don’t have to know that, they don’t have to see that, but it shouldn’t interfere with my ability to treat them, right.

If my OCD is to the point where I’m not encouraging them to do certain exposures, or I’m not willing to do exposures with them because it’s too hard for me, that would be an indicator for me that I’ve got to do my own work before I can treat them.

And that’s something that has always been pretty simple because it’s pretty easy for me to give into my OCD sometimes, but I would never give into my OCD at the cost of a patient. And I think that as long as you have that in mind but keep doing your work, right.

That’s one of the reasons I always do weekly therapy, even if it’s not interfering with work. Keeping it at bay, keeping it managed, it’s critical for me. What I’ll say is actually quite the opposite, which is that typically I get so much motivation and inspiration from my patients, that even if I’m triggered it pushes me that much more to do my own work.

Jenn: Can you provide a little more insight into how exposure and response prevention works with mental compulsions?

Elizabeth: Yeah. So same way it works with outward compulsion. So if a mental compulsion is reviewing, replaying, saying a prayer, thinking a color, neutralizing number, whatever it might be, it’s about intentionally not thinking that number.

Intentionally thinking the scary thought or engaging in the scary behavior, and not engaging in that mental ritual but doing the opposite instead. So it’s not just about let me just avoid or suppress this mental ritual we’re reviewing, because I’ll review later. But instead it’s about truly leaning into that fear.

So if you have an intrusive thought of, and a very common one, all right, especially with patients with social anxiety, of I don’t know if that conversation went as expected, right? Maybe I said something inappropriate, maybe someone’s mad at me. Maybe I said something offensive.

And so the mental ritual’s to replay that conversation. Oftentimes it’s not just replaying the conversation, it’s also replaying the interaction afterwards, right. Did they seem upset with me? Were they not upset with me? Would they have told me if they were?

Maybe we’re giving ourselves reassurance by saying like, okay, well I’ll go say hi to them later and make sure they respond. Or maybe we’re thinking to ourselves like oh, but they didn’t tell me they were upset or when they left they still waved and smiled.

So I must not have done any of those behaviors or rituals, right, it reinforces OCD. So how do we address it? Well instead we say like, yeah, like Sally may or may not be mad at me and like guess I’ll just have to find out later.

And when we have the urge to review, we instead push the intrusive thoughts. So when we have the urge to review, instead of reviewing, I want you to lean into uncertainty. So my quick response is can you say a maybe, maybe not statement, right. We can say that for any type of OCD.

Maybe I contaminated my mom, maybe not. Maybe something bad is going to happen, maybe it isn’t. Maybe I did say something offensive, maybe I didn’t, right. But quick uncertainty statements versus searching for certainty.

Jenn: Do you have any suggestions for when working through hierarchy and obsessions, when compulsion’s are changing but they’re still intense? So the example that the person provided was first it was hand washing, worked through the hand washing, then the focus shifted to something else like a fear of vomiting.

Elizabeth: Yeah, so again, we’re going to see this, we’re going to see symptoms wax and wane, and you just have to kind of be flexible and move with the patient and address them as they come up. But I think overall my biggest feedback would be that it’s really about pushing that core fear, right.

So what is the overall fear? Sometimes when we focus just on compulsions, it’s just one compulsion, another, and it’s a game of whack-a-mole, where one comes up, we address it, and the next one, versus what is the core fear?

If the core fear is causing harm to others, let’s actually do exposures around that fear, versus it being just around the specific compulsions. ‘Cause a lot of those on the hierarchy will fall apart if we’ve addressed the core fear.

Jenn: Could you talk a little bit more about leaning in and does a lot of that work involve acceptance-based interventions? If so, what does that look like?

Elizabeth: So the leaning in is all about ERP, right? So the principle behind the ERP is that we accept uncertainty versus searching for certainty in everything that we do that’s triggering or anxiety-related for us.

And so when we lean in, it’s truly about leaning into like yeah, I may or may not be a bad person and I’m still going to go do these things, right.

So it’s kind of both, it’s this acceptance-based model of still choosing to live a values-based life, still choosing to engage in everyday activities, despite the noise, despite the chaos, without trying to confirm or deny it, right. Just leaning in and living.

Jenn: Someone wrote in saying that they thought it was Abramowitz, which I think I butchered his last name, who said this year at IOCDF that doing random level of exposures might have better results. Could you speak to that?

Elizabeth: So, I mean, I can’t speak to exactly what Jon was talking about, but I’m assuming what he means is sometimes not necessarily following the strict hierarchy, which we don’t always do. Sometimes we-

Jenn: That’s exactly what they said.

Elizabeth: So sometimes we would jump around and we would just do different levels to address that core fear ‘cause, again, we don’t necessarily have to do it one, two, three, four, five, six, seven. If it’s someone’s first experience with ERP, we want to start low and work their way up.

But sometimes we can jump around a little bit because we don’t, you know, if we do seven, it will probably, like a domino effect, knock out one through six. And so I’m assuming he probably meant something like that.

Jenn: Do you have any resource recommendations for connecting middle and high school aged kids who are experiencing OCD with peers that are having similar experiences to them?

Elizabeth: 100%. So Jenn will put the link after for IOCDF. There’s wonderful resources there, including conferences for young adults, for teens groups. They can attend support groups, they can join, there’s amazing resources.

And I highly recommend that they find support groups and connections with others, so that they can have somebody to talk to who understands.

Jenn: I know you’ve mentioned that there are unfortunately pretty long wait lists for some of these programs. An individual wrote in saying for a non-ERP trained clinician, would teaching clients mindfulness and acceptance be a good preparation for ERP, especially if they’re waiting or on a wait list for a therapist or program?

Elizabeth: I think maybe a little. I think that I would encourage you to try to see if you could do some basic ERP work with them instead. So can you buy Abramowitz’s book? I’m sorry, John Grayson’s book “Freedom From OCD,” or Abramowitz’s “OCD Workbook.”

Both of those are amazing ways that you can work with them to start kind of thinking about their fears and thinking about uncertainty and understanding and doing some basics of ERP. The problem with mindfulness and other models is that sometimes we teach, sometimes like mindfulness and ACT can be very much incorporated into ERP in an effective way.

But if you don’t understand how to do ERP appropriately, sometimes what we teach patients, like distraction techniques and different things, end up being another thing we have to, another bad habit we kind of have to break in therapy later.

So I think if it’s possible, I’d rather you start working on low level ERP and getting some training on that with them first. Or really addressing CBT focused skills, right? Cognitive distortions, anxiety.

Like I think that makes sense to start with before we’d start with like, although mindfulness and like MI could be great to get them ready for treatment as well.

Jenn: What do you do if you have patients that are resistant to leaning in and are resistant to be actively practicing between sessions?

Elizabeth: You stop. The reality is that if a patient isn’t ready, us forcing them isn’t going to get them anywhere. And if a patient isn’t willing to do their homework, I always want to know what’s going on. And I go back to the basics, right? Why are you here, what do you want to get out of treatment?

If you’re not really ready and you don’t, you’re not at a point where you see the benefit and you’re willing to feel uncomfortable for the benefit, then we’re not going to be able to get very far in treatment, right? We’re going to get pretty stuck.

And so I think it’s really important, you have to spend time, a lot of time, on psychoeducation and really having patients accept and understand and agree with the model, with ERP, with why they would be willing to feel uncomfortable and uncertain.

And so if they’re not doing their work in between, a 45 minute session isn’t going to be enough, and so can you, you don’t necessarily have to kick ‘em out of treatment, but can you stop and do more psychoeducation and more kind of understanding of why they want to do treatment and why it would be useful.

But it’s also okay to say hey, you know, if you’re not doing your work in between session we’re not going to see the results. Like what’s going on. And see if is it because the homework’s too hard? Is it because it needs to be tapered down, right?

But sending them home with homework, if they’re continuously not doing it and doing that same thing, it’s not going to be useful.

Jenn: If someone is looking for an ERP clinician in their area, what’s the best way to go about finding one and like how do you start that conversation with somebody to find out if they do have ERP training?

Elizabeth: Yeah, so it’s actually pretty simple. I just go to iocdf.org and there’s a find help, and you can put the ZIP code and providers will show up. I will call the provider and say hey, do you treat OCD?

If they say yes I’ll say what treatment do you use? Don’t ask them if they use ERP, just say what treatment do you use. If on their own they don’t say ERP, you should question if they know how to treat OCD. If they say oh I do CBT or I do exposure therapy, that’s not OCD treatment.

They need to say ERP or exposure with response prevention. The second piece is ask them where they got their training, right. Did they get their training at an institute, at an OCD specialty clinic? At a place where they would have gotten more experience with ERP? Or did they do their training by reading a workbook?

Jenn: Can you talk a little bit about the correlation between eating disorders and OCD?

Elizabeth: Yeah, I mean they’re strongly correlated. We know that there’s a high comorbidity rate of eating disorders and OCD. I think what gets really confusing is when there’s overlap.

So when patients are restricting eating because of contamination or because of OCD reasons, so it’s really important that we tease apart what is the eating disorder, what is OCD, and how do we address it, so we know if they need eating disorder specialty work or OCD specialty work.

Jenn: As the parent of somebody in an OCD program, how can I help them?

Elizabeth: So again, be in touch with the family therapist, provide support and do what you can to get as educated as possible, and be prepared for what it’s going to look like when they return.

Ask them, what can I do to support you? What do you need from me? Start having those conversations now versus when it’s in the moment and we’re triggered.

Jenn: Two more questions. First and foremost, can you just have intrusive thoughts without a compulsion to act?

Elizabeth: Yeah, absolutely. Is it OCD, I’m not sure. So I think that if somebody has just intrusive thoughts, especially if the thoughts are pleasurable or desirable, we would question if it’s OCD. If there’s intent to act on it, might question if it’s OCD.

Remember, patients with OCD actually typically don’t ever have intent to act on their thoughts, right? The intrusive thought of I want to hurt someone, they don’t have intent to act on it. They’re so worried about what if they do. So that’s really important.

But I think it’d be really important to understand the core and what’s going on. I think it would be pretty rare for someone to have intrusive thoughts and zero behaviors at all to neutralize it or to try to feel better. And it’d be OCD.

Jenn: Sorry, and then last but not least. If somebody is having just a mental compulsion, how do you interrupt that cycle?

Elizabeth: You know, it’s hard. When someone’s engaging in mental compulsions, they have to be willing to tell you. They have to be willing to talk about it, ‘cause you can’t see it, right. Mental compulsions are not visible, which is what makes them sometimes a little bit more difficult to treat.

But I think that it’s really about kind of what are you thinking about, what’s going on, and then pushing them to lean into uncertainty, right. We can’t just interrupt mental compulsion. We can’t just have a mental compulsion or mental ritual, or the desire to ruminate there.

And for us just to say, okay, we’ll address that later and push it down. That’s not going to make it better. That’s not going to make it go away. We have to actually lean into it.

And so instead it really has to be that when you have that mental compulsion, that you lean in right then to the uncertainty of well, maybe, maybe not, and that you push it, versus trying to suppress it.

Jenn: I have to say this has been so eye-opening and so helpful. So Liz, thank you so much for doing this. It’s like, I feel like I’ve gone through both a sprint and a marathon, because there’s just been so much information crammed into the last like 55 minutes.

So just a huge thank you for everything you do and for jumping on here and talking about everything OCD and ERP with me today. And to everybody who joined, this actually concludes our session.

So thanks very much for joining. Thanks for taking some time to spend with us today. And until next time, just be nice to one another and yourself and wash your hands. Thanks so much. Have a good one.

Elizabeth: Thanks so much Jenn, thank you for having me.

Jenn: Thanks for tuning in to Mindful Things! Please subscribe to us and rate us on iTunes, Spotify, or wherever you listen to podcasts.

Don’t forget, mental health is everyone’s responsibility. If you or a loved one are in crisis, the Samaritans are available 24 hours a day at 877.870.4673. Again, that’s 877.870.4673.

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The McLean Hospital podcast Mindful Things is intended to provide general information and to help listeners learn about mental health, educational opportunities, and research initiatives. This podcast is not an attempt to practice medicine or to provide specific medical advice.

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