Podcast: Regaining Control Over OCD
Jenn talks to Dr. Jason Krompinger. Jason discusses various forms of treatment for OCD, ways to regain and maintain control over OCD, and myths about treatment for obsessive compulsive disorder.
Jason Krompinger, PhD, is a clinical psychologist with expertise in treating OCD and related disorders. He serves as director of Psychological Services and Clinical Research at McLean’s Obsessive Compulsive Disorder Institute. In his role at the OCD Institute, he serves as the director of the training program, supervising students, post-doctoral fellows, and early career psychologists in the delivery of empirically based interventions.
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.
So, hey everybody. Thank you for joining us today. Whether you’re joining us morning, afternoon or evening, Thanks for taking some time to hang with us.
So I’d like to introduce myself. I’m Jenn Kearney. I’m a digital communications manager for of McLean Hospital. And today’s session is all about OCD.
For those of us who have OCD, it’s understood that it’s a chronic disorder and depending on how in control someone feels, an intrusive thought could either feel like a light tap on our shoulder or like being mauled by a bear.
As debilitating as the condition can feel at times, it can also be managed. So there is hope. Those of us that have OCD know that the condition is as unique as each person so there really isn’t one size fits all prescriptive care.
So how do we know what’s beneficial for us and in a world that is so wildly unpredictable, like we were just talking about, how is it possible to maintain some sort of level of control over our OCD?
So over about the next hour, Jason and I are going to talk about the management of OCD, as well as how to wrestle back control over the condition from our intrusive thoughts and some of our behaviors.
Because one of the things we should remember is having a diagnosis of OCD doesn’t mean that you’re benched but maybe you just need to tweak your game plan. So if you are unfamiliar with him you are in for a real treat.
Dr. Jason Krompinger is a clinical psychologist with expertise in treating OCD and related disorders. He is also the Director of Psychological Services and Clinical Research at McLean’s Obsessive Compulsive Disorder Institute. So, Jason, hi. I’m super excited that you’re here as I was talking about how stoked I am to be hanging out with you again.
Jason: Thank you.
Jenn: So, first and foremost, thanks for joining. And I did want to start by asking how can we feel like OCD is controllable if we’re living in a really wild tumultuous kind of crazy world?
Jason: Yeah. Yeah, I think that that word control is really an important word that figures in pretty strongly into just the experience of OCD, but also in terms of the treatment. OCD in a nutshell, I think is so much about trying to control various things that really cannot be controlled essentially, right?
So trying to control, you were mentioning intrusive thoughts before, so trying to not have certain thoughts or trying to sort of police our thoughts, trying to control the emotions that we feel in any given situation, trying to control whether or not terrible things happen, trying to control or eliminate uncertainty.
All things that can only be controlled to a certain extent or just cannot be controlled at all. And cause it’s just like a constant alarm bells that are going off in your brain that is telling you, do this, do this, do this, and you just sort of a slave to it.
So when we talk about getting control over OCD, it’s kind of a paradox where the treatment actually starts when you start to acknowledge what you cannot control and you start to lose control. You start to let go of that control.
And the more you take a step back and allow yourself to feel that loss of control is actually when you can start to gain control. If that makes any sense. It makes some headway with it.
So we always talk, just to start simply, we talk about the core cycle in OCD which is typically no matter, you know, there’s so many different specific presentations of OCD that someone can have. They really run the gamut.
So you can have, I mean there’s some people who struggle with feelings of contamination and they do a lot of cleaning and washing behaviors and fears of getting sick and dying and disgust and all that sort of stuff.
And then there’s a whole other subset of folks who more struggle with intrusive violent thoughts and worry that they’re a terrible violent person and try to control those thoughts or control their impulses.
But whatever the specific form of OCD is there is the same kind of consistent cycle underlying it where you have a trigger that could be a thought, that could be a physical stimulus, that could be an emotion that creates distress, and then that distress leads to a behavior or a set of behaviors that’s designed to eliminate that distress in some way.
And usually, doing that behavior does “work” in a short-term sentence. So, you know, a person who worries about illness, washes their hands they feel better for some period of time.
Or if you have an intrusive thought, you found some way to eliminate, kind of neutralize that thought that probably does sort of “work” in a short-term sense. You replace the thought with something else or something like that.
But then what happens is that the next time that you’re triggered you get back in that cycle again. So you’re distressed all over again, you have to do that behavior again and it’s just this kind of like ongoing loop.
And when we talk about letting go of control in order to gain control, breaking that loop is essentially about recognizing that well, I can’t, or it’s not tenable for me to control all the thoughts and feelings that I have.
It’s not tenable to navigate my environment by trying to control and avoid all triggers because if I try to avoid all triggers in my environment I’m basically staying in my room all the time. If that, I mean, for some other people they can’t even escape that way.
So what I have control over is my behavior my reaction to these experiences. And once you start to get a handle on the different options you have in terms of your responses to those distressing thoughts and feelings that’s when you can start to make headway with treatment.
Jenn: So can you elaborate on more ways that we can wrangle OCD through treatment? Is it through medications, psychotherapy, is some sort of like exposure and response, all of the above?
Jason: So yeah. So the standard of care intervention for OCD is called exposure and response prevention. So, and it relates to that cycle that I was just describing.
So you’ll typically see it described in the acronym ERP or EXRP, but if you have OCD that is absolutely the treatment, the first kind of line treatment that you should be seeking out in a psychotherapeutic provider.
So what ERP stands for is, so, as I said, exposure response. So exposure, it means facing your fear.
So if we think about that cycle again you’re going to face that trigger whatever it is that scares you, that physical stimulus, face that thought, face that emotion, and then response prevention is that you resist engaging in that behavior that the OCD wants you to do in response to that trigger.
So just to stick with contamination as an example just cause it’s easier to talk about sometimes you’ll have folks who are triggered by various stimuli in their environment, doorknobs, light switches, anything that’s communally touched.
The exposure then would be to deliberately engage and come into contact with various stimuli, and then of course, resist washing their hands, allow themselves to feel that sense of contamination.
That sense of maybe I’m going to get sick, maybe something terrible is going to happen. But then what happens is the more you engage in that, in this treatment, the exposure, resisting those behaviors, you learn new things, you create new pathways in your brain about that stimulus that you’re encountering.
And in a nutshell, you’re essentially learning that this thing that I’m experiencing is so threatening doesn’t have to be experienced as threatening. I’m learning that I can sort of relate to that thing in different ways.
So, you know, most people with OCD sort of know, academically or kind of intellectually that they’re probably not going to actually get sick and die from touching a doorknob, probably not, but there’s that little chance that there is, and it causes them to behave as if that doorknob really will kill them essentially.
So you have to think of exposure as acting like that thing is not threatening even though you sort of feel like it is. And the more you engage in it over time, the more the new learning occurs and the easier it gets.
And that sequence I just described can apply to really any form of OCD. So again, just jumping over back to intrusive thoughts folks who struggle with intrusive thoughts, various types of intrusive thoughts kind of perceive the thoughts themselves as inherently threatening in some way.
So if I allow myself to have a thought that I’m going to attack somebody on the street or maybe that’s going to make it more likely that I’m going to actually attack somebody on the street or that’s indicative that I am inherently this violent person that needs to be sort of reigned in.
And again, the person does all these behaviors try to control those thoughts or avoid people on the street or whatever the case might be.
And all that does is reinforce this idea that the thought itself is dangerous, where what we want to learn is that actually having the thought is not dangerous. And again, the way to do that is by exposing deliberately to the thoughts.
So I’m going to let myself have this thought, this idea that maybe and this image whatever it is, that I’m going to attack somebody, resist engaging in those neutralizing behaviors, resist engaging the avoidances, and over time you develop this new learning in your brain and those stimuli become less threatening and you improve.
So that’s sort of the frontline behavioral intervention for OCD, I’m not a psychiatrist, so I won’t get into medication too much but standard part of standard of care and OCD is also pairing behavioral treatments like that with an SSRI.
So that’s usually sort of the frontline intervention and certainly a good OCD focused psychiatrist will always be somebody who is certainly prescribing SSRI if you’re naive to any other medication, but also is then really encouraging you to seek out a provider that does exposure and response prevention if they don’t do it themselves.
So that’s kind of the best combo possible, I think is to have somebody, a clinician with whom you’re doing ERP and then a good kind of OCD focused psychiatrist.
Jenn: So I know that you’ve touched upon it really lightly already but can you elaborate a little bit more on what the initial steps are in trying to regain control over OCD?
Jason: I think the first step is to understand, start to pay attention to how, what the OCD is telling you to do, is actually getting in your way.
So I think that what can happen is that because those behaviors... When I say these behaviors that OCD is compelling people to do to protect themselves. You can just sub in that word rituals or compulsions.
Those behaviors because they provide that short-term relief upfront. They can feel useful in some way or they can feel as though, I know they’re bad, I know I shouldn’t be doing this sort of thing but I need them. I can’t.
OCD kind of like, I can’t function unless I rely on these sorts of behaviors to sort of help me navigate my world. It’s like an algorithm. Like, well, if I have anxiety then I need to do these rituals and then I can live my life. You know what I mean?
But I think that a good first step in terms of thinking about treatment, which of course will involve starting to tackle and resist those kinds of behaviors is to take a step back, look at your life and say, “Okay, engaging in those behaviors, does it actually move me towards what I care about and like what I want to do with my life? Or do I just feel like I’m going in circles?” You know what I mean?
Or is it more that the OCD is kind of playing a trick on me where it’s telling me that this is the only way I can live but in reality what it’s telling me to do is keeping it alive not to anthropomorphize it too much but it’s keeping it alive but it’s not really doing much for me.
It’s actually just kind of wearing me down over time. I think it’s an important first piece of awareness to develop because I think I can foster some motivation cause the treatment is very hard.
I mean, this exposure in response prevention is you know, simple to talk about here. It’s easy enough for me to say, to face your fears but it’s obviously a very challenging treatment to do.
So I think to find, and recognize how the path that the OCD lays out for you is not leading you where you want to go is important. And then sort of help with that clarify, well, what do I actually care about in my life? What are my values? What’s meaningful to me?
Because again, the behaviors that the OCD is like leading to you, they may feel like, you’re OCD may tell you the story that leads you towards your values. But if you actually take a look you just sort of see how your life’s going, it probably isn’t.
Jenn: Is it possible to have obsessions without compulsion? And if yes, how common is this?
Jason: So it used to be that there was something that in the field that we would call Pure O. In which is a pure obsession. Pure obsession without compulsion.
And essentially what this is for people is folks who have a lot of obsessions, a lot of fears, a lot of intrusive thoughts that sort of thing, but they don’t have observable compulsions. Like they don’t have behaviors they engage in that with anybody can see.
With anything overt like that. And so I think that’s why I think in the field we sort of classified that as Pure O. In reality, though, if you kind of dig into what’s going on in folks who have that into their minds a little bit, there are compulsions but their mental compulsions.
So if I have a thought that, you know, my daughter could die today that might freak me out and that’s an obsession. So it just pops in there and that really freaks me out.
I might not physically do anything in response to that but what am I doing in response to that thought is think really deeply about it and think of what she’s doing right now and think of, and tell myself, “Well, no she’s probably safe because she’s home and she’s on her Zoom, obviously like everybody else is.”
And you know, there’s nothing really dangerous in her room or anything like that. I’m kind of going through this careful process to ensure in my mind that I don’t feel like she’s actually in danger. All of that is actually a compulsion.
It’s something that the OCD is compelling me to do. And then what tends to happen is that I go through that enough and then I kind of can placate myself a little bit. I feel a bit better, but then at some point soon after, the OCD, well, how do you know for sure.
Like maybe something terrible happens. And then I’m doing it again, you know? And then just kind of like this back and forth, that cycle that I was describing at the beginning that’s all happening in somebody’s mind.
So Pure O, isn’t quite... Some people really still connect to that idea just to call it that label of Pure O And if you connect to it then great stick with it. But if you really want to get nitty gritty was happening in that situation is that all the rituals are more mental.
And that’s where working with a good OCD therapist will help you identify the obsession, separate the obsessions from the compulsion in your mind.
Jenn: So based on the conversation we’ve had so far, it seems like obtrusive thoughts are pretty common, right? But there’s some people who aren’t debilitated by them. How would they deal with them if they don’t find them as debilitating as others might?
Jason: Do you mean like somebody without OCD? Yeah. Yeah. So I think that, I actually think that everybody’s got intrusive thoughts. No question about it. It’s not just me, there’s plenty of data out there to suggest that everybody has.
And I guess about what I say intrusive thoughts, I mean bad thoughts that you don’t really want to have.
So, you know, I certainly have had the thought, you know, back when we used to stand on subway platforms, you know, what if I just hurled myself in front of the subway as it was coming along or, you know, having the thought as if I’m like with a bunch of sharp knives, you know, cutting stuff in my kitchen or something like that, like, oh, I could just like reach over and stab somebody with this.
That image kind of comes into something like that, I think comes into everybody’s mind. What we know is that what makes it that thought threatening for some people versus others really comes down to a combination of somebody’s beliefs about those thoughts and then their behavioral response to those thoughts.
So it tends to be the case that if you you’re lower on the... I’m not going to... Instead of like say, “You do, you don’t have OCD.” It’s all like a spectrum, right? So I’ll say people who are lower on the OCD spectrum, who like don’t have a lot of it, if you’re low on the spectrum, you don’t really strongly believe that thoughts are inherently meaningful.
You kind of have more of this belief that thoughts are just kind of thoughts. And some of them are important but some of them are just like mental drift. It’s like, “I don’t really know why I was thinking that but so be it.”
So that’s kind of like the context in which they have those thoughts. So that’s the underlying belief system. And then, so then when the thought comes in of jumping in front of the subway, it’s sort of like, well, that was weird, but whatever I’m just going to keep moving forward with my day. And there’s not much of a response to it.
It’s just sort of like acknowledging that’s there, it’s okay, that exists but I’m going to go get on the subway now. And I’m not really going to engage with it further.
Whereas if you’re higher on the OCD spectrum, you have OCD, your beliefs tends to be more strongly that, for example that thoughts are really important or that things like simply having a thought is the same thing as acting on that thought or is it an inherently making it more likely you’re going to act on that thought.
If that’s the belief system that’s in place typically then what happens is you have that intrusive thought of jumping in front of the subway you’re going to try to control. It’s going to freak you out, first of all.
And then you’re going to try to control it in some way, Like, I want to not have that thought. I’m going to avoid going on the subway, I’m going to avoid standing close to the platform or various other compulsive types of behaviors.
And that’s kind of the fuel that stokes the fire of OCD and kind of keeps it going. So in terms of, again, going back to the treatment model essentially the way to think about it is we’re practicing responding to those thoughts in a way that somebody without OCD response to them.
Where I have those thoughts they’re there and then I don’t do those behaviors. I don’t do any of those avoidances, I don’t do those compulsive rituals, I don’t try to get rid of it, in any way just let that thought exist and then move forward.
And that’s kind of like a key component of the treatment as a way to get to make those intrusive thoughts become over time, less distressing.
Jenn: I did want to ask you a couple of questions about depression. So how often does depression accompany severe OCD? And it if it often does, how can it be treated alongside addressing OCD?
Jason: Yup. Very often I think that your numbers can be as high as 80% or above co-morbidity with depression. And I think that it’s so in terms of treating it, it comes down to the relationship between the depression and the OCD.
So for some folks their severe OCD has created the depression, so to speak. So just to put it simply, they’re depressed they have such bad OCD.
And in those cases, what you find is that you can essentially treat the OCD, work on the OCD and as those symptoms get better the depression gets better. It kind of makes sense, right?
Where there is less OCD, there’s less depression. In some cases, it’s more of a separate thing that depression is kind of more its own beast and kind of irrespective of OCD symptoms that depression can still can still be a thing.
I absolutely think that it’s possible to treat OCD and depression essentially simultaneously. Mostly because for a couple of reasons, one, this exposure and response prevention approach, behavioral approach, it actually fosters the kinds of interventions that tend to be most useful for depression.
So one of the most effective treatments for psychotherapeutic treatments for depression is called behavioral activation. And in a nutshell, what that is doing, is engaging in your life behaviorally. Doing more.
You know, doing things that are important to you. You know, going out, you know, just kind of making efforts to socialize, making efforts, to engage in hobbies, making that efforts to be out and engage with the world.
And that kind of approach tends to be going pretty hand in hand with exposures. Exposures are typically also about engaging with the world in some meaningful way.
So you kind of have this situation where the more you’re engaging in exposure, you’re also kind of doing a behavioral activation sort of a thing, and thus kind of treating the depressive symptoms.
Also OCD treatment is about... The crux of the treatment is really about developing a new relationship with among other things your thoughts. Wherein you’re learning to treat them less like seriously, yeah, you treat them less like their alarm bells going off and less like things that you have to necessarily respond to.
And if you think about depression where... So in OCD, you know, you’re practicing responding to all these various, like we’ve been talking about intrusive thoughts in different ways.
In depression it may not be intrusive thoughts that you’re responding to differently, but you’re practicing responding differently to thoughts like I suck, I’m worthless or, you know, I’m completely ineffectual or something along way, is depressive oriented thoughts.
In depression those kinds of thoughts can of course bring about various behavioral responses like inaction, isolation, avoidance, rumination, all that sort of stuff. And in OCD, we’re essentially treating people, encouraging people to respond differently to those thoughts.
We can talk about also responding differently to those depressive thoughts too, in more adaptive, healthy ways.
So when you have thoughts about how horrible a person you are, or how worthless you are, but one thing we could do is isolate and ruminate but we can also recognize those thoughts as simply thoughts and engage in meaningful behavior, amidst those experiences.
In the same way we might with OCD thoughts. So I think there’s a lot of overlaps like that are therapeutically there to make it possible to work on both.
Jenn: Does OCD often occur alongside addiction?
Jason: It can. And the base rates I’m not sure off the top of my head. OCD is a little... So certainly OCD and substance abuse or substance use disorders co-occur to a substantial extent.
And, you know, you can have situations where folks have learned to respond to their distress and their intrusive thoughts not just via rituals by compulsive behaviors but also by substance use or alcohol use or something along those lines.
Because those kinds of the substances and the alcohol have a similar sort of effect where they can start to essentially take the edge off and reduce the anxiety and make somebody feel better.
I think that often in those cases, the best-case scenario is you’d want to be in a treatment program that was able to accommodate both because the nature of substance abuse treatment can be a bit different from the nature of OCD.
In that, I’m not a substance abuse treatment expert but there’s one thing I can sort of touch on is that so if you’re treating OCD, what you’re doing is you’re working on exposing to the triggering stimulus, right?
You’re facing that fear and you’re resisting doing that compulsive behavior. If you’re treating substance use and alcohol use disorders it’s not like you would have the person go to a bar and just try to resist those behaviors.
You know what I mean? Like that’s cue exposure. Is something that happens in substance use treatment, but it’s something that happens later on down the road once it kind of develops in different skills upfront.
So that’s why I think the... So the approach is kind of different to an extent so ideally you’re in a treatment program that specialized in sort of a dual diagnosis approach.
Jenn: So we did have someone write in who said that their adult child feels as if they failed therapy for OCD, because the clinician didn’t use an evidence-based treatment approach.
So this person is inquiring, how as the parent of an adult child how can they encourage them to seek treatment especially now that they think that they might be untreatable?
Jason: Yeah, that’s really sad, first of all. So my heart goes out to them for having had to go through that. The good news is that I hope this doesn’t come across as insensitive but there’s never been a better time to have OCD because of all the resources that are out there if that makes sense.
So what I would really do is encourage that person to see what’s out there in terms of resources.
So for example, you know, seminars like this, like the work that you do, Jenn, to put these kinds of things together, watching these sorts of videos, on the International OCD Foundation website has tons of resources, stuff to read, stuff to watch, you’re seeing and hearing and reading about, reading from people who understand OCD really, really well. It’s a well understood disorder.
And the treatments that we have are pretty good. We have a pretty strong efficacy rate with these interventions but we’re still collectively working on making them better.
So I think that if they are steered toward some of these resources and, you know, watch those kinds of videos, read those kinds of resources, and iocdf.org is a great website to go to. The OCD stories is a great podcast to listen to.
And things like that, just kind of, and books to read include things like, just a classic one is “Getting Control” by Lee Baer, and “The Imp of the Mind” is another Lee Baer book that’s specific to intrusive thoughts. John Grayson has a book “Freedom from OCD.”
There’s a lot of great resources out there where people are again describing OCD in a way that I think that anybody who has it can really connect to and feel understood by first of all, and then ideally that can sort of open the door to this reality that, “Hey we’ve got treatments that actually work for it.”
So I think I I’d start there by like by kind of pointing the person in those kinds of directions and then go from there.
Jenn: And when it comes to people who are actively trying there, you know, there the pre-contemplation stage of seeking care, right? So this isn’t like, any of those resources that you’ve mentioned would be a really good way to almost be like a soft reintroduction to seeking care.
Jason: Yeah, definitely. Yeah. Especially again. Yeah, especially if they’ve had some negative experiences with it. I would also talk about, I think this is also where peer support can be very useful.
So people that have had lived experiences of OCD, or in this case, I guess, you know, if the person could be connected to other folks who have had, lived experiences of OCD and having treatment, going through good treatment for OCD, that like that’s where that kind of work is invaluable.
There’s plenty of people out there that do that kind of stuff. So Chrissie Hodges is somebody that talks a lot about, she’s on YouTube. She’s great but she kind of talks a lot about her experience with OCD and going through treatment is a big proponent of exposure therapy.
But just on a more local level, I’m pretty sure a support group like this, the IOCDF, your local state chapter of the IOCDF perhaps it’s running a support group that is probably in a Zoom format these days, but in some ways it’s kind of nice cause it easier to drop in on.
I think those would be great. Like you’re saying, I think soft and reentries into treatment.
Jenn: And I think another great resource too is McLean’s Deconstructing Stigma, which is a really shameless plug for a variety of mental health conditions, that they’re all lived experiences that are told in either first- or third-person narrative that talk about the variety of experiences.
And I know I have a couple of friends and colleagues who’ve talked about their experiences with OCD, but at the same time, there’s celebrities like Howie Mandel that shared his story on there too.
And they’re all living like very successful well-functioning lives too. So it’s a good way to re-introduce that there’s still hope for people.
Jason: Definitely. Yeah, totally agree.
Jenn: Someone did ask, how often do you recommend TMS to help alleviate the symptoms of OCD?
Do we know if that’s been shown to be effective and perhaps you could also elaborate a little bit on what TMS is for folks who may not know?
Jason: TMS, transcranial magnetic stimulation it’s an outpatient procedure, non-invasive, but it involves electrically stimulating certain parts of the brain that are thought to subserve OCD as a way of ameliorating symptoms.
So TMS as just an intervention generally, a psychiatric intervention, it’s been used for decades primarily to treat depression actually for many years. And it’s pretty standard. We offer it at McLean.
It’s often covered by insurance. TMS for OCD is relatively new. It gained FDA approval, not that long ago. Maybe a couple of years ago. And you know, so it’s again, it’s gotten FDA approval.
It’s been shown to be potentially a useful, I think the way to think about it it’s a potentially useful augment to all the other stuff that we’ve been talking about so far. So TMS for OCD is a little bit different in that it’s specifically targeting different brain areas.
Brain areas more specific to OCD. And actually as part of the TMS procedure, the actual procedure where these, you kind of go in and you sit and you kind of have these parts of the brain electrically stimulated, the thought is that it’s most effective when the OCD symptoms are activated.
So typically you would be asked by your clinician to do essentially an exposure. So it’s kind of bring up the anxiety bring up the obsessions, and then the intervention would take place. So even more of a reason to do it, sort of in concert with just exposure therapy more generally.
So there’s some good data to support it. Again, I just take this a little bit anecdotally in terms of my experience I think that, you know, for some people, again, it could be really useful to do in concert with exposure and with the traditional medications.
And for some people it’s less. It doesn’t seem to have as much of an effect, but it’s I think worth absolutely learning more about it and asking more questions about. Specific to your situation. And again, it’s an FDA approved intervention.
I don’t know that it’s quite at the point where a lot of insurance companies are covering it yet though. That’s the thing I haven’t, I don’t, but I don’t know. I haven’t kind of checked in on that lately, so it’s relatively new but it’s promising for sure.
Jenn: Is it common for OCD to change regularly? For example, can you have a type of OCD where your triggers, thoughts, symptoms are constantly changing or evolving?
Jason: Yeah. Yep. It’s super frustrating. We call it the whack-a-mole effect. Where, you know, you can have one sort of set of symptoms that arise and then they may be over, you know, maybe over the course of time, they sort of settle down then other sort of set of symptoms arise, and then another set of symptoms arise.
I’d say that typically when you’ve got somebody who has multiple subsets of symptoms that they’re dealing with, there’s a kind of a common thread that under that sort of undergirds all of them.
So just as an example, you can have somebody let’s say they have a lot of contamination concerns, a lot of hand-washing behaviors where they get triggered by touching various communal objects and then they’re afraid that they’re contaminated and they don’t want to touch other things that other people might touch because they’re afraid of getting them sick in some ways.
There’s a lot of hand washing and avoidance and all that sort of thing. That same person could also have a bunch of intrusive thoughts that they’re going to, just the same examples we’ve been talking about.
Interesting thoughts they they’re going to cause harm to other people, there are people that have thoughts that they are pedophiles. They’re going to harm a child or harm another person in some way.
So they’re doing all these rituals to control those thoughts. The common thread between those two is that I’m afraid I’m kind of a terrible person, right? And I’m going to cause some irreparable harm and I’m never going to be able to take that back.
And once you’ve sort of found that common thread I think that’s the thing to go after in treatment, is to practice coming in and taking that risk. Coming into contact with that possibility that I’m a terrible person, but still, you know, reducing my control over those possibilities.
That’s if you kind of go at the core of it, I think that’s a way to prevent that whack-a-mole thing from happening. Compared to if you’re too superficial in your exposure.
So if you’re just, you know, I’m going to practice, not washing, and I’m going to practice letting myself contaminate other people and just kind of dealing with it but not really kind of getting into the thoughts that come up around that, and the feelings that come up around that.
I think then the symptoms may go down but then they’ll just pop back up in another domain. But if you get at that piece that ties them together which is often the case for people. I think that that’s how you can protect against that happening.
Jenn: Do you have any idea of how often the use of ERP is successful in terms of treating severe OCD? I mean, you know, we are keeping in mind that every case is individual to each person.
Jason: Numbers are pretty good. I mean, you know, the lowest you’ll hear about is maybe 50% responder rate. So, and then the highest is maybe, you know, in the seventies or 80% responder rate.
And the definition of a responder can vary wildly, but, you know, generally you probably what you want to hear about a response rate is a 40% decrease in symptoms. So it’s an efficacious treatment for sure. And we’ve got ways to go with it.
We want to get better at it. So, you know, if you are somebody who has, who feels like you’ve tried exposure, or if you’ve kind of, you know, made some efforts to it and been haven’t really made a lot of headway with it, or haven’t revisited it in a while, I think we’re learning more every day about the kinds of factors that can undermine exposure therapy or kind of getting people’s ways they’re trying to do it.
I think an important revelation of the past few years or so has been to pairing exposure therapy with augmented interventions, like acceptance and commitment therapy, AC, ACT. Which you’ll oftentimes these days if you’re looking up people that work with OCD specialists they’ll say that they do ERP, and then they’ll say that they do ACT too or they’re ACT informed or something like that.
And that’s a good combo to have. ACT as an intervention it’s very complimentary to ERP. It’s an intervention that’s based around practicing and accepting of all inner experiences all thoughts and feelings and engaging in value-driven behaviors and just in a tight nutshell.
You’ll hear plenty of people who feel like they didn’t really make a lot of headway with ERP kind of alone. But when they start to hear about some of these ACT principles and build those in that’s kind of when things opened up for them. So and we’ve got, you know, people that do exposure alongside DBT.
So some people that really have a hard time just having emotions and regulating their emotions you can do an intervention where you practicing facing your fears but you’re also developing some skills around navigating those emotional experiences in a more effective way.
So there have been over the past few years augments to exposure therapy that have been really useful and again has sort of opened it up to more people, I think. And I think it’ll only get better from here.
Jenn: Is ERP something that would also be effective for Pure O?
Jason: Yeah. So what’s critical with Pure O, absolutely. And what’s critical is that you’re able to identify the compulsive, the mental compulsion’s that are going on because ERP is not going to be effective if you’re...
You can do all the exposure in the world you can face all the fears that you want but if you’re still doing the compulsive behavior it’s kind of like, I kind of say, it’s like you’re practicing having OCD. You’re just kind of engaging in that cycle over and over.
Where I’m triggered, I’m distressed, but then I’m just doing my behavior again. And then I’m back to the same cycle. I’m not breaking that cycle at any point. So it requires a pretty careful functional analysis of the person’s inner experience where we have to determine, okay, what are the thoughts that are popping in that we can’t control?
Again, back to my example of like, I can’t control the fact that I had this thought my daughter might die. That’s just a reality, I just exist.
But the extent that I grapple with that, that I respond to that thought in the way that I was describing before. I think I was saying like, you know, you kind of go, if I then go over what she’s doing or trying to tell myself that she’s okay and all that stuff, that’s a choice that I’m making.
I don’t have to do that. It’s a cognitive behavior. It’s a mental behavior, I can’t see it. Nobody can see it. But I’m doing that. And if I’m doing treatment, I have to learn to recognize that process happening and resist it.
And instead just say, “Okay, right. She might die.” And I’m going to move forward with my life and I’m not going to try and do anything to control it. If you can identify those ritualistic mental responses and absolutely ERP is just as effective for a Pure O.
Jenn: Would we know if something’s a compulsion versus a checking behavior?
Jason: I don’t see them as terribly as different. So checking, I think checking is a type of compulsion. And if I didn’t define this before, I should do this now. So compulsive behavior is a response to an obsession. A response to a distressing thought, impulse, image, stimulus. The main function of that behavior is to reduce or control the anxiety.
That’s the main reason why you’re doing that. That behavior. So I’m saying like, so that’s compulsion. And then checking is typically a subset of a compulsion.
So, you know, traditional examples are folks who check their door locks on the way out of their house, compulsively over and over again, check their windows, check their stoves, the obsession there is that, well somebody might break into my house, or my house might explode, might catch on fire.
So then the behavioral response is I need to check my stove, I need check my lock. And the issue in OCD is that you do it you feel a little bit better for a second, but then you’re not sure if you really check it or not.
And then that doubt is an obsession of itself that creates distress, and you have to do it again.
And then maybe it quiets down for a second then comes back and you’re kind of like you do it over and over again until you get to this point where, at some point you satisfied it and OCD kind of lets you off the hook and say, “Hey, cool. Like now that’s good enough.”
And then it’s just a matter of time until the next time. So, so yeah. Or checking just is a very common subtype of rituals.
Jenn: For folks who are in therapy for OCD, how can they approach their loved ones about the topic and ask for support? Often times it can be so hard to talk about even if you’re not in therapy for OCD specifically, and, yeah, sometimes it’s even about the people that you care about the most.
How do you have any tips for communicating what they’re going through and how loved ones might be able to help?
Jason: So one thing I would say is what I was saying before about directing. We were talking about the adult patient, who was kind of turned off of therapy and sort of steering them towards these resources, IOCDF, et cetera. Same thing applies to parents or caretakers, for sure.
They should learn as much. I would recommend they read about, listen to, watch anything related to OCD so that they can develop an understanding of what their loved one is going through too. I think it’s critical. An absolutely critical component of treatment is family therapy.
And for a bunch of reasons, but among them what we’re talking about, where I think in the context of a family therapy session, that’s a great context in which to have a discussion just about what’s going on where the therapist can explain to the family what this is and help them understand that OCD is indeed a mental disorder.
And this isn’t just a weird set of quirks. You know, they’re not just acting out or something like that. This is something that we about and we know how to treat and can do their part to help educate the family and sort of be an advocate for the patient.
I think that can be incredibly useful. And, you know, I think ideally you have a separate family therapist but I think, you know, a good clinician, a good OCD, ERP therapist also can, you know, within the context of the one-on-one therapy can occasionally have family meetings where they bring family members in to have those kinds of conversations.
And then I think the next component of that is to identify ways in which the family members might be invertedly accommodating the OCD.
So it happens often is that because OCD can look so it is such so distressing, and so torturous to the patient all the family member wants to do as they live this is swoop in and help and fix, and like, just make something better, you know, just to take the fear away.
And typically that looks like they are helping the patient do their rituals and essentially. And kind of like making the situation worse or at least maintaining the OCD without really knowing it.
You know, it can feel just like they’re helping them and they’re less distressed. But in reality, this just reinforcing that cycle that I talked about at the beginning.
So, you know, I’ve heard a family members who you’ve got a patient who’s stuck at the sink for an hour washing their hands, and a family members just worried about them being hungry. So they’ll bring them food while they’re in the bathroom so they actually get some food while they’re doing that.
But actually it’s just reinforcing the idea they should just stay in the bathroom and continue to wash their hands. So that’s a really important component of treatment is to ensure that especially in the case that a person’s living with their family members, so that the family members understand both what OCD is and how to best treat it.
Things have to resist some of those behaviors and behave in ways that are more supportive and in support of the treatment.
Jenn: Since we’re on the subject of therapies how do you work somebody through the paralyzing anxieties that might occur during ERP?
Jason: Yeah. So ERP is inherently a difficult treatment. It’s just, you know, exposure therapy is, there’s no way to I’m not going to sugar coat it, I mean, there’s no way that to make it sound like it’s fun or anything like that, it’s often not but I think there are ways to go about it that can help make it more palatable for people and increase motivation.
One element is kind of what I was saying before where I think it’s incredibly important to clarify why the person is doing this, you know. There’s why they’re doing treatment. Why they’re doing exposure.
So, you know, somebody comes to me and it’s like yeah, say, “You’ve chosen to come here voluntarily and deliberately face your deepest, darkest fears, you know, every day, or, you know, just as often we’re going to meet you know, why? What’s in it for you?”
“And what are you what’s important to you? What do you care about?” To do that work to properly contextualize the treatment is important and you know, most people will say things like, you know, “I want to better life.”
And I think to really get specific and say like, “I want to be able to hug my kids again” or I want to be able to, you know, “I want to be able to pursue my ambitions” or “I want to be able to just roll around on the ground at the park and not care, you know, with my dog,” whatever it is. I was going to say a small thing, that’s not a small thing.
That’s a major thing so I think to properly put the treatment for all the work in context, I think is really, really important. I have to take the anxiety away of doing the exposures but I think that’s really a critical piece.
And then as far as the actual exposures, typically where would you want to start, is something that’s not that you’re not starting by doing the most difficult exposure on your list. So oftentimes what you do in treatment is you’ll work with a patient to develop what we call a hierarchy.
So it’s just a list of different thoughts, triggers basically, different situations, thoughts, stimuli, emotions, images, that are distressing and you sort of rank order them according to how challenging they are for the patient to encounter.
And then, you know, we’ll usually is like a zero to 100 scale or like a 50 to a hundred to 100 scale something like that. Where a hundred is a if I encounter this, it’s like a full-blown panic attack the worst anxiety I can imagine 50 is like I don’t like it, but I can deal with it.
Zero is like, theoretical is like a corpse. It’s not even real. I don’t know. Nobody experience zero anxiety but so you’ll typically start by doing exposures that are more in the 50, 60 range just to kind of like, you know, begin to develop some mastery over these stimuli.
And have a success experience. And then go up from there. You don’t have to do things that do treatment that way. Where you kind of incrementally go up the steps.
In fact, there’s a lot of data coming out that it can be actually useful to jump around that hierarchy and do something a little bit easier one day and they just make it harder the next day.
And then kind of have to have a little bit more variability to help generalize. But I think if nothing else though it’s a good way to help ease somebody into treatment by starting relatively small.
Jenn: We had a parent write in saying that their child is struggling with OCD and needs some to engage in behaviors with them or else the child believes that they’ll be in danger.
While they’re seeking treatment, does the parent continue to engage in these behaviors to help alleviate the child’s concerns?
Jason: I think that you could, so what I was just saying about the hierarchy in terms of. you know, helping the person to go through things in steps.
You can apply that to the parent behaviors too, where, you know, for example, it so it might be too overwhelming for the kid to instruct the parent just to not have that conversation at all. Like right off the bat.
But what you might say is like, “Okay, you know that your mom is going to tell you that everything’s okay once.” You know what I mean. Or twice or something like that. And then that’s it.
After that we have to learn to kind of deal with that experience. And part of the treatment is going to be that, it’s still going to be distressing that the kid is going to be, you know, anxious, an important skill that a parent develops is their ability to withstand their child’s anxiety.
You know, like to be able to sit with the anxiety they have over the fact that their kid is so anxious, which is not a small thing.
But I think if you can kind of do it in steps like that too where we just sort of start by, okay, well, if we can’t completely take away this combination altogether, you know, where can we to peel back.
Jenn: Wanted to ask you the $64,000 question that everyone if you’re joining us in 2020, hand-washing.
How do you know the difference between OCD and being overcautious with hand hygiene due to the COVID? And what’s the threshold where we would consider it something of concern?
Jason: Yeah. It’s it all comes down... We, you know, we kind of touched this little bit at the last webinar, the COVID webinar, but it all comes down to the function of the hand wash. Put simply it’s why you’re washing your hands?
So like just to use this example again. You can take two people that are both washing their hands and on the surface, they’re doing the same thing. So they’re both washing their hands for, you know, 20 seconds or something like that.
They on there and then they soap off lather, they wash, they rinse and then they move on. But one person going to have OCD and the other person doesn’t. And in a nutshell the person who doesn’t have OCD is washing their hands for one reason, the person that has OCD is washing their hands for two reasons.
So the reason they both have is that they’re washing their hands because that’s the thing to do. You’re supposed to wash your hands. It’s a hygienic thing. This case it’s like following CDC guidelines.
Yes, wash your hands for 20 seconds, you know, use soap, lather up, rinse off and move on. That’s the reason why as the function of the hand wash. Is to kind of be hygienic and it’s what you’re supposed to do.
If you have OCD, it’s not just that, though you’re doing it to control your anxiety, and to control uncertainty, and to control whether or not you get COVID. And it, back to your original question about control that we were kind of talking about before.
So if the reason why you’re doing it is more, it’s just kind of like a subtle thing but if the reason why you’re doing the hand-wash is more about trying to control anxiety and control and try to eliminate the possibility of contracting COVID that’s more on the compulsive side then this is just the thing that I need to do.
Especially pay attention to if your brain is saying things like, “Well, if 20 seconds is good, then 30 seconds is even better. Or 40 seconds even better or 60 seconds.” That’s where OCD is really sort of, again, tripping up and asking, it’s not asking you to follow a guideline anymore.
It’s asking you to regulate your emotion, to get rid of this anxiety, to feel better about it, to walk away from that sink feeling okay. That’s when it’s more than the compulsive territory. And of course, things like frequency of hand-washing.
Are you washing your hands way more than the CDC would recommend? You know, are your hands raw and red and bleeding and cracked cause it’s so dry. Yeah. Those kinds of telltale signs is to compulsive hand washing.
Do you feel like you aren’t able to function unless you’ve washed it? Like, if you, if you’re just moving about your personal living space and just going from one room to another, and then all of a sudden you feel like you need to wash your hands, and you can’t function unless you get that thought out of your mind and wash your hands.
I think that’s more in the compulsive territory. And just to your question about when is it really a cause for concern do you have to do something about it? It’s what it’s impairing your life?
Like, I can’t work unless I feel completely clean or I feel like I’ve completely eliminated this possibility of getting COVID then I can function. If you feel like you decreasingly can function then that’s like that’s the time to start seeking out help.
Jenn: So if you have a client with OCD and they have compulsive hand-washing how would you address it when there’s realistic concern about developing illnesses, particularly if you’re trying to walk them through exposure therapy?
Jason: Yeah. What I want to do is help them to do a hand wash in a non-OCD way, essentially. So, you know, typically the way that the OCD compels those folks to wash their hands is again, very compulsive and very much in the service of getting rid of anxiety.
And what I want to do instead is say, “We’re going to do a by the CDC guidelines hand-wash but we’re not going to do anything more than that at all. Like at all.”
And nine times out of 10, if I’m working with somebody with OCD their brain yells to them for that. If they want more than, so the exposure essentially then becomes just following the normal CDC guidelines and, you know, doing a 22nd hand wash, turning off the sink, walking away, even though it doesn’t quite feel right yet.
You know, I wouldn’t be having people not follow the CDC guidelines. That’d be irresponsible of me.
I think it’s, that’s kind of, you know, the new normal that we’re all kind of dealing with that we didn’t really have to think about it as much before but the way that OCD works, there’s always this opportunity to where OCD is going to want the person to do more and more and more.
And I want to help them to see, like, you know, we’re not going to do more of that. We’re going to actually just stick with this.
And we’re going to just practice dealing with that feeling that come up when you do just sort of stick to the basics or stick to the, kind of the core guidelines. I think that’s where the workbook would kind of start.
Jenn: We had someone write in who has a client with intrusive thoughts that are focused about losing loved ones to illness. And the client does have a fear of being left alone.
They’re also really dependent and reactive to loss or separation, and they’re seeking advice. Would the recommendation be exposure to fear about losing a loved one?
Jason: It would come down to, I think the way that advice seeking was functioning for the person.
So the same thing, I was just sort of saying about the hand washing stuff applies to that where, you know, is it that you have, typically what the OCD wants you to do is not anything that’s actually helpful and adaptive.
Like it doesn’t actually help your life. It just kind of like keeps you stuck. And if what those thoughts are doing is to, you know, compel you to seek out advice it’s actually useful, and you can actually apply and your life moves in the right direction in the wake of that advice.
You know, it’s like you’re able to move forward. You’re not getting stuck. You’re not kind of like overly distressed by these thoughts that come about loved ones dying. Then that could be fine.
But this sounds more like, especially they’re characterizing them as intrusive thoughts like this idea that I can’t tolerate having these thoughts and I need to drop what I’m doing and ask for that advice to get rid of this anxiety.
And then I can move on. That’s more on the composing, I think. And the end of the spectrum where I would start to classify that more as OCD than just a normal, healthy behavior.
Because again, it’s more about controlling anxiety and uncertainty than it is about anything legitimate. Anything where it’s like the advice is putting you in a better situation or a better position to navigate your world after having it.
Jenn: If a healthcare professionals interested in being trained in evidence-based OCD treatments, do you have any local or online trainings that you would recommend?
Jason: Yeah. So the IOCDF, constant plug for the IOCDF. I don’t even, I don’t work for them or anything. I just keep throwing them out there.
Jenn: Are you sure?
Jason: No. No. So they run a training called the BTTI, but just a case in point I’m blank on exactly what it stands for right now, Behavioral Therapy, something, Training Initiative, I think. Behavioral Therapy Training Initiative. And which is awesome--
Jenn: Great cover-up.
Jason: So they offer, they have an essentially a number of tiers of training. I think the first year is if you are a part of a BTTI training, you go to a bunch of seminars and kind of classes and stuff and kind of didactics.
But at a certain point you start getting individual supervision with various experts that are hooked up with them, which is just a great model. So that’s, I think one of the best ways to get trained on this.
That’s local to Massachusetts but if I’m not mistaken, I’m pretty sure there’s a huge push to get those trainings more widely available across the country. I’m actually pretty sure that they are available in other places. I’m not sure I’ve that in my head.
I think that’s a great place to start. But there’s also, there are other kind of world-renowned centers for treatment, for anxiety disorders, for OCD treatment, that offer the occasional intensive training just off the top of my head.
Another center for treatment and study of anxiety at the University of Pennsylvania will offer an intensive training. You know, some of our professional organizations offer trainings, the Association for Behavioral and Cognitive Therapy or the Anxiety Depression Association of America.
If you joined them, there are tons of opportunities for intensive master clinician workshops. There’s lots of resources out there, but as I guess I was always I just start with the IOCDF cause they’re kind of a good centralized location for this kind of stuff.
Jenn: Alright. Do you have any advice because as we’re getting into another wave of COVID, there’s the likelihood of a lot of states going into lockdown, any thoughts on creative ways for behavioral activation or exposure during times where might be hunkered down in our homes?
Jason: Yeah, I think that, obviously it’s harder for sure. But I think that what this period of time has at least shown me, is that, you know, so it’s kind of gives us, first of all, it gives us this renewed appreciation for other people and being outside and engaging meaningfully with the world.
But I think that it’s important to recognize all the different ways that if you have OCD, your brain will still want you to protect yourself even when you are protected, like at home. So, you know, for some people with OCD it’s been almost a boon to their, in a bad way, I guess a boon to their OCD, these lockdowns.
Because, oh, I don’t have to be outside. I don’t have to be, you know, around my triggers. And that sort of thing. But what I really want to caution people is that still it’s not like OCD goes away. Like it’s still kind of floating around in there.
And it’s probably wanting you to avoid in various subtle ways just to get around your space. So notice that kind of stuff and push back against that in any way that you can. Do things that are uncomfortable for you.
So this Zoom stuff has really invited lots of opportunities to essentially do social anxiety exposures, right? Like, yeah, go join a video, Zoom support group or something like, right, exactly what I’m saying. Like, look at yourself. You know, look at your reflection the whole time.
Jenn: I have alluded in many other sessions that I always get social anxiety when coming on here cause you’re talking to a void, so yeah. Anxiety is real or on Zoom.
Jason: Exactly, I know what’s happening out there. Yeah. There are opportunities to do those sorts of things. You know, again, back to this idea of OCD always wanting more, we were talking about hand washes and it wanting, you know, if the guideline is 20 seconds it’s going to want 30 seconds.
With lockdowns it’s going to say things like, “Well, if it’s, you know, if you really shouldn’t be going, if you, you know...” Let’s take it literally, I guess, you know, just really literally never leave the house but I don’t know how helpful that is for a lot of people.
I think that, you know, be watchful of the extent that the OCD wants you to protect yourself and balance that against our needs for, I don’t know, fresh air, exercise, that sort of thing. So push back, like that’s a healthy thing to do.
Is to visit, like visit... We know that, you know, being outside, being in fresh air, it’s a relatively low risk activity especially if you got your mask on and if you’re going to be close to people, but if you aren’t close to people if you’re around people, it’s probably okay.
Even if they feel a little bit uncomfortable and it feels like it would be safer to do the thing inside go outside anyway like do the thing that feels a little bit more challenging.
If you think about it, if you look at your space more kind of critically, I think you can find these areas to push back and always be sort of, again especially if you’re somebody who struggled with OCD and mental illness, generally depression, isolation, finding ways to kind of lean against that, and push yourself forward is going to be only healthy for you to do so.
Jenn: So I’ve got one more question for you and it is kind of a hefty one. So bear with me. What is the outcome of a successful treatment for a person with OCD?
Do we get to a place where we feel as if we’re past an issue or are we always going to be fighting a compulsive thought?
Jason: Yeah, no. That’s a really good question. And I’ll try to answer it as succinctly as I can. Recovery is possible. A thousand percent. What do I mean by recovery in OCD?
I think that what we know is that people can get to the point where you can do anything in your life. And it doesn’t matter the level of severity of OCD that you’ve had before.
You will not be... If you engage in treatments, you do, you know, you kind of, you know, you put forth the effort that’s necessary. You absolutely can get to the point where anything that you want you can get. If you work towards it.
I think the way to think about it is think about it as analogous to somebody who’s really trying to get in shape. So, you know, let’s say they’re not in shape and they go to a personal trainer and nutritionist, et cetera, and they follow all their recommendations, right?
They eat right, they exercise, they kind of stay on top of everything. Once they’ve kind of gotten to that point “where they are in shape,” it’s not like they then turn to those people and say, “Am I done now? Can I just start eating cheeseburgers again?”
And just like, you know, not exercising anymore. Yeah. It’s a thing that you always have to do. You always have to sort of stay on top of that in some way.
And there’s analogies in OCD treatment where you’re always going to be sort of I think having to recognize, Oh, this is this behavior that I’m doing is veering into compulsive territory. Or, you know, these obsessions that I’m having more I’m starting to react to them.
Start to get more avoidant of things that are related to them. And I think it’s a matter of being keyed into that and then pushing back against that when that shows up.
And yes, that’s, I think that it’s part of your life but in the same way that again staying in shape is part of everybody else’s life or managing diabetes as part of somebody else’s life.
And it can become more and more second nature over time where you just don’t have to think about it as much.
And again, this is where, and don’t take it from me. I mean, take there are so many people out there who speak a lot about this really eloquently about people with lived experiences that have gone through treatment that can really speak to this in a way that’s really powerful.
So, you know, again, like the OCD stories podcasts that I mentioned before people like Chrissie Hodges and others are people to sort of pay attention to and listen to if you’re just thinking about that.
If you’re just not sure about how it’s going to look for you just know that absolutely that you can recover and that can live the life that you want.
Jenn: It seems almost like kismet that this is the way that we’re going to end the session. I feel like we’ve come like full circle in this. So Jason, Thank you so much for all of your insights.
This has been, I think a really valuable session not only for people who are going through OCD but people who care about those who are struggling with OCD. So Jason, huge, immense, Thank you. And to everybody who joined us, thank you.
Jason: Thank you.
Jenn: This is actually the end of the session. And until next time be nice to one another and be nice to yourself. You deserve it. Have a great day. Thank you.
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