Kimberley: Could I have PTSD or trauma? This is a question that came up a lot following a recent episode we had with Caitlin Pinciotti, and I’m so happy to have her back to talk about it deeper. Let’s go deeper into PTSD, trauma, what it means, who has it, and why we develop it. I’m so happy to have you here, Caitlin.

Caitlin: Yes, thank you for having me back.

INTRODUCING CAITLIN PINCIOTTI

Kimberley: Can you tell us a little bit about you and all the amazing things you do?

Caitlin: Of course. I’m an assistant professor in the Psychiatry and Behavioral Sciences Department at Baylor College of Medicine. I also serve as the co-chair for the IOCDF Trauma and PTSD in OCD Special Interest Group. Generally speaking, a lot of my research and clinical work has specifically focused on OCD, PTSD, and trauma, in particular when those things intersect, what that can look like, and how that can impact treatment. I’m happy to be here to talk more specifically about PTSD.

WHAT IS PTST VS TRAUMA?

Kimberley: Absolutely. What is PTSD? If you want to give us an understanding of what that means, and then also, would you share the contrast of—now you hear more in social media—what PTSD is versus trauma?

Caitlin: Yeah, that’s a great question. A lot of people use these words interchangeably in casual conversation, but they are actually referring to two different things. Trauma refers to the experience that someone has that can potentially lead to the development of a disorder called post-traumatic stress disorder. When we talk about these and the definitions we use, trauma can be sort of a controversial word, that depending on who you ask, they might use a different definition. It might be a little bit more liberal or more conservative. 

I’ll just share with you the definition that we use clinically according to the DSM. Trauma would be any sort of experience that involves threatened or actual death, serious injury, or sexual violence, and there are a number of ways that people can experience it. We oftentimes think of directly experiencing trauma. Maybe I was the one who was in the car accident. But there are other ways that people can experience trauma that can have profound effects on them as well, such as witnessing the experience happening to someone else, learning that it happened to a really close loved one, or being exposed to the details of trauma through one’s work, such as being a therapist, being a 911 telecommunicator, or anyone who works on the front lines. 

That’s what we mean diagnostically when we talk about trauma. It’s an event that fits that criteria. It can include motor vehicle accidents, serious injuries, sexual violence, physical violence, natural disasters, explosions, war, so on and so forth—anytime when the person feels as though their bodily integrity or safety is at risk or harmed in some way. 

Conversely, PTSD is a mental health condition. That’s just one way that people might respond to experiencing trauma. In order to be diagnosed with trauma, the very first criterion is that you have to have experienced trauma. If a person hasn’t experienced an event like what I described, then we would look into some other potential diagnoses that might explain what’s going on for them, because there are lots of different ways that people can be impacted by trauma beyond just PTSD.

PTSD SYMPTOMS AND PTSD DIAGNOSIS 

Kimberley: Right. What are some of the specific criteria for being diagnosed with PTSD?

Caitlin: PTSD is comprised of 20 potential PTSD symptoms, which sounds like a lot, and it is. It can look really different from one person to the next. We break these symptoms down into different clusters to help us understand them a little bit better. There are four overarching clusters of PTSD symptoms. There’s re-experiencing, which is the different ways that we might re-experience the trauma in the present moment, such as through really intrusive and vivid memories, flashbacks, nightmares, or feeling really emotionally upset by reminders of the trauma. 

The second cluster is avoidance. This includes both what we would call internal avoidance and external avoidance. Internal avoidance would be avoiding thinking about the trauma, but also avoiding any of the emotions that might remind someone of the trauma. If I felt extremely powerless at the time of my trauma, then I might go to extreme lengths to avoid ever feeling powerless again in my life. In terms of external avoidance, that’s avoiding any cue in our environment that might remind us of the trauma. It could be people, places, different situations, smells, or anything involving the senses. That’s avoidance. 

The third cluster of PTSD symptoms is called negative alterations, cognitions, and mood, which is such a mouthful, but it’s basically a long way of saying that after we experience trauma, it’s not uncommon for that experience to impact our mood and how we think about ourselves or other people in the world. You’ll see some symptoms that can actually feel a little bit like depression, maybe feeling low mood, or an inability to experience positive emotions. But there’s also this kind of impact on cognition—an impact on how I view myself and my capabilities, maybe to the extent that I can trust other people or feel that the world is dangerous. Blame is really big here as well.

And then the last cluster of symptoms is called hyperarousal. This is basically a scientific word for your body—sort of kicking into that overdrive feeling of that fight, flight, freeze response. These include symptoms where your body is constantly in a state of feeling like there’s danger or threat. This can impact our concentration. It can impact our sleep. We might have angry outbursts because we’re feeling really on edge. We may feel as though we have to constantly watch our backs, survey the situation, and make sure that we are definitely going to be prepared and aware if another trauma were to happen. 

Those are the four overarching symptom clusters. But somebody only actually needs to have at least six of those symptoms to a clinically significant and impairing way.

Kimberley: Right. Now, I remember early in my own treatment, a clinician using terms like little T trauma and big T trauma. The example that I was discussing is I grew up on a ranch, a very large ranch. My dad is and was a very successful rancher. Every eight to 10 years, we would have this massive drought where we would completely run out of water and we’d have to have trucks bring in water, and there were dead livestock everywhere. It was very financially stressful. I remember her bringing up this idea of what is a little T trauma and what is a big T trauma—not to say that that’s what was assigned to me, but that was the beginning of when I heard this term.

WHAT IS BIG T TRAUMA VS LITTLE T TRAUMA? 

What does it actually mean for someone to say big T trauma versus small T trauma?

Caitlin: Yeah, this is another common term that people are using. I’m glad that there is language to describe this because a lot of times, when I provide the definition that I gave a few minutes ago about what trauma is according to the DSM, people will hear that and think, “Wait a minute, my experience doesn’t really fit into that criteria, but I still feel like I’ve been really impacted by something. Maybe it’s even making me experience symptoms that really look and feel a lot like PTSD.” Some people can find that really invalidating, like, “Wait a minute, you’re saying that what I experienced wasn’t traumatizing and it feels like it was traumatizing.” 

Those terms can be used to separate out big T trauma, meaning something that meets the DSM definition that I provided—that really more strict definition of trauma. Whereas little T trauma is a word that we can use to describe these other experiences that don’t quite fit that strict criteria but still subjectively felt traumatizing to us and have impacted us in some way. 

What’s interesting is that there’s some research that suggests that the extent to which somebody subjectively feels like something was traumatic is actually more predictive of their mental health outcomes than whether or not it meets this strict definition because we see people all the time who experience big T traumas and they might be totally fine afterwards. And then there are people who experience little T traumas and are really struggling. 

We can use little T trauma to describe things like racial trauma, discrimination, minority stress, the experiences that you described, and even just significant interpersonal losses and things like that.

Kimberley: Yeah. Maybe even COVID. For some, it was a capital T trauma, would you say, because they did almost lose their lives or witness someone? Is that correct? Would you say that some others would have interpreted it as a smaller T and then some wouldn’t have experienced it as a trauma at all?

Caitlin: Yes, I think that’s a great example because there are definitely a lot of folks who don’t necessarily know someone who became really ill, lost their life, or didn’t have that personally happen to them. But there was this looming stress, maybe even related to quarantine and isolation and things like that.

WHO GETS PTSD AND TRAUMA?

Kimberley: This is really fascinating. I wonder if you could share a little, like, of all the people, what are the factors that you mentioned that increase someone’s chances of going on to have PTSD? Who goes on to get PTSD, and who doesn’t? How can we predict that? What do we know from the research?

Caitlin: This is an interesting question because I think that some people might intuitively think, “Well, somebody experienced this really horrible trauma. Of course, they’re going to go on to develop PTSD.” We actually know that people on the whole can be pretty resilient even in the face of experiencing pretty horrible tragedies. 

Our estimates of exposure to what we would call potentially traumatic experiences range from 70% to 90% of the population, and most of us will experience something at some point in our lives that would need that definition—that strict definition of a trauma. Yet, only about 6 to 7% of people will be diagnosed with PTSD at some point in their lives. So there’s this huge discrepancy here. 

There are lots of factors, and of course, we don’t have this perfectly nailed down where we can exactly predict, “Okay, this person is going to be fine. This person is going to have PTSD.” It’s really an interaction of lots of factors. But we know that there are some things that can either provide a buffering effect against PTSD or have the opposite effect, where they might put somebody at greater risk. 

One of the biggest things that’s come up in research is social support or the lack thereof, so that when people have really great social support after their trauma, whether it’s after a sexual assault or they’ve come home from combat, that can really buffer against the likelihood of developing PTSD. The reverse is true as well when people don’t have social support. We saw this, for example, after the Vietnam War, where a lot of veterans came home and really were mistreated by a lot of people. Unfortunately, that’s a risk factor for developing PTSD. 

But there are other things too, like coping. Not necessarily using one particular coping skill, but rather having a variety of coping strategies that somebody can use flexibly, even something like humor. We see this as a resilience factor. Obviously, there are times when using humor can serve as a distraction or avoidance, and there are times when it can be really adaptive too.

Obviously, of course, genetics that people may have a predisposition in general towards having mental health concerns. Sex, we know that people assigned female at birth have a higher likelihood of developing PTSD after trauma. 

And then there are things that may be specific to the experience itself, so the type of trauma. Sexual assault is unfortunately a really big risk factor for developing PTSD, whereas there are other trauma types where fewer people go on to develop PTSD from those. 

And then there’s something that we call peritraumatic fear, and that just means the fear that you were experiencing at the time that the event was happening. In the moment that the trauma was happening to me, how scared was I? How much did I feel like I might lose my life? People who experience more of that fear at the time of the event are more likely to go on and develop PTSD. 

But it’s pretty interesting too, because, as with everything, there isn’t just this binary, like you either have it or you don’t have it. I want to normalize this too for anyone who might be listening and maybe has recently experienced something really horrible and is struggling with some of these symptoms that we talked about. It doesn’t necessarily mean that you have PTSD or that you’re going to continue to have PTSD. 

Most people, about 50 to 65%, will experience mild to moderate post-traumatic stress symptoms after the event that will just gradually go away on their own. We call that a resilience trajectory. We also have about 10 to 15% of people who have what we call a recovery trajectory, where maybe right away they did have a spike in post-traumatic stress symptoms, right away in that first month or so. But after a year, again, it’s resolved itself. 

And then we have two trajectories that go on to describe people who will have PTSD. That would be a chronic trajectory where somebody would have this elevation in symptoms after the trauma that persists. That’s usually about 15 to 20% of people. And then less likely is what we call a delayed trajectory. This is about only 5 to 10% of people who may have had really mild symptoms right away or perhaps no symptoms at all. And then, after about six to 12 months, it might just all of a sudden skyrocket for whatever reason.

IT IS OCD OR AM I IN DENIAL? 

Kimberley: Right. So interesting. I was actually wondering what you often hear about people who, especially as someone who treats OCD and anxiety disorders, often questioning whether there was a trauma they had forgotten. Like, did I repress or am I in denial of a trauma? What can you share statistically about that?

Caitlin: Yeah, that’s a really great question. It’s definitely more of a controversial topic in the field, not because people don’t have the experience of having these recovered memories, but rather because of what we know about how memory works and how fragile it can be, that as clinicians, we have to be really careful that we’re not, in our efforts to help someone, inadvertently constructing a false memory. 

I would say that most of the time, this delayed trajectory of PTSD symptoms is less so about the person not remembering the event, but more so like they just have continued on with their life and are probably suppressing, avoiding, and doing all sorts of things that are maybe keeping it at bay temporarily. And then there may be, in a lot of cases, some big life event that may bring it up, or perhaps another traumatic experience or something like that.

WHAT IF I HAVE REPEATED TRAUMAS? 

Kimberley: Yeah. I was going to ask that as well, as I was wondering. Let’s say you’ve been through a trauma. You recovered on that trajectory you talked about. Are you more likely to then go on to have PTSD if you repeat different events, or do we not have research to back that up?

Caitlin: That’s a great question. I’m not sure specifically about, depending on which trajectory you were initially on, how that increases the likelihood later on. I can say that repeated exposure to trauma in general is associated with a greater likelihood of PTSD. I would say that, probably regardless of how quickly your symptoms onset, if at all initially, experiencing more and more trauma is going to increase the likelihood of PTSD.

WHO CAN DIAGNOSE PTSD AND TRAUMA? 

Kimberley: Right. Amazing. Thank you for sharing that. I know that was very in-depth, but I think it helps us to really understand the complexity and the way that it can play out. 

Who can make these diagnoses? I know, as I mentioned to you before, even my daughter has said she found herself on some magazine website that was having her do some online tests to determine whether there was trauma. It seems to be everywhere, these online tests. Can you get diagnosed through an online test? Would you recommend that or not? Who can we trust to make these diagnoses?

Caitlin: That’s a great question. I would not recommend using something like an online test or even a self-report questionnaire to help you figure out if you have PTSD. Now, it can give you a sense of the specific areas that I might be struggling with that I could then share with a licensed provider, who can then make the diagnosis. But if you were to just find a quiz online and take it, and it says you have PTSD, that would not be something that we would consider to be valid or reliable in any way. 

I would recommend talking with a psychologist, a psychiatrist, any sort of general practitioner, an MD, or maybe even someone’s primary care physician. Definitely, if you can get in touch with a licensed provider who specializes in PTSD and can really be sure that that’s what’s going on for you. 

Now, TikTok and all these things exist out there. As with anything on the internet, it can be used for good and it can also be very harmful. I think it just comes down to gathering information that may be helpful but then passing it on to someone who can sift through the misinformation and give you a clearer answer.

Kimberley: Yeah. Thank you for that. I think, as someone myself who’s had their own mental journey, I do remember during different phases of my own recovery where our brains just don’t make sense. I had an eating disorder—a very bad eating disorder—and my brain just couldn’t see clearly in some areas, and me being so frustrated with that. I know lots of people with, let’s say, panic disorder feel the same way or health anxiety, their condition feels so confusing and makes no sense that in the moment of being grief-stricken by this and also very confused, it’s pretty easy to start wondering, “Could this have been a trauma or is this PTSD? This doesn’t make sense. Why am I having this mental health issue?” Especially if it’s not something that was genetically set up in your family. I’m wondering if you can speak to the listeners who may have dabbled in thinking maybe there is a trauma, a big T, a little T, or PTSD. Can you speak to how someone might navigate that?

Caitlin: Most definitely. I’ll validate too that it’s really complex. We use the DSM to help us understand these different diagnoses, but there’s so much overlap. Panic disorder—obviously, panic attacks are the hallmark feature of panic disorder, but people can have panic attacks in PTSD as well. People with eating disorders might have issues with their self-image and their self-esteem. That can happen in PTSD as well, as I mentioned, even with mood disorders. There are symptoms in PTSD that sure look and sound a lot like depression. 

If it feels confusing, “Well, wait a minute, I have this symptom. What does it belong to? What does it mean?” We do really have this very imperfect and overlapping classification system that we use. That being said, it’s a legit question to ask if somebody feels like, as you were saying, “I’ve been struggling with these symptoms, but it really feels like there’s something more here.” 

When we diagnose PTSD, we go through all of the 20 symptoms, some of which I referenced earlier. For each symptom, we’ll ask about when that symptom started for the person relative to trauma and whether or not it’s related to trauma in some sort of way, if there’s some content there to work with. 

For example, somebody maybe wasn’t having any issues with their mood whatsoever, and then they experienced trauma, and all of a sudden, it was just really hard for them to get out of bed. Well, that could potentially be a symptom of PTSD because it started after the trauma. 

One thing that I hear a lot, because unfortunately, childhood trauma is really common, when I ask folks about this, they’ll say, “I don’t know. The trauma happened when I was so young that I don’t even remember who I was before this person that I am now, who’s really struggling.” In that case, people usually have a pretty good insight into this. Like, do you think that this is related in any way? Or maybe, if you have any recollection, you had a little bit of this experience and this symptom initially, and it got worse after the trauma. That, again, could potentially indicate that that’s a symptom of PTSD. 

I would say for those folks who are listening, who are struggling with things like panic attacks, difficulty with eating, mood, whatever it might be, even OCD, which we talked about recently, really checking in with yourself about how and if those symptoms are related to your trauma. If they are, then find someone that you trust that you can talk to about it. Hopefully, a therapist who can help you piece this apart. 

It could still be maybe the disorder you thought it was, maybe it is panic disorder, maybe it is OCD, maybe it is an eating disorder that’s still informed by trauma in some way or impacted in some way, which would be important to be able to process in treatment. Or it could just be PTSD entirely. And then that would be really important to know because that would significantly change what the treatment approach would be.

Kimberley: Yeah. It’s so true of so many disorders. You could have social anxiety and panic attacks because of social anxiety, and a mental health professional will help you to determine what’s the primary, like, “Oh, you have social anxiety and social interactions are causing you to have panic,” and that can sort of help. I think as clinicians, we’re constantly ruling out disorders using our professional hat to do that. I think you’re right. Speak to a professional and have them do our assessment to help you pass that apart. Because I think in general, any mental health disorder will make you feel like something doesn’t feel right, and that’s the nature of any disorder. 

Caitlin: Right. The good news, too, is that, within reason, some of the treatment techniques that we have can be used more broadly. Interoceptive exposures, we can use that for people who have panic disorder, just people who struggle with panic attacks, or maybe people who have OCD or GAD and just feel really sensitive to those sensations in their body that suggest that they might be anxious. Same thing with behavioral activation. We use that for depression, and that can really easily be added to any treatment, whether it’s treatment for PTSD or something else. You’re exactly right, getting clarity on what’s going on for folks, and then what are some of these techniques that might be most helpful for these symptoms?

PTSD AND TRAUMA TREATMENT 

Kimberley: Yeah. Thank you. You perfectly segue this into the next question, which is, can you describe the treatment or give us names of the treatment for this comparison of trauma versus PTSD? Are they the same treatments? Does it matter whether it’s a big T trauma or a little T trauma? Can you give us some idea of the treatments for these struggles?

Caitlin: Definitely. Most of the evidence-based treatments that exist are specifically for PTSD. Obviously, they touch on trauma, of course, as the reason why somebody has PTSD and where all of these symptoms stem from. But there aren’t as many treatments that are, let’s say, specifically for trauma, at least not in terms of a standardized way of working through that. If somebody’s experienced trauma and they don’t have PTSD, and let’s say they don’t have any diagnoses, but they are still impacted by this experience, just doing behavioral therapy or whatever treatment feels like a good fit for what somebody is trying to work through might be sufficient. And then we have these evidence-based treatments that have been shown to really target PTSD symptoms and help reduce them.

A few years back, I think it was 2017, the American Psychological Association reviewed all of the research on PTSD treatments. They reviewed it using lots of different criteria for what it means to feel better after treatment beyond just reducing PTSD symptoms, but also looking at other things too, like mood and suicidality and things like that. They essentially created this list of treatments that they rank orders in different tiers, depending on how effective they were shown to be. 

In the top tier are four treatments. There’s cognitive behavioral therapy just broadly, cognitive therapy also broadly, and then the two specialized treatments are prolonged exposure (PE) and cognitive processing therapy or CPT. I can talk a little bit more about those two if you’d like. 

In the second tier are things like acceptance and commitment therapy, EMDR—these treatments that people may have used themselves and have found really effective, and they are effective. They’re just maybe a little bit less effective for fewer people, if that makes any sense. It’s not to say that EMDR doesn’t work, but rather that there’s just more of an evidence base for things like PE and CPT.

DIFFERENCE BETWEEN PTSD AND TRAUMA TREATMENTS 

Kimberley: Great. To speak to those two top-tier treatments, can you compare and contrast them for someone just so that they feel they understand the difference?

Caitlin: Yeah. If I had a whiteboard, I would just draw out the CBT triangle, but hopefully, folks listening know that in the CBT triangle, you have your emotions, your behaviors, and your thoughts, and all these things are constantly interacting with one another. We could say, just on a really simplified level, that when we are seeking treatment for PTSD, we want our emotions to be different. We want to feel less emotionally impacted by the trauma that we’ve experienced.

PE and CPT are both under the umbrella of cognitive behavioral therapy, so they both use that triangle. They just get at it a different way. PE starts with the behaviors, knowing that the thoughts and emotions come along for the ride. CPT starts with the thoughts, knowing that the behaviors and the emotions come along for the ride. 

Now, they’re both extremely effective at reducing PTSD symptoms. They’ve done head-to-head comparisons. They’re both great. You’re not going to find one that’s significantly better than another, but you might find one that feels like a better fit for what you’re currently struggling with. 

Cognitive processing therapy, again, starting with the thoughts, cognitive processing, basically involves-- I almost think of this as looking at our thoughts and our beliefs about things and examining them from different lenses. I always picture plucking an apple from a tree. Like, okay, this is a belief that I developed from my trauma. This was really adaptive for me at the time because this belief told me that I can’t trust anyone and I have to always watch my back. Boy, did that help me when I was in combat and I was always watching my back and making sure I was safe. But as I look at it from these different angles, I might realize, well, I’m not in combat anymore, and I’m living in a pretty safe environment with safe people. So maybe this belief doesn’t really serve me anymore. 

You work with your therapist to identify what we call stuck points, which are these really deep-seated beliefs that somebody has about themselves, other people, or the world that either developed from trauma or were reinforced by trauma, because sometimes people will say, “Well, I’ve never trusted people. I’ve always been in an environment where things weren’t safe.” And then there we go, the trauma happened, and it just proved me right. Cognitive processing therapy helps people work through these stuck points and come up with alternative perspectives on these thoughts. 

Prolonged exposure is a lot more similar to what I imagine lots of the folks listening may have done with exposure therapy generally, or exposure and response prevention for OCD. Again, we’re starting with the behavior, knowing that if we target the behavior first, that’s going to change our cognitions, and it’s going to change our emotions. 

PE involves two different types of exposure. The first one being in vivo exposure, which is really similar to just any sort of ERP exposure where you expose yourself to something in the environment that triggers a thought about the trauma or some sort of emotional reaction. You do those over and over again until they feel like no big deal to you, you feel really awesome about yourself, and you can conquer the world because you can. 

And with your therapist, you do an imaginal exposure, which is where, in a really safe environment, you talk through the experience of your trauma and what happened to you. You do this actually in a unique way to really engage with that memory because, as we talked about, that internal avoidance is so common in people with PTSD. This imaginal exposure would be describing the experience in the present tense, painting a picture as though it was a film that was playing out right in front of our eyes, and really digging into the details of, what am I feeling in the moment that this trauma is happening? What am I hearing? What am I sensing? And doing that imaginal exposure, again, with your therapist in a really safe space until it doesn’t have an impact on you anymore. 

I always say this to people when they start PE with me: I know that this may sound nuts right now. But a lot of people who do PE will get to a point where they’ll look at me and say, “I’m so bored telling this story again. I’ve told this story so many times. It doesn’t even bring up this emotional response for me anymore.” That feels really unlikely for people who are just starting out in treatment and are so impacted by this memory, and they do everything in their power to avoid it. But people can and very much do get to a place where they feel like they’ve conquered this memory and it doesn’t control them anymore. 

That’s how PE and CPT work. Again, they both eventually target the same thing. It’s just sort of, which route do you go?

COMPLIMENTARY PTSD TREATMENTS 

Kimberley: Right. Amazing. Thank you. From my experience too, and actually, this is a question, not a statement—my experience, some people who I’m close with or clients who have been through PTSD treatment also then had to develop some coping skills, mindfulness skills, compassion skills, or maybe sometimes even DBT skills to get them across the finish line. Has that been your experience? What is your feedback from a more scientific perspective?

Caitlin: Yeah, it really depends on the person. There are also combinations of these treatments. There’s a combined DBT and PE protocol out there for folks who do need a little bit more of those skills. Some people do feel like they would benefit from having some of these coping skills, maybe upfront or throughout the course of treatment. But they’ve also done research where they’ve started with that skill-building before they go into PE or CPT, compared to people who go right in. Actually, what they often find is that starting with skill building, sometimes it’s just colluding with avoidance, and it just lengthens the amount of time that somebody needs before they start to feel better. 

I’m glad you asked this question because it’s so common for people with PTSD to feel like, “I can’t. I can’t do this thing. I can’t feel this thing. I can’t talk about this thing.” And they really can. Sometimes if we allow people to really challenge those “I can’t” beliefs, then they’ll realize, “I really thought that I was going to need all this extra support or I was going to need this or this, and I was able to just move right through this treatment.”

Now, of course, again, that’s not the case for everyone. There are some folks who maybe have much more severe PTSD, maybe have some different comorbidities like personality disorders or something else where it might be helpful to involve some of that, or people who had really chronic exposure to, say, childhood trauma. But far and away, people are often much better able to jump right into some of these treatments than they think they are.

HOW TO FIND A PTSD TRAUMA THERAPIST 

Kimberley: Thank you for sharing that. I think that’s super helpful for us to feel hopeful at the end. One more question before you tell us about you and some of the amazing things that you’re doing. Where might people go? As we know, with OCD and health anxiety, we want a specialist to be helping us, ideally. I’ve noticed as a consumer that everybody and their Psychology Today platform says they treat trauma. I’m wondering how we might pass through that and find treatment providers who are skilled in this area. How might they find a trained professional?

Caitlin: I’m glad you mentioned that about Psychology Today. That’s the advice that I give people when they’re using Psychology Today, or really any sort of platform. If this person is saying that they treat everything under the sun, then it’s probably not a person that you want to link up with for something really specialized because it’s-- what is the saying? “Jack of all trades, master of none.” And I start to get suspicious even that this person even does evidence-based treatment for trauma and PTSD when they’ve listed a thousand things. It’s definitely a red flag to consider for those who are listening and maybe have had this experience. 

In terms of finding a therapist, if folks are interested in PE or CPT, there’s actually directories of therapists who’ve been trained and certified in those modalities. You can find them on-- I’m trying to think of the exact website. If you Google “Prolonged Exposure providers,” something will come up, I believe it’s through Penn. You can do the same for cognitive processing therapy. If you Google, I think it’s like “CPT provider roster,” you’ll get a whole list of providers as well.

Now, just because somebody isn’t on there doesn’t mean that they haven’t been trained in these things. There’s just a certification process that some people go through, and then they can get added to this list. If your provider says, “I’m trained in PE, I’m trained in CPT,” I would probably trust that person that, for one thing, they even know what those things are, and I’d be willing to give them a shot.

Also, and I know we mentioned this on the last episode too, for anyone listening who might have PTSD and OCD, I’ve compiled a list of providers on my website—providers who are trained to treat both OCD and PTSD. I have that broken down by state and then a couple of international providers as well. My website is www.cmpinciotti.com. 

In terms of broad resources beyond finding a provider, there are lots of organizations that have put out some really great content about PTSD—videos, handouts, blogs, articles, all sorts of things. I think the biggest place that I send people is the National Center for PTSD. This is technically run through the Veterans Administration, but anyone can use these resources. They’re not only for veterans. It’s very, very helpful. I’d recommend people who want more information to go there. 

You can also find things on the Anxiety and Depression Association of America, the National Institute of Mental Health, the National Alliance on Mental Illness, and so on. And then, of course, I mentioned the Trauma and PTSD in OCD Special Interest Group that I co-chair, that folks can sign up for that too, and we send out materials through there as well.

Kimberley: Amazing. I am so grateful for you because I think we’ve covered so much in a way that feels pretty easily digestible, helps put things in perspective, and hopefully answers a lot of questions that people may be having but didn’t feel brave enough to ask. Where can people find out more about you? You’ve already listed your website. Is there any other thing you want to tell us about the work that you’re doing so that we can support you?

Caitlin: On my website, in addition to the treatment provider directory, I also have some handouts and worksheets. Again, these are specific to co-occurring OCD and PTSD. That might be helpful for some folks. I also usually list on there different studies that are ongoing. I have two right now that are ongoing that I can-- oh, actually, I have three—I lied to you when I said two—that people can participate in if they’re interested. There’s one study that we’ll be wrapping up at the end of December. That’s about OCD and trauma. People can email OCDTraumaStudy@bcm.edu for more information. We also have a study that’s specific to LGBTQIA+ people with OCD that also covers some things related to trauma and minority stress in that study. If folks are interested in participating in that, they can email me at PrideOCD@bcm.edu. 

And the last one, and I’ll plug this one the most, that if folks are like, “Well, I want to participate in a study, but I don’t know which of those,” or “I only really have a few minutes of my time,” we have a really, really brief survey, and we’re trying to get a representation of folks with OCD from all over the country. For anyone who’s listening and who has OCD and is willing to participate, it’s a 10-minute survey. You can email me at NationalOCDSurvey@bcm.edu. All of these cover the topic of trauma and PTSD within them as well.

Kimberley: Thank you. I’m so grateful for you. You’ve come on twice in one month, and I can’t thank you enough. I do value your time, but I so value as well your expertise in this area and your kindness in discussing some really difficult topics. Thank you.

Caitlin: No, I appreciate it. Thanks for having me on. I hope that folks who are listening can feel a little bit more hopeful about what the future can hold for them.

PTSD & TRAUMA LINKS AND RESOURCES 

Find a PE provider: https://www.med.upenn.edu/ctsa/find_pe_therapist.html

Find a CPT provider: https://cptforptsd.com/cpt-provider-roster/

For educational resources on PTSD: https://www.ptsd.va.gov/

To participate in a brief, 10-minute national survey on OCD: NationalOCDSurvey@bcm.edu

To participate in the OCD/Trauma Overlap Study (closing at the end of December): OCDTraumaStudy@bcm.eduTo participate in a study for LGBTQIA+ people with OCD: PrideOCD@bcm.edu

Radical acceptance when things get hard can be a very difficult practice. In fact, it can be almost impossible. When things get hard, one of the things we often do is we spend a lot of time ruminating about why it’s so hard and what we could have done to prevent it from being so hard. And, instead of using radical acceptance, we often go into beating ourselves up, telling ourselves, “We should have done this; we could have done that. If only we had looked at it this way or treated it this way.” I want us to really zoom in on these safety behaviors that you’re probably doing. Hopefully, today, you leave here committing to reducing or eliminating those behaviors.

Now, I get it. When things are hard, we don’t want to feel the suffering that goes with it. I get it. I don’t want to feel it either. You’re not alone. But when things are hard, often, instead of letting it be hard and feeling our feelings and being kind to ourselves so that we can move into effective behaviors, we get stuck resisting the emotions and doing these other behaviors that increase the shrapnel of the event. I call it ‘shrapnel’ because it does look like that. It creates more damage around us. Let’s look at how we might prevent this. 

HUMANS SUFFER

You’re suffering. The reason I know this is because you’re a human being, and all human beings have sufferings in their lives. Some of us, more than others. If you’re in a season where the suffering is high, I would basically say, the higher the level of suffering, the more you need to listen in. Maybe listen to this multiple times, get your notepad out, and let’s really go to work. 

SOLVING DOESN’T ALWAYS WORK

When you’re suffering and your suffering is high, again, it’s very normal to want to solve why you’re suffering, thinking that yes, that may prevent it from happening in the future, prevent us from having more pain, or prevent us from having to feel our feelings. That’s effective behavior, except... if you’re relying on that and you’re spending too much time doing that, chances are, you’re increasing your shrapnel. If that’s the case, let’s talk about other alternatives. 

When we’re going through difficult things, there is a strong pull toward figuring out why. But my guess is, if you haven’t solved it yet, chances are you won’t. I know this is true for me. It might be true for you, but you’ve probably already identified the problem of one of the things that may be if, in 20/20 hindsight, you could have done differently. And that’s okay, right? There’s many times I’ve looked back and been like, “Yeah, it didn’t handle that well,” or “That didn’t go as well. Maybe now, knowing what I know, I could have done something different.” But often, we spend too much time resisting the fact that it is hard right now. 

If you’re someone who’s spending a lot of time going over and over on repetition, all the things you could have done, chances are, you’re not radically accepting what is. What we want to do first is move to radical acceptance as fast as we can. We’re not saying that you can’t go back and do some effective addressing of what went wrong and what went right. You can do that for short periods of time. But if you’re someone who’s doing it repetitively, catch yourself. We want to move into radical acceptance that yes, things are hard right now.

WHY DOES RADICAL ACCEPTANCE SUCK?

Often, we resist practicing radical acceptance because of one core reason, and that’s because we don’t want to feel bad. We don’t want to feel the guilt. We don’t want to feel shame. We don’t want to feel the uncertainty. We don’t want to feel sad. We don’t want to feel angry, grief, or panic, whatever it might be. It might be physical pain. We don’t want to feel it.

And so hand in hand goes this work of radically accepting the suffering that you’re experiencing in whatever form, whether it be emotional, physical, spiritual, or other, and then really being willing and creating a safe place to feel those feelings. I’m not saying ruminate on those feelings, make them worse, or agree with everything you’re thinking and feeling. No. I’m just saying, being able to observe that yes, sadness is here, or grief is here, or anxiety is here. It’s showing up in these ways in my chest, in my head, in my shoulders, in my neck, in my hips, in my tummy, wherever it’s showing up for you. First radically accepting it and then being willing to feel those experiences and those sensations. We alternate between those two. We radically accept, then be willing and open. Then we have to go back and radically accept, be willing, and be open.

RADICAL ACCEPTANCE IS REPETITIVE

I want to remind you that it’s okay that you have to do this on repeat. Often, with my patients—and I do this too, I have to admit—we practice radical acceptance, we practice self-compassion, we practice willingness for a little while, and then we get frustrated because it’s not making it go away. It’s not fixing it. It’s not making it disappear. So we go back to trying to solve, “Why is this happening? Why shouldn’t it be this way? What did I do wrong?” instead of knowing that this is a repetitive practice that we commit to over and over again. It’s like brushing our teeth. We don’t do it once and go, “Great, it should be done.” No, we go back, and we’ve accepted that we’ll do it every morning and we’ll do it every night. For some of you, at lunchtime too.

I really want you guys to catch this deep urge and urgency to resist what really is and resist the feelings that go ahead and accompany that experience. We want to move back as fast as we can into radically accepting that it is what it is. 

RESISTING RADICAL ACCEPTANCE

Now, if you’re anything like me, a part of your brain is going to go, “But it’s not fair. This is not fair. It is too much. Other people don’t seem to be having these problems. It’s not fair that I have this problem. It’s not fair that mine is so big right now and theirs is not.” I get that too. 

Also just acknowledge, you may even want to just validate and go, “Yeah, this is my season. They’ll have theirs.” I promise you, they’ll have theirs. Hopefully not. We don’t want to spread more pain around. But with being a human, it’s 50/50. It’s 50% hard and 50% wonderful, and that’s a part of being human. They’ll have their season; you’re in yours. It is temporary. 

Again, resist the urge to stay in the rumination of “It’s not fair.” You can validate that by going, “Yes, it is not fair. This is a hard deck of cards that I’ve been dealt right now. I’m going to again try to reduce the shrapnel by not engaging in the why me and why did this happen and it shouldn’t have, and it’s not fair.” 

I want to also say it’s okay that you land there. That is a normal part of the grief process to land in that bargaining phase of grief. What we’re really speaking to today is when you get caught in that. 

I NEED RADICAL ACCEPTANCE TOO

Now, I am speaking to you about this because I needed to hear this message more than any of you today. This is actually as much for me as it is for you. I think that as I go through very difficult seasons in my life, I find them incredibly humbling because it helps me to see the story that I have told myself, the story that things should go well for me, that things shouldn’t be hard, that I shouldn’t suffer as much as I do in certain areas, that I should somehow magically be able to solve this or control this, and that other people want me to be able to handle this, so therefore, I should be able to. 

I forget my humanness. I keep getting humbled by my humanness. I feel like the world keeps coming to show me, “Kimberley, you’re just like everybody else.” Everybody suffers. How can you lean in and have this be an opportunity to deepen your self-compassion practice, deepen your mindfulness practice, and deepen your ability to feel any emotion that shows up? Because they will, many times in my lifetime. They will continue to show up in different ways because I’m a human, not because I’m a faulty person. All humans have these feelings. 

For you, you also have to remember, these are normal human feelings. You didn’t do anything wrong. It’s not your fault that you’re having them so strong right now. Resist the urge to go into self-punishment for the fact that you’re suffering. 

Again, radically accept that it is painful right now, and then move into willingness and openness to feel those feelings and create the safest, softest, gentlest landing for you as you navigate these really difficult emotions. As you do it, not to replace it, not to make them go away, but to help guide you through them. 

YOU CANNOT BYPASS EMOTIONS

You can’t bypass emotions. I have learned that one the hard way. You can’t bypass them. If you do, you’re probably increasing your problems. If you’re doing compulsions to get your uncertainty and your anxiety to go away, you’re going to have more of that obsession. If you’re avoiding the thing that’s hard, you’re probably going to feel disempowered, and it’s going to be a bigger problem. If you’re resisting your emotions and you’re resisting your experience, at some point, they will probably blow up and explode, and you’ll feel them a lot. 

Our job, again—and this is my goal for myself, and I hope it’s your goal too—is I want to be a place, a container. I want to be able to experience the full range of emotional experiences safely so that in the future, when hard days come, when I lose loved ones, when I go through hard times, when I witness difficult things, I already know that I have the ability to wade through this. 

WHEN YOU FEEL LIKE YOU CANNOT HANDLE IT ANYMORE 

The people who are struggling with “I can’t handle this,” they’re the ones who have done everything they can to avoid feeling their feelings, and they haven’t gotten much experience with learning to master emotions. When we do learn that we can have emotions and we do learn that we can tolerate them, then we do learn that we can ride them out. There’s a sense of empowerment, like, “I can do really, really hard things.”

As I’m navigating a tough season, I’m actually blown away and in awe of myself, knowing that I can handle a lot. I’ve handled a lot in other difficult seasons in my life, and I come out of it usually being like, “Wow.” Actually pretty impressed. I feel that way, especially when I stay out of that sort of rumination. I call it the inner tantrum. I have a tantrum like, “It’s not fair, and it shouldn’t be.” 

RADICAL ACCEPTANCE SUMMARY

I wanted to make this a very quick episode. Hopefully, it’s exactly what you needed to hear. 

Number one, if you’re in a difficult season, that doesn’t mean there’s anything wrong with you. That’s just a human thing. 

Number two, if you’re in a difficult season, let’s back off from trying to solve what you could have done better because, coulda, woulda, shoulda, it’s all 20/20 hindsight. You had no idea. Let’s just leave that alone. Be very aware of that and work towards catching it and moving towards radical acceptance, willingness, and self-compassion. 

If you’re somebody who really needs to improve your self-compassion, we have a whole mindfulness vault called The Meditation Vault. You can go to CBTSchool.com, and it will guide you through self-compassion practices that were led by me. It’s all audio. It’s all there. I’ll teach you how to do it, and that hopefully will help you have my voice in your head so that you can start to practice self-compassion no matter what shows up for you, no matter what emotion you’re experiencing, no matter what hardship you’re experiencing. 

I hope that’s helpful. Have a wonderful day. I’m sending you all the love, and I will talk to you next week.

Kimberley: Is ERP traumatizing? This is a question I have been seeing on social media or coming up in different groups in the OCD and OCD-related disorders field. Today, I have Amy Mariaskin, PhD, here to talk with us about this idea of “Is ERP traumatizing” and how we might work with this very delicate but yet so important topic.

Thank you, Amy, for being here.

WHY MIGHT PEOPLE THINK ERP IS TRAUMATIC? 

Kimberley: Let’s just go straight to it. Why might people be saying that ERP is traumatic or traumatizing? In any of those kinds of terms, why do you think people might be saying this?

Amy: I think there’s a number of reasons. One of which is that a therapy like ERP, which necessitates that people work through discomfort by moving through it and not moving around it or sidestepping it, is different than a lot of other therapies which are based more on support, validation, et cetera, as the sole method. It’s not to say that ERP doesn’t have that. I think all good therapy has support and validation. However, I think that’s part of it. The fact that’s baked into the treatment, you’re looking at facing discomfort and really changing your relationship with discomfort. I think when people hear about that, that’s one reason that it comes up.

And then another reason, I think, is that there are people who have had really negative experiences with ERP. I think that while that could be true in a number of different therapeutic modalities and with a number of different clinicians and so forth, it is something that has gained traction because it dovetails with this idea of, well, if people are being asked to do difficult things, then isn’t that actually going to deepen their pain or worsen their condition rather than alleviate it? That’s my take.

Kimberley: When I first heard this idea or this experience, my first response was actual shock because, as an ERP therapist and someone who treats OCD, I have seen it be the biggest gift to so many people. I’ve heard even Chris Trondsen, who often will say that this gave him his life back, or—he’s been on the show—Ethan Smith, or anyone really who’s been on the show talk about how it’s the most, in their opinion, like the most effective way to get your life back and get back to life and live your life and face fear and all of those things. 

DO PEOPLE FEEL ERP IS A DIFFICULT TREATMENT?

I had that first feeling of surprise and shock, but also then asked more questions and asked about their experience of ERP being very pressured or feeling too scared or too soon, too much too soon, and so forth. Do you have any other ideas as to why people might be experiencing this difficult treatment?

Amy: I do. I think that sometimes, like any other therapy, if you’re approaching therapy as a technician and not as a clinician, and you’re not as a therapist really being aware of the cues that you’re getting from the very brave people sitting in front of you, entrusting their care to you—if we’re not being clinicians rather than technicians, we can sometimes just follow a protocol indiscriminately and without respect to really important interpersonal dynamics like consent and context, personal history, if there’s not an awareness of the power dynamic in the room that a therapist has a lot of power. 

We work with a lot of people as well who might have people pleasing that if you’re going to be quite prescriptive about a certain treatment, you do this, and then you do this, and then you do this without taking care to either lay the foundation to really help somebody understand the science of how ERP works or get buy-in from the front end. I know we’ll talk a little bit more about that, as well as there’s a difference between exposure and flooding. There’s a difference between exposure that serves to reconnect people with the parts of their lives that they’ve been missing, or, as I always call it, reclaims. We want to have exposures that are reclaims, as opposed to just having exposures that generate negative emotion in and of itself. 

Now, sometimes there are exposures that just generate negative emotions, because sometimes that’s the thing to practice. There are some people who feel quite empowered by these over-the-top exposures that are above and beyond what you would do to really have a reclaim. I’m going to go above and beyond for an exposure, and I’m going to do something that is off the wall. I am eating the thing off of the toilet, or I have intrusive thoughts about harming myself, and I’m going to go to the top of the parking garage, and I’m really going to lean all the way over. Would I do that in my everyday life? No. There are some clients for whom that is not something that they’re willing to do or it’s not something that’s important for them to do to reconnect with the life that they want to live, and there are others who are quite empowered. 

If you’re a therapist and you don’t take care to listen to the feedback from clients and let their voice be a part of that conversation, then you may end up, again, as a technician, prescribing things that aren’t going to land right, and that could result in some harm. My heart goes out to anyone who’s had that experience, because I think that’s valid.

Kimberley: I will be completely honest. I think that my early training as an ERP therapy clinician, because I was new, meant that I was showing up as a technician. When I heard this, again, I said my first thought was a little bit of shock, but then went, “Oh, no, that does make sense.” When I was an intern, I was following protocols and I was learning. We all, as humans, make mistakes. Not mistakes so much as if I feel like I did anything wrong, but maybe went too fast with a patient or pushed too hard with a patient or gave an exposure because another person in supervision was saying that that worked for their client, but I was learning this skill of being attuned to my client, and that was a learning process. I can understand that some people may have had that experience, even me. I’m happy to admit to that early in my training, many years ago.

Amy: That’s a great point. I think if we’re all being honest with ourselves, whether it be within the context of ERP or otherwise, there is a learning curve for therapists as well. I think going back to the basic skills and tenets of what it means to have a positive therapeutic relationship is that so much of that has to do with the repair as well. If there are times, because there will be times when you misjudge something or a client says, “I really think that I’m ready to try this,” then we say things like when exposures go awry, when the worst-case scenario happens, or what have you. 

That’s another philosophical question because I think in doing exposures, we’re not necessarily, at least my style, saying the bad thing’s not going to happen. It’s about accepting the risk and uncertainty, which is a reasonable amount. However, I think when those things happen where it does feel like, “Hey, this felt like too much too soon,” or this felt like, “Wow, I wasn’t ready for this,” or “I don’t feel like that’s exactly what I consented to. You said we were going to do this, and then you took an extra step”—I think being able to create an environment where you can have those conversations with clients and they feel comfortable bringing it up with you and you can do repair work is also important. That it’s not just black or white like, “This happened and I feel traumatized.” Again, I don’t want to sound like I’m blaming anybody who’s had that experience, but I’m just saying that I think that happens on a micro level, probably to all of us at some point. 

I think it’s also important to acknowledge, and later we’re going to talk about it, but the notion of the word ‘traumatizing’ is a little bit difficult for me to hear as well because I think from the perspective of an evidence-based practitioner, the treatments that we have, even for so-called big T trauma, many of them integrate in exposure. All of my first-line treatments, including ones that maybe come at it a little bit more obliquely like EMDR or something like that, which is not something that I personally use, are certainly out there as like a second-line trauma treatment. But things like prolonged exposure and cognitive processing therapy, they all have this exposure component to them. Even the notion that if there’s trauma, you can’t go there or that talking about hard things is traumatizing. I don’t know. Can we talk a little bit about that? Because I don’t know if that’s something you’ve thought about too, that it’s hard to reconcile.

Kimberley: Yeah. Let me give a personal experience as somebody who had a pretty severe eating disorder. I was doing exposure therapy, but I didn’t get called that, and I didn’t know what to be that at the time. But I had to go and eat the thing that I was terrified to eat. While some people might think, “Well, that’s not a hard exposure,” for me, it was a 10 out of 10. I wanted to punch my therapist in the face at the idea that she would suggest that I eat these things. I’m not saying this is true for other people; I’m just giving a personal experience. I’m actually really glad that she held me to these things because now I can have full freedom over the things that used to run my life. I know that there is nothing on any menu I can’t eat. If I had to eat on any plane, whatever they served me, I knew I was able to nourish my body with what was served to me, which I didn’t have before I did that. 

The other piece is somebody who has also been through trauma therapy. A lot of it required me to go back and relive that event over and over. Even though I again wanted to run away and it felt like my brain was on fire, that too was very helpful. But what was really helpful was how I reframed that event. If I was doing it and, as I was doing it, I was saying, “This is re-traumatizing me,” it was a very bad experience. But if I was saying, “This is an opportunity for me to learn how to have our full range of emotions, even the darker stuff,” that ended up being a very important therapeutic experience for me. That’s just my personal experience. Do you want to speak to that?

Amy: Yeah. I wasn’t planning on speaking to this part of it, but I will say as well that having had a traumatic event—a single event, big T trauma—that happened at my place of employment years ago. This is over 10 years ago now, which involved being held at gunpoint, which involved a hostage-type situation. It’s interesting when you talk about trauma, that you want to tell the whole story, but I’m like, “Oh, we don’t have enough time,” which is interesting because our brains first don’t want to tell the stories or we want to bury them. But suffice to say that after this very painful, very terrifying experience, after which all the hallmark symptoms of hypervigilance and quick to startle and images in my head and avoidance of individuals who looked like this particular individual and what have you. The most powerful thing for me in knowing this as somebody who works in exposure protocols, going back to work and being so kind to myself as I was, again, I come back to this word reclaim. It doesn’t happen overnight. It’s not something I wish there were. I do wish there’s, “Oh yeah, we just push this button in our brains, and then that’s just where we feel resilient again.” 

But the process of building resilience for me was confronting this environment, reclaiming this environment. I think any exposure protocol has the ability to have that same effect if the framing is there and if it resonates with the person. Being somebody who’s such a believer in exposure therapy for my clients, I was able to step into a role where I came out of that situation feeling so empowered and the ability to hold all of my experience gently and with compassion, as opposed to sweeping it under the rug and then having it come out sideways.

Kimberley: I really appreciate you bringing that up because, similarly, I stowed mine down for many years because I refused to look at it until I was forced by another event to have to look at it. I think that’s a piece of this work too. You have to want to face it as part of treatment. In my case, I either avoid the things that are so important to me or I am going to have to face this; I am going to have to. I showed up and made that choice. I think that’s also a piece of it, knowing that that’s an opportunity for you to go and be kind and to train your brain in different ways. 

HOW TO MAKE ERP ETHICAL AND RESPECTFUL

We’re speaking directly now about some ideas and solutions to making ERP ethical and respectful. Are there other ways that someone who’s undergoing ERP, considering ERP, or has been through it—other things we might want to encourage them to do moving forward that might make this a more empowering and validating experience for them?

Amy: That’s a great question because I think we can talk about it both from the perspective of clients who are looking for a new therapist as well as what therapists can do. But if we start first with clients and maybe you’re out there, and it’s been something you’ve either been hesitant to engage with because of some of these ideas about it being harmful or you’ve had a negative experience in the past, I do think that there is a mindset shift into feeling really empowered and really willing. 

The empowerment part is coming in and bringing in-- your fears about ERP are also fears that can be worked on. If you’re white-knuckling from the first moment of like, “Okay, I’m in here, I know I’m supposed to do this. I already hate it and it hasn’t started,” sharing that with a clinician. I know I’m used to hearing that. I’m very used to hearing that. I’ve had folks come in who have been in supportive therapy, talk therapy, or other modalities that haven’t been effective for many, many years. There is a part of me-- I’m sorry, this is a tangent, but it’s a little soapboxy tangent. I feel like when I think about my clients who’ve had therapy for sometimes 10, 20 years and it hasn’t been effective, I don’t think we talk enough about how harmful that is for people, like putting your life on hold for 10 or 20 years. I don’t hear the word necessarily ‘traumatizing,’ but that can be harmful as well. People will go through that. 

BE OPEN WITH YOUR ERP THERAPIST

After these contortions to maybe even avoid ERP because it’s scary, they’ll come in, and I welcome them, saying, “I’m really nervous about this,” because guess what? Saying that aloud is a step in the direction of exposure. You’re owning it. And then having a therapist who can say, “I’m so proud of you for being here.” This is exposure number one. Sitting down on this couch, here we are. Well done, check and check. Because I think that a therapist who’s looking at exposure, not just as what’s on a strict hierarchy, or even from an inhibitory learning perspective, like a menu—exposure is what you’re doing day to day to help yourself get closer to the life that you want and the values you have. When you said, “I can eat anything because I want to nourish my body,” that’s a value.

When I say ‘empowerment,’ like empowerment to discuss that with your therapist. And then that shift into willingness versus motivation or comfort or like, “Oh, I want to wait till the right moment,” or “Things are tough now. I don’t want to add an extra tough thing.” I know you’re not here to tell anybody, “Well, this is the way you should think.” But if there’s any room to cultivate even a nugget of willingness to say, “I can do something difficult, and I am willing to do difficult things on the path toward the life that I want,” those would be two things that come to mind right away.

Kimberley: Yeah, I agree. It takes me to the second piece for a client. I think a huge piece of it is transparency with your therapist or clinician. There have been several times where we’ve discussed an exposure—again, this was more in my earlier days—agreed that that would be helpful for them, gone to do it, and then midway through it, them saying, “I felt like I had to please you, but I’m so not ready for this,” or “I was too embarrassed because this is such a simple daily task and I should be able to do it.” I think it’s okay to really speak to your therapist and share like, “I don’t know how I feel about this. Can we first just talk about if I’m ready?” We don’t want to do that to the degree of it becoming compulsive, but I want to really encourage people who are undergoing treatment of any kind to be as completely honest as you can.

Amy: Right. I think that, again, it’s an interesting dynamic because people are coming to specialists because we do have the knowledge and awareness of protocols and so forth. But again, I think mental health is-- well, I wish all medical health folks were a little bit more open to these kinds of conversations too. But that being said, I think having that honesty and knowing that-- if you go in and you say, “Oh, I’m a little bit nervous,” and you’re getting pushback of, “Well, I’m the doc, this is what you do. Here’s step one, here’s step two,” frankly, there are going to be therapists who are like that regardless of modality. 

It was interesting because I was talking to somebody about this and about—I think if we frame it as a question—"Is ERP inherently harmful” is a really different question than “Can ERP be harmful?” I think any modality implemented without that clinical touch can be potentially harmful. 

I know your motto is, “You can do hard things.” That kind of shift as well is so powerful at the beginning of ERP. You’ve been transparent. You’ve said, “Look, here are my fears about this.” 

And then often, what I will do as a clinician if people don’t get to that place of like, I” can do things through the discomfort, there’s no going around it,” is ask them about things. If they’re adults, it could even be like, “When you were a little kid, did you have any fears, and how did you get over those? What was that like?” Not always, of course, but 9 nine times out of 10, it is some kind of like, “Well, I did the thing.” Or sometimes it’s more complicated, “Well, I did the thing and then I got support from others, and then I learned more.”

But I think people have this innate capacity to learn by changing behavior and to do things that are outside of their comfort zone, and that doesn’t have to mean way outside of their comfort zone. Often, that notion of these hard experiences or these difficult thoughts that you need to-- people will come in and feel like, “Well, I need not to be thinking about them.” That’s not really an option. Being a human with a full life, there are going to be things that are provocative. But I think I’ve heard you talk about this notion of shifting from wanting protection from negative thoughts or discomfort to almost willingness and acceptance. I love that as well.

Kimberley: I agree. I want to also maybe back up a little bit and speak to that just a little bit. I do hear the majority of people saying this, coming from those who are seeking treatment from unspecialized people. Even this morning, people are emailing me saying, “I’m following this OCD coach online, and they’re saying, ‘Follow my six-month program and you will be OCD-free.’” That sounds good. I’ll do whatever you say if that’s what I can give you. There is a power dynamic. 

But then you’re in the program and being told that you have literally two months to go and you better double down or you will fail my program. I think that urgency to get better can cause you to sometimes agree to things or seek out treatment from people who aren’t super trained and who aren’t taking an approach of, “Let’s practice being uncomfortable, let’s practice having every single emotion kindly and compassionately so that there is no emotion you can’t ever have in your lifetime through the darkest ages.” They’re more coming from a, “I’m on a timeline here and I have to get this done, so I’m going to do these things that are absolutely terrifying.” I think a lot of people are speaking to this.

Amy: I think that’s right. A lot of times, people have been-- I think we, as a field, like mental health professionals, there’s this delicate balance of wanting to instill hope and really talk about like this works and to not overpromise or not simplify the circuitous way that we get there together as a therapist and client, because there are a lot of sound bites out there. I know you and I have talked about this. It’s like these “better in 12 weeks” or “better in with these five tips” or what have you.

I think even looking at research, and I have a strong research background, I was training to be a researcher when I was in grad school. I think it’s important as well to remember that even with research, we are looking at-- if we say like, “Hey, this is a 12-week protocol that’s been effective.” Okay, what does effective mean? Does effective mean that you get to pick up your baby again? Or does it mean, oh no, it probably means an X amount reduction in the Y box? Does effective mean it was that amount of reduction for everyone? Well, no, it’s averages and things like that. 

I can wear both hats and say, this is an incredibly empirically validated treatment that works for many people. It’s not going to work the same way for every person, so why would we as clinicians go in and be like, “Here’s a timeline?” You can’t do that.

Kimberley: Yeah. Let’s speak to the therapist now. What can therapists be doing to make this a more effective, compassionate, and respectful practice? Do you have anything that you want to speak to first?

Amy: Yes. I think that if we start at the beginning of therapy itself and the steps that you go through, the very first step is assessment because exposure is something that we know is very effective for anxiety, to a lesser degree, disgust, and not quite right feelings as well, and some sensory issues, to a lesser extent. But exposure is effective for certain things. We want to make sure that those are the things that are occurring. So, making sure because somebody can have OCD, or can have anxiety, or something like that and also have other things going on.

I think sometimes when exposure is treated-- exposure and response prevention. I know we talk a lot about exposure, but even response prevention, that side of things, it’s just this one size fits all. Okay, something you don’t like doing, we’re going to expose you to it, and something that alleviates your distress, we’re going to eliminate those. If you’re doing that outside of the context of where it’s clinically indicated for OCD, i.e., areas that provoke obsessions and compulsive behaviors, then you’re really missing the target. 

I know there’s been a lot of discussion about neurodiversity and for autistic people who may have routines and things like that or may have stereotypies or stimming behaviors, things that are pleasant for them or self-regulatory to really get a good assessment in there. Again, you’re not having people do exposures or engage in response prevention in places where it’s not clinically indicated.

I think even if somebody has a trauma history, for something like PTSD, exposure is often, as I mentioned, a part of treatment protocols. The way in which we are doing those kinds of exposures and really centering the sense of agency in the client who’s had that sense of agency taken away by prior experiences is really important. I think assessment is the first thing that comes to mind, followed--

Kimberley: I would add-- sorry, I didn’t mean to cut you off, but I would add even assessment for depression. A lot of what we teach in ERP school for therapists and what I teach my staff is, if a client has depression, I might do more exposures around uncertainty and not around their worst-case scenario happening because sometimes that can make the depression come in so strong that they can’t get out of bed the next day. We can tailor exposure even to make depression, and so forth. 

I think it is so important that we do get that assessment and really understand the big picture before we proceed. Even understanding other anxiety disorders, health anxiety, the history of trauma with health, and so forth, or even the things you were taught as a child, can be really important to understand before we proceed with exposure.

Amy: I love that you added that in—the things that we were taught as a child—because I love this story. I mean, I love it and hate it, and you’ll understand why in a moment. But when I was on my internship—this was back in 2008, 2009—there was a fellow intern. He and I were co-presenting on a case, and we had the other interns. They were asking questions, and this was a makeshift IOP case. We were both doing a little bit of individual therapy, and people in the audience were asking questions, and somebody asked about childhood. This was an adult. The other intern said, “We don’t care about that stuff.” I said, “Time out, I care about it,” and we all laughed. 

I get where he was coming from in the sense that he was like, “Hey, here are the symptoms, here’s the protocol for the symptoms, and it is important.” Like you said, I mean, even from a CBT, this is very consistent with CBT and how we form core beliefs and schemas and our ideas about the world and fairness and justice, and all of that is a part of it. We don’t want to lose the C part, the cognitive part as well in ERP. But I love that you said that about depression as well, because even something co-occurring can just nudge. It just nudges the way that we do exposure and so forth.

Kimberley: Yeah. I think culturally too. Think about the different traditions that come with different cultures or religions. Sometimes some of their rituals can seem compulsive. If I didn’t know that that’s why they’re doing these, I could easily, as an untrained or ineffective therapist, be like, “Just expose yourself.” We’ve got to break this ritual, without actually understanding, like, is this actually a value-based ritual that you’re doing because of a religion or a culture or tradition that is in line with your values? I think that’s very, very important. After assessment, what would you say the next steps are?

Amy: I think that-- and this is the part where I’m really going to own that. I get really excited, and I just want to jump into treatment. This is me, I’m calling myself out. But I think psychoeducation, that not only very clearly lays out the evidence and the why, like here’s the process, here’s why we’re asking you to do these things that are really difficult, here are the underlying patterns, and here’s what we’re looking out for, and so forth. 

I think not only that, but also laying out very clearly what the expectations are. “This is how this is going to look,” and maybe at that point as well, clinicians saying—this is very collaborative—"I am here to provide this information, and then together we are going to formulate a treatment plan and formulate these exposures.” I have heard so many people who do a lot of ERPs say how proud they are by the end of therapy when clients come in and they say, “I was thinking I need to do this as my exposure.” They’re really taking that ownership. 

I think not only again talking about the science and all the charts and things like that, but really talking about this as a collaborative, consensual process, that it’s like, “I’m handing this off to you, and this is going to be something you have for the rest of your life.”

Kimberley: Yeah. I’ll tell a similar story. I had a patient who-- I’ll even be honest, I don’t think this was in my internship. This was in my career as an OCD therapist. But my client was just doing the exposures that he and I had agreed to. He would come back and be very frustrated with this process until he came to me and said, “I need you to actually stop and explain to me why I’m doing this.” I thought I had done a thorough job of that. I truly, really, honestly did. But he needed me to slow down and explain. We got out the PET scans of the brain, and I had a model of the brain. I showed him what part of the brain was being triggered and where the different parts of why-- from that moment, he was like, “I got you. I know what we’re doing. I’m on board now. I got this.” 

I think that I was so grateful that he was like, “Hold up, you need to actually slow down and help me to understand because this still doesn’t make sense to me.” This was a very important conversation. In my case, I think it’s checking in and saying, “Do you understand why we’re doing this? Do you understand the science of this?” I think it’s so important. What else might a therapist do?

Amy: I love that. I was just going to say, I love that you create that culture because that’s what I was talking about earlier. Sometimes we don’t quite get it right. And then it’s like, “What can I do better?” It’s such a powerful question. 

Knowing the why of ERP and then also the why, like, why is it worth it for you? Why is this? ACT has these wonderful metaphors about it. We’ve heard the monsters on the bus analogy. You’re driving the bus, and all your symptoms are the passengers yelling out or different fears you might have. But so often we don’t talk about, where are you driving the bus toward? Where are you going? 

I get misty when I think about this. I get almost a little teary because I think that people with OCD have such incredible imaginations, and yet, having OCD can make it so hard to dream and dream about what you truly want. Especially if it’s quite entrenched, it can just feel like, “Well, that’s a life that other people have. I don’t get to have that.” On the one hand, there’s this expansive imagination about illnesses, danger, harming others, or what have you. These things that are just dystonic—you don’t want to be thinking about them. 

I love to see people exercise that other part of their imagination and really encourage them to dream because if you have that roadmap, or rather that end destination of what you want your life to be, those very concrete moments that you want-- for some people, it’s like, “I want to have a family,” or “I want to travel,” or “I want to have the freedom to be around whomever I want to be around, regardless of the thoughts that come up,” whatever it is. Sometimes it can feel scary to even dream and envision that, either through values work or if it’s somebody who had a later onset thinking about where were you heading before. How did this derail you? What were you heading toward? I think that’s really important as well. If we don’t do that-- I mean, frankly, I wouldn’t want to do anything if I didn’t know my why.

Kimberley: No, agreed. I think that another thing—I often talk about this with my therapists in supervision—is one thing that I personally do-- and this is just me personally. Every therapist has their own way of doing it, but I often will ask my patients, “What kind of Kimberley do you need today?” I have the question as an opening where they can be like, “No, we’re good. Let’s just get to work.” We knew what we were going to do and so forth. My patients now know to say, “I need you to actually push me a little today.” They’re coming to me saying, “I want you to push you.” Or they’ll say, “I’m feeling very vulnerable today. I’m on my period,” or “It’s been a hard week,” or “I haven’t slept.” I don’t consider that me accommodating them. I consider that me being attuned to them. It might be that I might go, “Okay, but there’s been several weeks in a row that you’ve said that. Can we have a conversation?” It’s not that I’m going to absolutely let them off with avoidant compulsions, but I love offering them the opportunity to ask, what kind of Kimberley do you need? Sometimes they’ll say, “I need you to push me today, but I also need you to really encourage me because I have run out of motivation and I don’t have a lot.” 

I think that as clinicians, the more we can offer an opening of, what is it that you’re ready for? What do you want to expose yourself today? Is there something coming up that you really need to be working on? I think those conversations create this collaborative experience instead of like, “I’m the master of treatment, and you’re my follower” kind of model.

Amy: Right. I love that, and I love the idea that we can be motivational, encouraging, and celebratory in the face of exposure. Like exposures, I do feel like there has been a shift, and perhaps with the shift away from the strict habituation paradigm in the field, where it’s not like you have to just do the thing and be scared, be scared, be scared, be scared, be scared, and then it goes down. You can explore, “Hey, are you feeling stronger now? Are you feeling like I’m nervous, but I’m also curious?” 

Again, some of this is just personal style, but I use a lot of humor. There are often a lot of inside jokes with clients and things like that. I don’t see that as incompatible with really good exposure work because you’re learning that you can be scared and laughing. You’re learning that you can feel discomfort and empowerment. These kinds of things are huge. But again, I think when I was newer to ERP, there was a little bit of like, “Nope, we’re not cracking a joke, because that would be avoiding negative emotion.”

Kimberley: Yes. I remember that. Or being like, “I hope I don’t trigger them. I’m not going to [unintelligible].” The joke is what created an attunement and a collaboration between the two of us, which I think can be so beautiful. Another question I ask during exposure is, would you like to keep going? Would you like to make it a little harder? How could we? Even if we don’t, how might we? No pressure, but how might we make it so that they’re practicing this idea of being curious about making decisions on their own? Because the truth is, I’m only seeing you for 50 minutes a week. You have to then go and do this on your own. We want the clients, us as therapists, to model to them a curiosity of like, “Oh, it’s here.” Am I going to tell myself this is terrible and I can’t handle it? Or am I going to be curious about what else I could introduce? Would I like to send them a text to a loved one while I do this exposure? How would I like to show up? What values do I want to show up with? Those questions can take the terror out of it.

Amy: Yes. I think that all of this is hitting on something. I’ve noticed that oftentimes this notion of ERP is traumatizing. Again, not to discount anybody’s personal experiences with it if that has been negative, but it’s often based on this caricature of ERP that all those things that we’re saying don’t need to have that element of consent. It needs to have that collaborative nature, really good assessment, really good psycho-ed. I think that’s something I just realized because I don’t like feeling defensive about things. If I feel defensive, I’m like, “Uh-oh, this is a me thing.” I think in this case, it’s because I’m seeing a lot of misinformation about ERP, or perhaps just poorly applied ERP.

Kimberley: Yeah, for sure. I want to be respectful of time. We could make this into a whole training easily, but let’s end here on the healing because we’ve talked about everything today—ideas, concepts, mindsets, conceptualizations. But I also want to really make sure we are slowing down and creating a safe place where some people may actually, like you said, have had not great experiences. What might we do, and what might patients do in terms of healing moving forward?

Amy: It’s a good question. There’s a couple of things. I think if it’s something that we were talking about with the transparency and the talking, number one, finding support and finding support from, ideally, somebody who’s going to understand ERP enough that they can speak to. That doesn’t have to be the type of therapy that you’re getting with them, but understands it well enough to have a conversation like this. Just knowing it should never feel disrespectful, it should never feel non-consensual, and if that was your experience, then—I mean, I hate to say this, but I do think it’s true—I know I would want to know if somebody felt that way. If somebody was working with me and they felt that way, I know that can be quite a burden for people to reach out to someone with whom they’ve had a negative experience. 

But I think if you’re able to do that, that can be really helpful and really restorative, even if you’re not looking for a response, even if it’s just something that you’re letting them know. If you still have a relationship with that therapist, or let’s say it’s a clinic where you saw a therapist and you ended up moving to a different therapist, consider sharing it with them directly. I think we live in a very contentious culture of, “Well, I’ve made my mind up. That’s bad, and I’m moving on.” 

But truly, I think validation also starts with self-validation. My hope is that even though we’re both clearly ERP therapists who believe very strongly in its positive application for many people, we want to validate that if you’ve felt any harm, that’s valid. I think that also starts with self-validation as a first means of healing and then seeking support.

Kimberley: Yeah. What I think too, if you’re not wanting to do that, which I totally understand, sharing with your new clinician. One of the questions we have about our intake is what therapy was helpful and why, and what therapy wasn’t helpful and why. As you go with a new therapist, share with them, “This was my experience. This is what I found to be very effective. This is what I am very good at, but these are the things that I struggled with, and here’s why.” And then giving them the education of your process so they can help you with that, I think, is really important. 

I think you hit the nail on the head—also being very, very gentle. The administering of therapy is not a perfect science; it’s a relationship. It’s not always going to go well. I wish it could. I truly wish there was a way we could, but that doesn’t mean that you’re bad, that therapy won’t work for you in the future, or that all therapists are similar to what your experience was. I think it’s important to know that there are many therapists who want to create a safe place for you.

Amy: That’s so well said.

Kimberley: Anything else you want to add before we finish up?

Amy: No, no, I think this has been great. Again, anybody out there, I don’t know. I feel like, as therapists, sometimes we’re the holders of hope. If this could give you any hope, and again, ERP may not be the route that you choose, but just anyone who’s felt like therapy hasn’t been what you wanted, you deserve to find what’s going to feel like the best, most helpful fit.

Kimberley: Amy, I have wanted to do this episode for months now, and there is no one with whom I would feel as comfortable doing it as much as you. Thank you for creating a place for me to have this very hard conversation and a conversation I think we need to have. I’m again so grateful for you, your expertise, your kind heart, and your wisdom.

Amy: Thank you. 

Kimberley: Welcome back, Ethan Smith. I love you. Tell me how you are. First, tell me who you are. For those who haven’t heard of your brilliance, tell us who you are.

Ethan: I love you. My name is Ethan Smith, and I’m a national advocate for the International OCD Foundation and just an all-around warrior for OCD, letting people know that there’s help and there’s hope. That’s what I’ve dedicated my life to doing.

Kimberley: You have done a very good job. I’m very, very impressed.

Ethan: I appreciate that. It’s a work in progress.

Kimberley: Well, that’s the whole point of today, right? It is a work in progress. For those of you who don’t know, we have several episodes with Ethan. This is a part two, almost part three, episode, just catching up on where you’re at.

The last time we spoke, you were sharing about the journey of self-compassion that you’re on and your recovery in many areas. Do you want to briefly catch us up on where you’re at and what it’s been like since we met last?

Ethan: Yeah, for sure. We’ll do a quick recap, like the first three minutes of a TV show where they’re like, “So, you’re here, and what happened before?” 

Kimberley: Previously on.

Ethan: Yeah, previously, on real Ethans of Coweta County, which sounds super country and rural. The last time we spoke, I was actually really vulnerable. I don’t mean that as touting myself, but I said for the first time publicly about a diagnosis of bipolar. At that time, when we spoke, I had really hit a low—a new low that came from a very hypomanic episode, and it was not related to OCD. I found myself in a really icky spot.

Part of the reason for coming or reaching that bottom was when I got better from OCD into recovery and maintenance, navigating life for the first time, really for the first time as an adult man in Los Angeles, which isn’t an easy city, navigating the industry, which isn’t the nicest place, and having been born with OCD and really that comprising the majority of my life. The next 10 years were really about me growing and learning how to live. But I don’t know that I knew that at the time. I really thought it was about, okay, now we’re going to succeed, and I’m going to make money, live all my dreams, meet my partner, and stuff’s going to happen because OCD is not in the way. That isn’t to say that that can’t happen, and that wasn’t necessary. I had some amazing life experiences. It wasn’t like I had a horrible nine years. There were some wonderful things.

But one of the things that I learned coming to this diagnosis and this conclusion was how hard I was being on myself by not “achieving” all the goals and the dreams that I set out to do for myself. It was the first time in a long time, really in my entire life, that I saw myself as a failure and that I didn’t have a mental illness to blame for that failure. I looked at the past nine years, and I went, “Okay, I worked so hard to get here, and I didn’t do it. I worked so hard to get here in a personal relationship, and I didn’t get there. I worked so hard to get here financially, and I didn’t even come close."

In the past, I could always say, “Oh, OCD anxiety.” I couldn’t do it. I couldn’t finish it. I dropped out. That was always in the way. It was the first time I went, “Oh wow, okay, this is on Ethan. This is on me. I must not be creative enough, smart enough, good enough, strong enough, or brave enough.” That line of thinking really sent me down a really dark rabbit hole into a really tough state of depression and hypomania and just engaging in unhealthy activities and things like that until I just came crashing down.

When we connected, I think I had just moved from Los Angeles to Atlanta and was resetting in a way. At that time, it very much felt like I was taking a step back. I had left Los Angeles. It just wasn’t a healthy place for me at that time. My living situation was difficult because of my upstairs neighbor, and it was just very complicated. So, I ended up moving back to Georgia for work, and I ended up moving back in with my parents. I don’t remember if we talked about that or not, but it was a good opportunity to reset.

At that time, it very much looked and felt like I was going backwards. I just lived for 10 years on my own in Los Angeles, pursuing my dreams and goals. I was living at home when I was sick. What does this mean? I’m not ready to move. I’m not ready to leave. I haven’t given up on my dream. What am I doing?

I think if we skip the next three years from 2019 on, in retrospect, it wasn’t taking a step back; it was taking a step forward. It was just choosing a different path that I didn’t realize because that decision led to some of the healthiest, most profound experiences in my life that I’m currently living. I can look back at that moment and see, “Oh, I failed. I’ve given up.” This is backwards. In reality, it was such a beautiful stepping stone, and I was willing to step back to move forward, to remove myself from a situation, and then reinsert myself in something.

Where I am now is I’m engaged, to be married. I guess that’s what engaged means. I guess I’m not engaged with a lawyer. I’m engaged, and that’s really exciting.

Kimberley: Your phone isn’t engaged.

Ethan: Yeah, for sure, to an amazing human being. I have a thriving business. I’m legitimately doing so many things that I never thought I would do in life ever, whether it had to do with bipolar or more prominently in my life, OCD, where I spent age 20 to 31, accepting that I was home-ish bound and that was going to be my life forever and that I’m “disabled” or “handicapped,” and that’s just my normal. I had that conversation with my parents. That was just something that I was going to have to live with and accept.

I’m doing lots of things that I never expected to do. But what I’ve noticed with OCD is, as the stakes seem raised because you’re engaging yourself in so many things that are value-driven and that you care about, the stakes seem higher. You have more to lose. When you’re at the bottom, it’s like, okay, so what? I’m already like all these things. Nothing can go wrong now because I’m about to get married to my soulmate, and my business is doing really well. I have amazing friends, and I love my OCD community.

The thoughts and the feelings are much more intense again because I feel like I have a lot more to lose. Whereas I was dismissing thoughts before, now they carry a little bit more weight and importance to me because I’m afraid of losing the things that I care about more. There’s other people in my life. It’s not just about me. With that mindset came not a disregard but almost forgetting how to be self-compassionate with myself.

One of the things that came out of that bipolar diagnosis in my moving forward was the implementation of active work around self-compassion. I did workbooks, I worked very closely with my therapist, and we proactively did tons and tons of work in self-compassion. You can interrupt me at any time, because I’ll keep babbling. So, please feel free to interrupt.

I realized that I was not practicing self-compassion in my life at all. I don’t know that I ever had. Learning self-compassion was like learning Japanese backwards. It was the most confusing thing in the world. The analogy that I always said: my therapist, who I’ve been with for 13 years, would say to me, “You just need to accept where you are and embrace where you are right now. It’s okay to be there. Give yourself grace.” She would say all these things. 

I always subscribe to the likes of, “You have to work harder. You can’t lift yourself off the hook. Drive, drive, drive, drive.” That was what I knew. I tried to fight her on her logic. I said, “If there’s a basketball team and they’re in the finals and it's halftime and they’re down by 10, does the coach go to the basketball team and say, ‘Hey guys, let’s just appreciate where we are right now; let’s just be in this moment and recognize that we’re down by 10 and be okay with that.’” I’m like, “No, of course not. He doesn’t go in there and say that. He goes, ‘You better get it together and all this stuff.’” I remember my therapist goes, “Yeah, but they’re getting out of bed.” I’m like, “Oh, okay, that’s the difference.” They’re actually living their life. I’m completely paralyzed because I’m just beating myself down. 

But what I’ve learned in the last three or four years is that self-compassion is a continuous work in progress for me and has to be like a conscious, intentional practice. I found myself in the last year really not giving myself a lot of self-compassion. There’s a myriad of reasons why, but I really wanted to come on and talk about it with you and just share some of my own experiences, pitfalls, and things that I’ve been dealing with. 

I will say the last two years have probably been the hardest couple of years and the most beautiful simultaneously, but hard in terms of OCD, thoughts and triggers, anxiety, and just my overall baseline comfort level being raised because, again, there’s so many beautiful things happening. That terrifies me. I mean, we know OCD is triggered by good stress or bad stress. So, this is definitely one of those circumstances where the stakes seem higher. They seem raised, so I need more certainty. I need it. I have to have more certainty. I don't, really. I’m okay with uncertainty, but part of that component is the amount of self-compassion that I give myself. I haven’t been the best at it the last couple of years, especially in the last six months. I haven’t been so good.

Kimberley: I think this is very validating for people, myself included, in that when you are functioning, it doesn’t seem like it’s needed. But when we’re not functioning, it also doesn’t feel like it’s needed. So, I want to catch myself on that. What are some roadblocks that you faced in the implementation of this journey of self-compassion or the practice of self-compassion? What gets in the way for you?

Ethan: I will give you a specific example. It’s part of my two-year journey. In the last year and a half, I started working with a nutritionist. Physical health has become more important to me. It may not look like that, but getting there, a work in progress. But the reality of it is, and this is just true, I’m marrying a woman who’s 12 years younger than me. I want to be a dad. I can’t wait to have children. The reality of my life—which I’m very accepting of my current reality, which was something I wasn’t, and we were probably talking about that before—was like, I wanted to be younger. I hated that everything was happening now. I wasn’t embracing where I was and who I was in that reality. I’m very at peace with where I am, but the reality of my reality is that I will be an older father.

So, a value-driven thing for me to do is get healthier physically because I want to be able to run around and play catch in 10 years with my kid. I would be 55 or 60 and be able to be in their lives for as long as I possibly could. I started working with a nutritionist, and for me, weight has always been an issue. Always. It has been a lifelong struggle for me. I’ve always yo-yoed. It’s always been about emotional eating. It’s always been a coping mechanism for me.

I started working with a nutritionist. She’s become a really good friend, an influence in my life, and an accountability partner. I’m not on a diet or lifestyle change. There’s no food off the table. I track and I journal. But in doing this, I told her from the beginning, "In the first three months, I will be the best client you’ve ever had,” because that’s what I do—I start perfectly. Then something happens, and I get derailed. I was like, my goal is to come back on when I get derailed. That is the goal for me. And that’s exactly what happened. I was the star student for three months. I didn’t miss a beat. I lost 15 pounds. The goal wasn’t weight loss, mind you; it was just eating healthier and making more intentional choices. Then I had some OCD pipe up, my emotions were dysregulated, and I really struggled with the nutrition piece. I did get back on track. 

Over the last year, I gained about seven pounds doing this nutrition. Over the last six months, I was so angry at myself for looking at my year’s journey. This is just an example of multiple things with self-compassion, but this is the most concrete and tangible I can think of at the moment. But looking at my year and looking at it with that black-and-white OCD brain and saying, “I failed. I’m a piece of crap. I’m not where I want to be on my journey. I’ve had all of the support I could possibly have. I have all the impetus. I want to be thinner for my wedding. I want to look my best at my wedding. What is wrong with me? In these vulnerable emotional states or these moments of struggle, why did I give in?”

In the last couple of months, I literally refused to give myself any compassion or grace around food, screw-ups, mess-ups, and any of that. I refused. My partner Katie would tell me, “Ethan, you have to love--” I’m like, “No, I do not deserve it.” I’m squandering this opportunity. I just wholeheartedly refused to give myself compassion. Because it’s always been an issue, I’m like, “What’s it going to take?” Well, compassion can’t be the answer. I need tough love for myself. 

I think I did this in a lot of areas of my life because, for me, I don’t know, there’s a stigma around self-compassion. Sometimes, even though I understand what it is on paper-- and I’ve read your workbook and studied a lot of Kristin Neff, who’s an amazing self-compassion expert. On paper, I can know what it is, which is simply embracing where you are in the moment without judgment and still wanting better for yourself and giving yourself that grace and compassion, regardless of where it is. 

I felt like I couldn’t do that anymore because I wasn’t supposed to. I wasn’t allowed. I suddenly reframed self-compassion as a weakness and as an excuse rather than-- it was very much how I thought about it before I even learned anything about self-compassion, and I found myself just not a very loving person myself. My internal self-talk was really horrible and probably the worst. If somebody was talking to me like this, you always try to make it external and be like, “Oh, if somebody talked to you like this, would they be your friend? Would you listen to them?” I was calling myself names. I gave myself a room. It was almost in every facet of my life, and it was really, really eating at me. It took a significant-- yeah, go ahead.

Kimberley: When I’m with clients and we’re talking about behaviors, we always talk about the complex outcomes of them, like the consequences that you were being hard on yourself, that it still wasn’t working, and so forth. But then we always spend some time looking at, let’s say, somebody is drinking excessively or doing any behavior that’s not helpful to them. We also look at why it was helping them, because we don’t do things unless we think they’re helping. What was the reason you engaged in the criticism piece? How did that serve you in those moments?

Ethan: It didn't, in retrospect. In the moment, I think behaving in that way feels much like grabbing a spear and putting on armor. I don’t know if it’s stigma or male stigma. I mean, I’ve always had no problem being sensitive, being open to sensitivity, and being who I am as an individual. But with all of this good in my life, my emotions are more intense. My thoughts are more intense. My OCD is more intense. I felt like I needed to put on-- I basically defaulted to my original state of thinking before I even learned about self-compassion, which is head down, bull horns out, and I’m just going to charge through all of this because it’s the only way. It’s just like losing insight. When you’re struggling with OCD, it’s like you lose insight, you lose objectivity. It’s like there’s only one way through this. 

I think it’s important to note, in addition to the self-compassion piece, this year especially, there’s been some physical things and some somatic symptoms that I’ve gotten really stuck on. I’m really grateful that-- and I love to talk about it with advocacy. It’s like, advocates, all of us, just because we’re speaking doesn’t mean that we have an OCD-free life or a struggle-free life. That’s just not it. I always live by the mantra: more good days than bad. That is my jam. I’m pleased to report that in the last 13 years, I’ve still had more good days than bad, but it doesn’t mean that I don’t have a tough month. 

I think that in the last couple of years, I’ve definitely been challenged in a new way because there’s been some things that have come up that are valid. I have a lot of health anxiety, and they’ve been actual physical things that have manifested, that are legitimate things. Of course, my catastrophic brain grabs onto them. You Google once, and it’s over. I have three and a half minutes to live for a brown toenail, and--

Kimberley: You died already.

Ethan: I’m already dead. I think it all comes back around to this idea of self-stigma, that even if you know all this stuff like, I’m not allowed to struggle, I’m not allowed to suffer, I have to be a rock, I have to be all things to all people—it’s all these very black and white rules that are impossible for a human being to live by because that’s just not reality. I mean, I think that’s why the tough exterior came back because it was like, “All right, life is more challenging.”

The beautiful thing about recovery is, for the most part, it didn’t affect my functioning, which was amazing. I could still look at every day and go, “I was 70% present,” or “I was 60% present and 40% in my head, but still being mindful and still doing work and still showing up and still traveling.” From somebody that was completely shut down, different people respond in different ways to OCD. From somebody who came from completely shutting down and being bedridden, this was a huge win. But for me, it wasn’t a huge win in my head. It was a massive failing on my part. What was I doing wrong? How was it? 

Just as much as I would talk every week on my live streams and talk about, it’s a disease, not a decision, it’s a disorder. I can say that all day long, but there are times when it tricks me, and I stigmatize myself around it. 

It’s been very much that in the last year, for sure. It’s been extremely challenging facing this new baseline for myself. Because, let’s face it, I’m engaging in things that I’ve never experienced before. I’ve never been in a three-year relationship with a woman. I’ve never been engaged. I’ve never bought a house. Outside of acting, I’ve never owned a business or been a businessperson. I mean, these are all really big commitments in life, and I’m doing them for the first time. 

If I have insight now and it’s like, I can have this conversation and say, “Yeah, I have every reason to be self-compassionate with myself.” These are all brand new things with no instruction manual. But it’s very easy to lose sight of that insight and objectivity and to sit there and say-- we do a lot of comparing, so it’s very easy to go, “Well, these are normal human things. Everybody gets married. Everybody works. This should be easy.” You talk about, like, never compare struggles, ever. If somebody walks to the mailbox and you can’t, never compare struggles. But that’s me going, “Well, this is normal life stuff. It’s hard. Well, what’s wrong with me?”

Kimberley: Right. I think, for me, when I’m thinking about when you’re talking, I go in and out of beating myself up for my parenting, because, gosh, I can’t seem to perfect this parenting gig. I just can’t. I have to figure it out. What’s so interesting is when I start beating myself up and if I catch myself, I often ask myself, what would I have to feel if I had to accept that I’m not great at this? I actually suck at this. It’s usually that I don’t want to feel that. I will beat myself up to avoid having to feel the feelings that I’m not doing it right. That has been a gateway for me, like a little way to access the self-compassion piece. It’s usually because I don’t want to feel something. And that, for me, has been really helpful. 

I think that when you’re talking about this perceived failure—because that’s what it is. It’s a perceived failure, like we’re all a failure compared to the person who’s a little bit further ahead of us—what is it that you don’t want to feel?

Ethan: It’s a tough question. You’ve caught me speechless, which is rare for me. I’m glad you’re doing video because otherwise, this would be a very boring section of the podcast. For me, the failing piece isn’t as much of an issue. It was before. I don’t feel like I’ve failed. In fact, I feel like I’m living more into where I’m supposed to be in my values. I think for me, the discomfort falls around being vulnerable and not in control. I think those are two areas that I really struggle with.

I always say, sometimes I feel like I’m naked in a sandstorm. That’s how I feel. That’s the last thing you want to be. Well, you don’t want to be in a sandstorm—not naked, but naked in a sandstorm—you don’t want to see me naked at all. That’s the bottom line. No nudity from Ethan. But regardless, you’re probably alone in the sandstorm. You feel the stinging and all of that. No, I’m just saying that’s what I picture it feels like. 

Kimberley: Yeah, it’s an ouch. That feels like an ouch.

Ethan: It feels like a big ouch. I think that vulnerability, for me, is scary. I’m not good at showing vulnerability. Meaning, I have no problem within our community. I’ll talk about it all day long. I’ll talk about what happened yesterday or the day before. I’ll be vulnerable. But for people who don’t know me, I struggle with it. 

Kimberley: Me too.

Ethan: Yeah. We all have our public faces. But vulnerability scares me in terms of being a human being, being fallible, and not being able to live up to expectations. What if I have to say I can’t today? Or I’m just not there right now and not in control of things that scare me.

Those feelings, I think, have really thrown me a bit more than usual, again. I keep saying this because things feel more at stake, and they’re not, but I feel like I have so much more to live for. That’s not saying that I didn’t feel like I didn’t have a reason to live before. That’s not what I’m saying at all. I’m simply saying, dreams come true, and how lucky am I? But when dreams come true with OCD, it latches onto the things we care about most and then says, “That’s going to be taken away from you. Here are all the things you have to do to protect that thing.” I think it’d been a long time since I’d really faced that. 

To answer your question in short, I think, for me, vulnerability and uncertainty around what I can’t control, impacting the things that I care about most, are scary.

Kimberley: I resonate so much with what you’re saying. I always explain to my eating disorder clients, “When you have an eating disorder and you hit your goal weight, you would think we would celebrate and be like, ‘Okay, I hit it. I’m good now.’” But now there’s the anxiety that you’re going to go backwards. Even though you’ve hit this ridiculous goal, this unhealthy goal, the anxiety is as high as it ever was because the fear of losing what you’ve got is terrifying. I think that’s so true for so many people.

And I do agree with you. I think that we do engage in a lot of self-criticism because it feels safer than the vulnerability, the loss of control, or whatever that we have to feel. What has been helpful for you in moving back towards compassion? I know you said it’s like an up-and-down journey, and we’re all figuring this out as we go. What’s been helpful for you?

Ethan: A couple of things. I think it’s worth talking about, or at least bringing up this idea of core fear. I’ve done some recent core fear work, just trying to determine, at the root of everything, what is my core fear? For me, it comes down to suffering. I’m afraid of suffering. I’m not afraid of dying; I’m afraid of suffering. I’m afraid of my entire life having to be focused on health and disease because that’s what living with OCD when I was really sick was about. It’s all I focused on. So, I’m so terrified of my life suddenly being refocused on that. 

Even if I did come down with something awful, it doesn’t mean that my life has to solely focus on that thing. But in my mind, my core fear is, what if I have to move away from these values that I’m looking at right now and face something different? That scares the crap out of me. 

The first thing around that core fear is the willingness to let that be there and give myself compassion and grace, and what does that look like, which is a lot of things. This fear—this new fear and anxiety—hasn't stopped me from moving forward in any way, but it sure has made it a little bit more uncomfortable and taken a little bit of the joy out of it. That’s where I felt like I needed to put on a second warrior helmet and fight instead of not resisting, opening myself up, and being willing to be naked in a sandstorm. 

One of the things that I’ve learned most about is, as a business owner yourself, and if you’re a workaholic, setting boundaries in self-care is really hard. I didn’t really connect until this year the connection, the correlation between self-care and self-compassion. If I don’t have self-compassion, I won’t allow myself to give myself self-care. I won’t. I won’t do it because I don’t deserve it.

There’s a very big difference between time off, not working, sleeping, but then actually taking care of yourself. It’s three different things. There’s working, there’s not working, and then there’s self-care. I didn’t know that either. It was like, “Well, I didn’t work tonight.” Well, that’s not necessarily self-care. You just weren’t in a meeting, or you weren’t working on something. Self-care is proactive. It’s purposeful. It’s intentional. 

Giving myself permission to say no to things, even at the risk of my own reputation, because I feel like saying no is a big bad word, because that shows that I can’t handle everything at once, Kim. I can’t do it all. And that is a no-no for me. Like, no, no, no, everybody needs to believe that you can do everything everywhere all at once, which was a movie. That’s the biggest piece of it. 

Recently, I was able to employ some self-care where it was needed at the risk of the optic seeming. I felt like, "Here I am, world. I’m weak, and I can’t handle it anymore." That’s what I feel like is on the other end. 

I was sick, and I had been traveling every week since the end of March. I don’t sleep very well. I just don’t. When I’m going from bed to bed, I really don’t sleep well. I had been in seven or eight cities in seven or eight weeks. I had been home for 24 hours. This was only three weeks ago, and I was about to head out on my last trip, and the meeting that I was going for, the primary reason, got canceled, not by me. I was still going to meet with people that I love and enjoy. I woke up the day before I was traveling, and I was sick. I was like, “Oh man, do I still go?” The big reason was off the table, but there were still many important reasons to go, but I was exhausted. I was tired. I was sick. My body was saying, “Enough.” I had enough insight to say, I’m not avoiding this. This isn’t anxiety. This is like straight up. 

When I texted the team—this is around work and things that I value—I was like, “I’m not coming.” I said, “I’m not coming.” They responded, “We totally understand. Take care of yourself.” And what I read was, “You weak ass bastard. You should suck it up and come here, because that’s what I would have done. Why are you being so lame and lazy?” That is what I read. This is just an instance of what I generally feel if I can’t live up to an expectation. I always put these non-human pressures on myself. 

But making this choice, within two days, I was able to reset intentionally. This doesn’t mean I’m going to go to bed and avoid life. I rested for a day because I needed to sleep to get better. But the next few days were filled with value-driven decisions and choices and walks and exercising and getting back on nutrition and drinking lots of water and spending quality time with people that I care about, and my body and brain just saying, “You need a moment.” Within a couple of days, everything changed. My OCD quickly dropped back down to baseline. My anxiety quickly dropped back down. I had insight and objectivity. 

When I went back to work later that week—I work from home—I was way more effective and efficient. But I wouldn’t have been able to do that. It was very, very hard to give myself self-compassion around making that simple decision that everybody was okay with.

Kimberley: I always say my favorite saying is, “I’m sorry, but I’m at capacity right now.” That has changed my life because it’s true. It’s not even a lie. I’m constantly at capacity, and I find that people do really get it. But for me to say that once upon a time, I feel this. When I was sick, the same thing. I’m going to think I’m a total nutcase if I keep saying no to these people. But that is my go-to sentence, “I’m at capacity right now,” and it’s been so helpful. 

Ethan: In max bandwidth. 

Kimberley: Yes. What I think is interesting too is I think for those who have been through recovery and have learned not to do avoidant behaviors and have learned not to do compulsions, saying “I need a break” feels like you’ve broken the rules of ERP. They’re different things.

Ethan: You hit them down. I was literally going to say that. It also felt when I made that decision that it felt old history to me, like old Ethan, pre-getting better. I make the joke. It was true. I killed my grandfather like 20 times while he was still alive. Grandpa died. I can’t come to the thing. I can’t travel. I can’t do the thing. This was early 2000s, but I had a fake obituary that I put into Photoshop. I would just change the date so I can email it to them later and be like, it really happened. I would do this. It’s like, here was a reason. It was 100% valid. Nobody questioned it. It was not based on OCD. It was a value-driven decision, and it felt so icky. My body felt like I might as well have sent a fake obituary to these people about the fake death of my grandfather. It felt like that. So, I wholeheartedly agree with you.

Kimberley: I think it’s so important that we acknowledge that post-recovery or during recovery is that saying acts of compassion sometimes will feel like and sound like they’re compulsions when they’re actually not. 

Ethan: That’s such a great point. I totally agree with you.

Kimberley: They’re actually like, I am actually at capacity. Or the expectation was so large, which for you, it sounds like it is for me too—the expectation was so large, I can’t meet that either. That sucks. It’s not fun. 

Ethan: No, it’s not. It’s not because, I mean, there’s just these scales that we weigh ourselves on and what we think we can account for. I mean, the pressure that we put on ourselves. And that’s why, like the constant practice of self-compassion, the constant practice of being mindful and mindfulness, this constant idea of-- I mean, I always forget the exact thing, but you always say, I strive to be a B- or C+. I can never remember if it’s a B- or C+, but--

Kimberley: B-.

Ethan: B-. Okay, cool. 

Kimberley: C+ if you really need it.

Ethan: Yeah. To this day, I heard that 10 years ago, and I still struggle with that saying because I’m like, I don’t even know that I can verbally say it. Like, I want to be a B... okay, that’s good enough. Because it sounds terrifying. It’s like, “No, I want to be an A+ at everything I do.” 

I know we’re closing in on time. One of the things I just wanted to say is thank you not only for being an amazing human being, an amazing advocate, an amazing clinician, and an okay mom, as we talked about.

Kimberley: Facts. #facts.

Ethan: But part of the reason I love advocating is I really didn’t come on here to share a specific point or get something across that I felt was important. I think it’s important as an advocate figure for somebody who doesn’t like transparency or vulnerability to be as transparent and vulnerable as possible and let people see a window into somebody that they may look at and go, “That person doesn’t struggle ever. I want to be like that. I see him every week on whatever, and he’s got it taken care of. Even when it’s hard, it isn’t that hard.” 

For me, being able to come on and give a window into Ethan in the last six months is so crucial and important. I want to thank you for letting me be here and share a little bit about my own life and where I met the goods and the bads. I wouldn’t trade any of it, but I appreciate you.

Kimberley: No, thank you. I so appreciate that because it is an up-and-down journey and we’re all figuring it out, myself included. You could have interviewed me and I could have done similar things. Like here are the ways that I suck and really struggle with self-compassion. Here are the times where I’ve completely forgotten about it as a skill until my therapist is like, “Uh, you wrote this book about this thing that you might want to practice a little more of.” I think that it’s validating to hear that learning it once is not all you need; it is a constant practice.

Ethan: Yeah, it definitely is. Self-compassion is, to me, one of the most important skills and tools that we have at our disposal. It doesn’t matter if you have a mental health issue or not. It’s just an amazing way of life. I think I’ll always be a student of it. It still feels like Japanese backwards sometimes. But I’m a lot better at putting my hand-- well, my heart’s on that side, but putting my hand in my heart, and letting myself feel and be there for myself.

I never mind. I’m a huge, staunch advocate of silver linings. I’ve said this a million times, and I’ll always say, having been on the sidelines of life and not being able to participate, when life gets hard and stressful, deep down, I still have gratitude toward it because that means I’m actually living and participating. Even when things feel crappy or whatever, I know there’ll be a lesson from it. I know good things will come of it.

I try to think of those things as they're happening. It’s meaningful to me because it gives me insight and lets me know that there’ll be a lesson down the road. I don’t know if it’ll pay itself back tomorrow or in 10 years, but someday I’ll be able to look at that and be like, “Well, I got to reintroduce myself to self-compassion. I got to go on Kim Quinlan’s podcast, Your Anxiety Toolkit, and be able to talk to folks about my experience.” While I didn’t quite enjoy it, it was a life experience, and it was totally worth it for these reasons. Now I get to turn my pain into my purpose. I think that’s really cool.

Kimberley: Yeah, I do too. I loved how you said before that moving home felt like it was going backwards, but it was actually going completely forward. I think that is the reality of life. You just don’t know until later what it’s all about. I’m so grateful for you being on the show. Thank you so much for coming on again.

Ethan: Well, thanks for having me, and we’ll do one in another 200 episodes.

Kimberley: Yes, let’s do it.

Ethan: Okay.