Welcome back, everybody. Today we’re talking about sleep anxiety relief. We’re talking about how to get a good night’s rest.

Oh, the beauty of a good night’s sleep. I can’t even tell you and I can’t even explain for me personally how much sleep impacts my mental health and my mental health impacts my sleep. Hence why we’re doing this episode today. 

For those of you who are new, my name is Kimberley Quinlan. I’m a marriage and family therapist in the State of California. I have a private practice. I am the developer of an online program called CBTSchool.com. I’m an author and I am the host of this podcast. 

A few weeks ago, a psychiatrist reached out and said, “I have been listening to you for years, not realizing that I work literally down the street from you.” It made me realize that I never introduced myself on the podcast. I just talk and talk and talk and I actually don’t tell people where I am and what I do and what I offer. So that was a really big lesson. 

Let’s talk about sleep anxiety relief. I’m going to tell you a bit of a story first. For years, my daughter has been telling us that she can’t sleep, that she has terrible sleep. She lays awake, staring at the roof. She said she always feels tired during the day and that she “can’t get to sleep” when she tries. We have taken her to the pediatrician and we’ve talked to her about it and checked in, “Are you worrying about anything in particular?” She says, “No, I just worry about getting enough sleep.” Again, she’s saying, “When will I go back to sleep? Will I go back to sleep? Will I wake up at night?” She says she struggles to get comfortable as she settles into bed. 

We took the plunge and took her to a sleep specialist and we were expecting either a sleep disorder diagnosis or a sleep anxiety diagnosis. He did this thorough assessment and asked her all these questions and he was incredible. At the end, he said, “I’m going to tell you, it sounds like you’re getting good sleep. You sound like you sleep very normally for a kid your age and we address some issues that may be happening.” But he said, “A lot of this is about managing anxiety about sleep,” because he tracked like, “You’re getting enough. We will track it during the night. Everything looked good. This is actually about you managing your mind around sleep.” Now I understand that may not be your experience, but this blew me off my feet. I was expecting serious bad news. I have this conversation with my patients so often and it made me feel like, let’s talk about sleep anxiety relief. 

SLEEP ANXIETY SYMPTOMS 

Now, before we talk about sleep anxiety relief, let’s talk about sleep anxiety symptoms because some people who don’t experience this or aren’t sure if they’re experiencing this, I wanted to make sure you feel like you’re in the right place. For those who have sleep anxiety, they experience a lot of anxiety around going to bed or when going to bed. They may report racing thoughts in bed, inability to concentrate when they’re preparing to go to sleep or they’re laying in bed. They might experience a lot of irritability, whether that’s emotional or physical sensations in the body. A lot of jitteriness. There may be also an experience of nervousness or restlessness. They may have feelings of being overwhelmed. Some people report this impending danger or doom as they approach the bed or as they approach bedtime. They may experience a lot of anticipatory anxiety about it. 

There are also some physical sensations or effects of anxiety before bed and that might include some tummy troubles. Kids in particular will report before bed, “My tummy hurts,” and often their tummy hurts is a sign of anxiety. This is true for adults too. They may have an increase in heart rate, which may make them feel like something bad is about to happen. They may have rapid breathing. They may experience sweating. They may experience tense muscles. They may experience trembling, even nausea. These are symptoms that could be your regular day-to-day anxiety, or it could be that you’re specifically managing anxiety related to sleep. 

IS THERE A CURE FOR SLEEP ANXIETY? 

When talking about sleep anxiety relief, often people talk about this idea of a sleep anxiety cure. Now, I’m not going to give you any specific “cure” today because I don’t know your exact case and you would need to be assessed by a doctor. I encourage you to go and see your doctor if you’re struggling with sleep because it is so important. If you need, go and get a referral for a sleep specialist or do some research. There are some amazing books on sleep as well. 

Now, do I consider that we can overcome sleep anxiety? Yes, 100%. I do believe you can get to a place where you have healthy sleep. Again, I’m always very cautious about talking about the word “cure,” but if we were to really address sleep anxiety relief in terms of what you need to practice, I’m going to first always do a ton of psychoeducation with my patients and with you today about sleep hygiene. 

WHAT IS SLEEP HYGIENE? 

Think of sleep hygiene as like, how clean your bedtime routine is. Clean, meaning has it got a lot of stuff that dirty up your sleep routine, or does it free up and clean up your sleep hygiene, sleep routine? I’m not talking here in terms of contamination. I don’t want to get that confused. It’s about making your bedtime routine something that is with ease, and even if there’s anxiety, it’s a routine that you follow and you are pretty consistent with it so that you can start to get better sleep. 

Now, how do we do that? First of all, I strongly recommend you first decide when you want to be asleep by or when you want to be in bed preparing to wind down. Pick an actual time. A lot of people miss this step. They just go, “Oh, I’m going to light candles and I’m going to read and hopefully, I’ll fall asleep when I want to.” That’s fine and that’s good. We will talk about that here in a second. But I’m going to strongly encourage you, pick a time you want to be in bed. And then from there, we work backwards. From one hour minimum, from the time you want to be in bed starting to wind down, you must turn off your tech. I know you want to turn off your podcast right now because you don’t want to turn off your tech that early, but I’m going to stress to you that your phone and your device are causing havoc on your bedtime routine unless you are using it for meditation, soothing music, something that actually deeply calms you. But I’m going to say a minimum of one hour, preferably two, you turn off your tech before that time that you picked. Let’s say you picked 10 PM. That’s the time I pick. All phones, technology should be off by 9:00 PM, even 8:30 or 8:00 is better. 

What you do during that hour is that’s when you start to do the wind-down routine or program. Now this doesn’t have to be compulsive, it doesn’t have to be exact to the minute, but what we’re talking about here is now starting to implement things that bring you to a place of comfort. I understand if you’re having a lot of anxiety, you might still feel it in every single part of the sleep routine. That’s okay, but you’re engaging in behaviors that don’t make your anxiety worse. You might be reading. However, if reading is something that makes you hyper-aroused in an anxiety way, maybe it’s not reading. Maybe it’s meditation, maybe it’s listening to an audiobook, not something that’s going to, again, rev you up and get you going. Something boring, something simple, something a little more monotone. It could be listening to sounds. There are so many free YouTube videos with just sounds of the waterfall or rain or birds or waves. If you have a specific sound that you like, I’m sure you can find it. These are all great options. 

You may also want to engage in a wind-down routine. This is my personal routine, you don’t have to follow it, but without too much being pedantic, I have a routine. I go downstairs. I brush my teeth. I floss my teeth. I wash my face. I then go plug in my devices. I go to bed. I get my Kindle out. I actually am fine with the Kindle as long as you’re not reading something too overwhelming because the lighting is different on a Kindle compared to an iPad that shoots light right into your eyes. I might take a glass of water. I make my bed actually before I go to bed. Meaning it’s pretty messy usually, so it’s something I like to feel like the covers are all neat on me. I then allow a wind-down. That’s just me. My husband doesn’t do any of that. He just brushes his teeth, goes to bed, and starts reading. Not that different, but for me, I have more steps. You can do whatever you think is helpful, but sleep hygiene has to be a piece and you have to work backwards by removing the technology. 

Some people say, “What about if I use my phone for my alarm?” That’s fine, I do too. However, if it’s in your room or it’s next to you, that’s fine as long as you can practice some restraint of not picking it up and going on social media because you can lose hours by just picking up your phone and opening up the Instagram app. You can lose hours. 

One thing I’m going to encourage you to do here is consider we have a course called Time Management for Optimum Mental Health and we talk all about scheduling. I’ll give you a little bit of information that I share during the Time Management course. I personally calendar a lot of my life and I have found that that has been very beneficial for my sleep. The reason being is because I have to wake up at 6:15 to get my kids to school. I used to get to bed whenever I could and then I realized I was massively sleep deprived. When I looked at the calendar and I thought, okay, if I have to be up at 6:15 and if I need a certain amount of sleep (I do better on eight hours), I have to be in bed asleep by 10:15. What am I doing? Going to bed at 10:30, I’m already setting myself up for failure. 

When you’re scheduling, you actually look at your wake-up time and you even plan backwards for that on when you need to be in bed. And then you plan backwards from that on when you need to work on your sleep wind-down program. Again, you don’t have to be pedantic, you don’t have to be too hyper-controlled on this. But doing it a couple of times is life-changing in realizing, at the way I’m going, I’m never going to get enough sleep.

SLEEP ANXIETY REMEDIES

Now, in terms of talking about sleep anxiety help or sleep anxiety relief, there are some additional sleep anxiety remedies you may say that may help you. Let me add here, there’s not a ton of research. I try to only bring research-based stuff to you. But a lot of people say things like oils or candles or deep breathing. I mean, we have research on deep breathing. It can be very beneficial. But you can bring in anything that soothes you, certain sense people love. I have a sister and family members who love those satin pillows. That really helps them. Just get a feeling for textures and sensations that also help you to wind down in the evening. 

SLEEP ANXIETY TREATMENT

Now, if you’re doing these things and you’re still really struggling with sleep anxiety and getting to sleep and insomnia, I would encourage you to look into some kind of sleep anxiety treatment. We do have science-based treatments to manage sleep anxiety or even chronic insomnia. One of those things is mindfulness training. In mindfulness training, what we are doing here is we’re training you to be able to get a hold of your attention. Because as you know, anxiety, if you really let anxiety lead the way, it’s going to ping-pong you to all the worst-case scenarios. It’s like what I said about my daughter. Will I fall asleep? Will I wake up? How long will it take? What if I don’t? 

A lot of people also report anxiety around, “I don’t like the feeling of falling asleep. I feel like I’m losing control or feel going to sleep is scary. I don’t know what’s going to happen.” If you’re someone who’s very hypervigilant, being asleep can actually be very triggering for you. 

Mindfulness trains us to stay present and not engage in all of that drama that our brain creates around all the possible worst-case scenarios. It also allows us to practice non-judgment about the anxiety and about the sensations that we’re experiencing, so we can just be present with them and practice. When I say practice, I mean over and over and over again because this is not easy. Practice being willing to be uncomfortable but keep our mind attending to the present instead of the worst-case scenarios. 

Another piece of this when we’re talking about sleep anxiety treatment is general stress management. Now, if you have an anxiety disorder during the day that also starts to leak into the evenings, particularly if you’re someone who has more anxiety in the evenings, you will need to use a lot of cognitive behavioral therapy to manage that anxiety. Or if you have a lot of stress in your life, maybe your work or your school or your relationships are very stressful in this season, CBT (cognitive behavioral therapy) can be helpful in first looking at your cognition—that’s the cognitive part of CBT—and then also looking at your behaviors.

Now, the cool thing is a lot of the behavior stuff, you and I have already talked about in that sleep hygiene piece. We know that the behavior of being on your phone is not helpful. In addition with sleep hygiene, getting a lot of exercise less than two hours before bed isn’t really great for sleep either because your body’s metabolism is all sped up from that. Those are some behavior changes. Not watching scary movies or very activating movies or books—reading those books is very important behavior changes, or having difficult conversations. 

For me, I have had to learn that if I work after about 7:00 PM, I can’t fall asleep. I need about three to four hours to wind down from work before I can fall asleep. Now that’s not always possible and I understand there’s a lot of privilege that goes with these ideas sometimes, but you just can do the best that you can, and if you can change things, go ahead and try. But those are some behavioral changes you can additionally do. 

Now, if you are somebody who struggles with severe insomnia, in addition to sleep anxiety, because sometimes sleep anxiety goes alongside actual insomnia where biologically you don’t sleep much or you can’t sleep much, there is a specific type of cognitive behavioral therapy that is being scientifically proven to help called CBT-I. That is a specific form of CBT that is directed towards managing sleep anxiety and insomnia. It is really cool, it’s very effective. It’s very hard to get treatment, but if you do some Google searches, you might be able to find a CBT-I specialist in your area.

GIVE ME SOME MORE SLEEP ANXIETY TIPS..

In general now, because I’m trying to move us through this and not give you a full-on lecture, let’s just talk about some general sleep anxiety tips. As you’re approaching bed, the first skill I want you to practice is not tending to the noise that your brain creates about how bad this is going to go. For me, my mindfulness mantra is “not happening now.” I’ve done a whole episode on that in the past, not happening now. Meaning I’m not tending to something that has not yet happened. Until it happens, it does me no benefit by trying to focus on it right now. My brain is going to keep saying, “But what if you don’t? What if it’s bad? What if you’re really tired tomorrow? How is it going to go? What if you wake up? What if you have a panic attack at night and so forth?” I’m just going to say over and over, “You know what, it’s not happening now. I’m tending to what is happening.”

Another sleep anxiety tip I really want you to practice is compassion. Be really gentle with yourself, particularly as you start to practice these behavioral changes, and clean up your sleep hygiene. It takes time. The other thing with compassion is also be kind to yourself when you’re tired because a lot of us are exhausted. You have an anxiety disorder. Maybe it’s making it even harder for you to fall asleep. Then you’re tired, so now you’ve got two problems. Be as gentle and kind as you can. Again, when it comes to self-compassion, check in with yourself. Am I doing and engaging in behaviors that are kind towards me and my long-term goal? I’ll tell you what I used to do. When I had young toddlers, by two o’clock I’d be exhausted because I hadn’t gotten enough sleep, so I’d have a coffee or a tea. But the tea and the coffee then prolonged how much I could get to bed, and it was made later and later. Again, reducing coffee, tea, some energy drinks is another important piece of sleep hygiene and behavioral changes that will benefit you if you struggle with sleep anxiety or insomnia. 

We have mindfulness, we have compassion. These are really important sleep anxiety tools or tips. Another piece here is, as I’ve said before, engage in things that soothe you. If you’re doing exposures, if you’re doing ERP, try not to do them before bed unless you’ve been instructed by your therapist. Sometimes that’s not helpful. Now, that being said, if you have really severe anxiety around sleep, you may need to do exposures around bedtime as the exposure. That is an actual part of CBT-I. Sometimes they even have you set alarms to wake up at 2:14 in the morning and 4:45 in the morning so that you have to practice these skills over and over. That is okay and that is, again, where this can be very paradoxical, but that will be up to you to decide what’s best for you. 

WHAT ABOUT SLEEP ANXIETY MEDICATION? 

Another thing to remember is that there is sleep anxiety medicine. You can talk with your doctor about medicines that can help with sleep, help staying asleep, help you regulate what time. Some people take medication a few half an hour before they go to bed so that it helps ease them into sleep. Please do speak with a psychiatrist or a medical doctor about that because I’m not a doctor, so I’m not going to be giving you medical advice about that. 

Now, before I wrap up, there’s a couple of specific groups of people I also don’t want to miss here. First, I want to address sleep anxiety in association with depression. Sometimes a symptom of depression is insomnia. If that is the case, you could use some of these skills and I encourage you to, but we don’t want to miss the fact that if depression is what’s causing your insomnia or your sleep anxiety, please seek out a CBT therapist because it’s very important that you address that depression. One of the side effects of having depression can be sleepless nights, so I don’t want to miss that. 

Another thing is, a lot of folks with OCD experience obsessions about sleep. Again, as I was mentioning before, it may mean that you do have to do some exposure around sleep and that would be advised to you because the best treatment for OCD is exposure and response prevention. We actually wrote an entire article about this on the website. If you want to go to KimberleyQuinlan-LMFT.com and then type in OCD and insomnia, it will be there. We did a whole article on that just a couple of weeks ago. 

>>>OCD AND INSOMNIA ARTICLE IS HERE<<<

That’s it, guys. That’s what I want you to be really looking at. Please remember, and this is the most important part, the biggest message that our sleep specialist gave my daughter was stop putting so much pressure on yourself to fall asleep because the pressure creates anxiety and the anxiety stops you from sleeping. The best sleep anxiety tip I can give you at the outset of this podcast episode is try to take the pressure off. The truth is, even if you’re not sleeping as long as you’re resting, that is enough. You can’t force yourself to fall asleep. It usually creates more frustration, more anxiety. It just creates a lot of irritability. 

Try to take the pressure off. Give yourself many weeks to get this down. It may take tweaks, it may take some reworking. You may require some help from people and assistance from a medical doctor if you need to. You can also reach out to a sleep anxiety specialist or an insomnia specialist who specialize in sleep deprivation anxiety or sleep deprivation in general. If you need sleep anxiety treatment, there are specific treatments out there for sleep anxiety in adults, children, and teens. 

If you’re wanting to come and work with us again, you can go to our website and we have some amazing therapists who can also help. My hope is, soon I will be bringing out some sleep anxiety-guided meditations for you as well. That’s coming down the pipeline here very soon. 

Please take the pressure off. Please be gentle. Just tweak little things. Again, as we always say, it’s a beautiful day to do hard, repetitive things where we practice and we practice. 

I hope that’s been helpful. I hope you do go on to have a good night’s rest here very soon. I will see you next week.

Welcome back, everybody. Today we are talking about Acceptance Scripts with Dr Jon Grayson. 

So happy to be here with you as we tie together our series on imaginals and scripts. Today, we have the amazing Dr. Jon Grayson and he is going to talk about acceptance scripts and the real importance of making sure we use acceptance when we’re talking about scripts and imaginals. I’m so excited to share this episode with you. I think it really does, again, tie together the two other guests that we’ve had on the show in this series. 

For those of you who are listening to this and haven’t listened to the other two episodes of the series, go back two weeks. We’ve got the first one with Krista Reed and she’s talking about scripts and the way she uses them. Then we have Shala Nicely and she talks about her own specific way of using scripts. Again, the reason that I didn’t just have one person and leave it at that is I do think for each person, we have to find specific ways in which we do these skills and tools so we can make it specific to your obsessions and your intrusive thoughts. One explanation or one version or variety of this is probably not enough. I want to really deep dive in this series so that you feel, number one, you have a good understanding of what an imaginal and a script is. Number two, you know how to use them, you know the little nuanced pieces of information that you need to help make sure OCD and your OCD-related disorder doesn’t make it a compulsion because it can. I really wanted to get some groundwork so that you feel confident using imaginal and scripts in your own treatment and your own recovery.

Again, for those of you who are a little lost and feel like you need a better understanding of OCD, of how OCD works, how it keeps you stuck, the cycle of OCD and you want to make your own individual OCD and ERP plan, you can go to CBTSchool.com. We have a full seven-hour course that will walk you through exactly how I do it with my patients, and you can do that at your own pace. It’s an on-demand course. It is not therapy, but it will help you if you don’t have access to therapy or if you’re really just wanting to understand and do a deep dive and understand what ERP is and how you can use it. That is there for you. But if you are someone who is just wanting to get to the good stuff, let’s go over to the episode with Dr. Jon Grayson. Thank you, Dr. Jon Grayson, for coming on the show again. Always a pleasure to have such amazing people who really know their stuff. I’ll enjoy this episode with you. Let’s go.

Kimberley: Welcome, Dr. Jon Grayson. I’m so happy to have you back.

Jon: It is always fun to be with you.

Kimberley: Okay. It’s funny that you are number three, because I probably need you to be number one. Almost all of the scripting I ever learned was from your book. I think that even Shala Nicely came on and spoke about how a lot of what she does is through your book as well. Let’s just talk about the way in which you walk people through an imaginal or a script. Now do you call it imaginal or script? Do you think they’re synonymous? Do you have a different way of explaining it?

Jon: I think jargon-wise, they’re synonymous. I think by definition-- I feel weird saying that by definition because we made it up. I came up with the name “script” because originally, imaginal exposure suggested I’m just dealing with all the horrors and person’s just going to think about it. I changed the name to “script” because I was including both. What are you being exposed to? What might happen and why would you take this risk? Because I feel like the script is not only to get used to the material, but we remind the person, why am I doing this? What am I getting out of taking this horrible risk? Why would I want to live with that? 

WHAT IS AN ACCEPTANCE SCRIPTS/IMAGINALS? 

Integral to the Acceptance Script is the whole idea of learning acceptance. Because too often, I think the biggest problem I see in most therapists is they just jump into doing exposure without making sure the person has done level 1 acceptance, which is “I want to live with uncertainty,” because to say “I want to live with uncertainty” is to say, “I am willing to cope if the worst things happen.” It’s not just this general idea, it’s like going to the extreme. “I’m willing to live, even if this happens. I’m willing to drive a car knowing that I might get paralyzed and disfigured in a car crash.” I think that’s acceptance because if you’re telling me you’re never going to crash in a car and you know that’s true, I guess that’s a nice comforting thought that you might be in for a shock. We’re willing to take that risk. I think across the board, it’s always willing to live with the worst possible. 

Scripts try to encapsulate that. They’re trying to help bring the person not only to confront their fear but remind them of all the ways they want to cope with it. It is not a reassurance thing because let’s face it, the worst thing happening, saying “I’ll cope with the worst” is not really reassuring in a sense because it’s something you really don’t want to happen. But I guess the goal is, first of all, if it happens, you will do something that’s coping or not. 

I think non-acceptance-- God bless you. I’m glad we’re live so people can see you were sneezing. I just didn’t go into a religious ecstasy. I think we see non-acceptance insidiously all over the place without realizing it. In the beginning of the pandemic, so many people were going like, “Well, this can’t last all summer. I can’t deal with that.” That is a statement of avoidance and non-acceptance. I was listening to that and in the back of my mind, it’s like, “Let’s see. Everything they’ve told us makes it seem like this is going on for two years because they’re not finding a vaccine.” Seriously, you can’t take it. You’re not going to do it. What are you going to do? In retrospect, everybody would have to admit, “Well, yeah, it was not fun, it was awful, but I lived through it.”

Acceptance would’ve been, “Well, how am I going to try to make the best of this?” Making the best of it isn’t wonderful, which I guess brings us to the first point about acceptance because I think in the Western world, we make everything glossy and pretty and beautiful. Acceptance is just this wonderful land of zen happiness. It’s like I’m accepting everything is so good and, in reality, the best way to describe acceptance is that it sucks in the short run. In the short run, acceptance means “I’m going to be willing to embrace what seems to me the second-best life. This is what I want, I can have it, I will embrace this.” 

WHY DO WE NEED TO PRACTICE ACCEPTANCE? 

The prime reason to do acceptance is you don’t have a choice. The other world doesn’t exist. In the beginning of the pandemic, Kathy and I were doing our pandemic walk, my wife Kathy. We were doing our pandemic walk. I remember because you’re terrified of everybody and you’re walking looking around. Kathy says to me, “God, this would be such a great day if all this wasn’t happening.” I said to her, “You’re wrong, Kathy,” which for all the listeners should immediately cue them into the idea that being married to a psychologist is not necessarily fun. I said to her, “It is a beautiful day. We’re with each other. Here we are. We’re holding hands, taking a walk. It’s really pretty. We’re going to be spending the whole day together.” The truth is, it is a great day AND it’s horrible that all of this is happening. I think acceptance is always AND. We always talk about letting stuff be there as if it’s very passively like, “Oh, I can just let it be there and not bother me.” No, it’s really horrible.

Let me tell this really horrible story, which I can’t remember if I’ve told on here, but it’s a more graphic description of what acceptance looks like, if I may. A young girl was brought to me, 17, was really in terrible shape. I mean, she had been hospitalized, she had suicide attempts. So anxious, she couldn’t tolerate being in a counsel’s office for more than one hour when she first came in. Her meds were a mess. Over the next three months, we got her meds in line and she really worked incredibly hard considering where she was. And then in December, they asked, could she be in my support group? I said, “Well, it’s not really for kids.” They talked me into things, “We think she’s mature.” First of all, whenever she spoke up in the group, whatever she said would be brilliantly insightful that would just knock everybody out. She did not look old, but nobody could believe she was only 17. 

As the year went on, we were tapering off sessions. The last time I saw her in June, her parents, her and her brother were driving out to the desert outside of LA looking for a vacation getaway place. On their way there, a drunk driver in her third DUI rammed the car and killed my patient Ruby and her 14-year-old brother. I don’t have to tell you how devastated the parents were. I could talk a lot of stories that are amazing about them because I saw them starting about three weeks after their loss. At which point they said, “We want to be more than the parents of dead kids, but we can’t imagine anything else.” I said, “Well, I can tell you what treatment will be like, but it just seems like words.” They agreed it’ll be just words, but it’s just nice to hear there’s something. They coped amazingly well. But the only good thing about coping, in this case, is it’s better than not coping. Maybe that’s true a lot of the time.

After a year and a half, they did buy the place where they were going to that they were looking for that day. They bought it because it made them feel closer to the kids. They didn’t push that away at all. After a year and a half, they were at the place. It was one night where there was a meteor shower. They go, “Oh, we’re going to go out and watch the meteor shower.” They go out at midnight, lay down on their backs and both immediately burst into tears because this 17-year-old, 14-year-old were actually the kind of kids they would’ve happily gone out there with their parents and enjoyed the whole time. I said to the dad, “Was it a pretty meteor shower?” He said, “Yeah.” 

“Are you sorry you saw it?”

“No.”

I said the truth, “It was a beautiful meteor shower AND it’s horrible that your kids were murdered.”

It’s a dark sense of humor and said, “Well, I thought we’d have at least a few moments. I said, “Yeah, that wasn’t happening.” That’s acceptance. They were living in the present. They could enjoy things and there was a hole in their heart. The alternative to that is comparing life to every second of life to how much better it would be. Whenever I compare life to a fantasy, I ruin the present. I have nothing. 

I think the reason for acceptance is to make the best of whatever we can have. I think one of the wonderful things sometimes is that a lot of what we avoid is not something so devastating. It’s maybe more in our head what we’re trying to avoid. But a low probability event is not a no probability event. If that’s what I’m scared of, low odds are comforting because I want no odds. Am I answering your question?

Kimberley: You are. I think it’s a really great opportunity for us to segue. You’ve talked about the first step being to familiarize yourself with uncertainty before doing scripts and acceptance. You’ve beautifully explained this idea. For the listeners, you can also go back. Dr. Grayson has been on the show before. You can listen to it. We’ve talked a lot about that, which is so beautiful and I think very much compliments what you’re saying. Let’s talk about the script that you’re speaking of. Once you’ve done that work of acceptance, how would you--

Jon: I may have to call you Ms. Quinlan since you referred to me as Dr. Grayson. 

Kimberley: No, call me Kimberley. 

HOW CAN WE ACCEPT UNCERTAINTY USING SCRIPTS/IMAGINALS? 

Credit: https://www.instagram.com/p/CmZUliJKhQB/

Jon: When considering how to accept uncertainty, that first step, are you willing to learn to live with uncertainty? That step is variable of talking in therapy for the first session. I’ve had some people take three months before they agree like, it’s not like I really have a choice, and that’s really what we’re getting. What are you losing to that? I can’t remember if I just said this before, but one of the biggest things that I end up teaching therapists who have been around the field for years is do not start exposure until the person has actually agreed that they’re willing to learn to do this because obviously, they can just accept uncertainty. Then we’re done with session 1. It takes one session to three months. The loose measure is to accept uncertainty to say if the worst happens, I will try to live with it and I will try to cope with it. If somebody says to me, “If that happens, I’ll kill myself.” No, no. That’s an avoidance. In this scenario, you are condemned to life. You’re going to have to figure out how to cope no matter how awful. 

In scripting, the idea of a script is not only to provide the imaginal exposure, which is like this terrible thing might happen. Because a lot of times, people go, if you say X might happen, “I don’t want to think about it.” As I said to you in the beginning of the show, I can get any parent into an immediate statement of denial by saying, “What if your kids die,” the response of almost every parent is, “I don’t want to deal with that. I don’t want to think it through.” But if you’re being tortured by the thought, that normal level of denial, which I don’t think is the ideal way to handle it, but you already can’t do it because you keep going into, “What about no, what about no, what about, no?” 

How to write an Acceptance Script

The very first step of how to write an  acceptance script is essentially asking the question, “why would I take this risk?” Because within that statement is part of your answer of why I’m going to pursue acceptance. It is not the same as acceptance, but it’s why I’m being motivated to go after this. 

Kimberley: What would that look like? How would you word that?

Jon: As to why would I take this risk? 

Kimberley: Uh-hmm.

Jon: I’m trying to think of how horrible to go. 

Kimberley: Let’s pick an example because I think examples are helpful. Let’s say someone has relationship OCD and they’re afraid they’re making the wrong choice in their partner.

Jon: You picked one, I think, that’s not necessarily the most horribly devastating consequences on one hand compared to like, am I an old child molester? 

Kimberley: You go there.

Jon: I have a really wonderful acceptance thing I do with that, so we will go there. But with the ROCD, I want to know, am I making this terrible mistake with my spouse? What we’re asking them to accept is never knowing.

Kimberley: You’d just say that in the script? 

Jon: No, because we’ll talk to them and we’ll talk about why like, why am I willing to never know for sure? Because some of it is like they’re looking into a relationship with the thermometer and taking the measure every minute. What’s the temperature now? What’s the temperature now? There’s this fantasy that I should have no questions. I mean, depending on how deep they’re in, I should find no one else attractive, but every moment should be great and I should have no complaints. Well, that is a fantasy marriage. 

Kathy and I took a trip to France and it was an incredible trip. Of course, when you say going to Paris, everybody’s eyes glaze over. We ate at a patisserie every morning, but let’s face it, it’s just a damn croissant. One place had the best café au lait. We were there for two days, but it was great. We saw the Catacombs where we had to wait in line for three hours in the hot sun. Went to a really fine restaurant, but we’re not super foodies, so we’re not necessarily going to like it. The experience can’t just depend on, “This was great food,” or “This is terrible, we just spent a lot of money for what.” We go in knowing that. It was a great vacation. A great vacation. It’s not like every second is great. Three hours in a hot sun, five-hour bus ride to go see the site, but it was still a great vacation. I think a relationship is like that, so I can’t look at that now. 

I think for the person with ROCD, we’re going to say they are not perfect. Like any relationship, we want a hundred things and we’re only getting 70 of them. It should be more than 20, but we’re only getting 70. Are you making a mistake? Now, most people with ROCD can say they don’t want to leave right now or sometimes they want to leave because of the anxiety. It’s like, then you have to stay. I don’t want you talking about all your fears and confessing because if you are wrong, you’re just making this person feel bad for no reason. 

My thought is, you can leave this relationship when you know for two weeks solid you want to leave with no question. No question. You know it is, sure, as you know you’re sitting there because they generally accept that. We have to point out what are the realities of a relationship. Everyone on their wedding day thinks they’re going to be married forever, but that’s wrong 50% of the time. Whomever we marry, my spouse being an exception, 40 years later, they don’t look as good as you did the day you married them. Technically, you were accepting second best in looks 40 years later.

Kimberley: Did you know the rate of divorce is higher in therapists?

Jon: Wow. So, Kathy and I are really against the odds. This is a little scary to you probably. We started dating in 1970 and this year, it’ll be our 50th anniversary. 

Kimberley: Wow. Congratulations.

Jon: Having met at the age of two and started dating then, we don’t really have much significant history before that. You will get angry and there are going to be things they don’t want to do. Yes, you’re going to have to learn to live not knowing that. That’s going to be part of the script, that you don’t get to know. What if you’re making a mistake? Even if you fell wildly happily in love now and you had no question, really nice feeling. If the relationship seems good, no reason to question it. Now of course, if you have ROCD, you’re checking all these reasons. It’s like you’re not ready to leave yet. Yes, when you’re answering your questions, it’s maybe. Even if I feel wonderfully in love with you, it might be that next year or after 20 years ago, I discover you’ve been having a seven-year illicit affair. I discover, “Oh hey, guess what? You’re leaving me.” There are all kinds of things that could go wrong. Or I’ll ask the person in this relationship, if this relationship was good and you felt constant passion affair and next year your spouse suddenly gets a dread disease that’s going to make them really messed up and crippled and sick for the next years, I guess you’re leaving them. Of course, everybody goes like, “No.” But the bottom line is, that’s good, but that’s not going to be what you signed up for. 

How do we make the best of it? I did this one thing with one couple that worked like magic. I’m saying that worked like magic because I’d do it with everyone across the board, but usually, it doesn’t work like this. This was the low probability. Oh my god, this was the killer intervention as opposed to, this is a start for most people. It was such a cute couple, but I’d given him the thing. “This weekend, when you’re spending time with her, I want you to notice whenever you’re having fun, and although part of you wants to compare it to what it should be, I want you to consciously just notice whatever it is, like if it’s 5%.” Because a lot of times, you’re comparing your current feeling to what it should be. There could be good things happening and you don’t even notice because it’s like, “I was just thinking about this, I was just thinking about this.” He had that assignment to notice it, whatever. He came back and he was like, “We had a great weekend. I still don’t know if I love her or not, but if it could be like this forever, I’m good.” Now, that was a rarity, but that was the beginning of acceptance for most people, just noticing, oh, I’m not miserable every second. I agree a two-minute 20% joy isn’t like, oh wow, that makes it all worth it. But it’s stuff that you don’t notice all along. We’re trying to notice the good and the other stuff.

Acceptance is not a decision; trying to learn it is. But when I talk about that couple who lost two kids, when I say it was more than a year for them to get to acceptance and what acceptance means for them is they didn’t compare every moment to what it would be like if their kids were still alive. In fact, I didn’t know this at the time when I told them that everything goes well after a year. You’ll still have a hole in your heart, but you’ll stop comparing every moment to if they were still alive. They just listened. But the dad wrote a book about mourning and he also did a one-man show called Grief, which I wish I could show everyone. But in one of those places, he said that when I told them that, in his mind, he was saying, “F you! I am never going to stop wishing my kids were alive.” And then he wrote that two years later, he’s come to realize it doesn’t do him or his kids any good to wish they were alive.” He’s in acceptance. He still misses them greatly. He can still cry at them, but he’s no longer making that comparison. I’m mentioning it because that takes time. No one expects a couple, three weeks after their kids are murdered, to be in acceptance. The same with anything I have to accept. 

The person with OCD, they have this goal, but getting to that great state where “I’m living with this and it’s okay, I embrace this life” is hard. Luckily, most of the time what they have to accept isn’t devastating in the sense that nobody dies of AIDS. Am I with the wrong person forever? Well, maybe it’s the second-best life, but that’s the life I’m asking you to live for now, because all of us have no choice.

Kimberley: Right. Let’s break it down. 

Jon: I’m sorry.

Kimberley: No, you’re great. 

Jon: Okay. You’re good at being back on target.

Kimberley: I’m a real visual person too. I don’t know if you know that about me, like if I need to see it visually--

Jon: By the way, that’s fantastic because to say something and show it visually just makes it easier for everyone else around you that you’re talking to. I appreciate what you’re going to do.

Kimberley: Okay. Walk me through the visual here. The first step is what? 

Jon: Why would you take this risk?

Kimberley: Okay, what’s the second?

THE SECOND STEP OF ACCEPTANCE SCRIPTS

Jon: The second step of acceptance scripts is, if I do X, here’s a list of the things I’m actually scared might happen. I say actually scared because I want to go, what’s their fear? I can always go beyond even more horrible things, but I need to know what is their actual worst fear.

Kimberley: Right. Let’s say for two if it was relationship OCD, it would be, “I find out I’m in a terrible relationship and I’m stuck with them.” Or if they were having harm obsessions, it would be, “I harm and kill my wife or my grandparent or so forth.” You would write that down.

Jon: Yeah. “Here’s what might happen.”

Kimberley: Okay. What’s step number three?

Jon: If this happens, how would I try to cope with this in a positive way?

Kimberley: That’s key, isn’t it? How would I cope in a positive way?

Jon: Right. And that will often be second best.

Kimberley: Which is acceptance.

Jon: Well, it’s the road to acceptance. Remember, acceptance is not just this logical thing; it’s this emotional thing. I have clients and they appreciate it. It’s like, if we were just doing a therapy test, like say all the right stuff, they could ace therapy right away. They know how to say everything, they can do it. But feeling it takes time and behavior. I not only have to know it; I have to do the work of getting there. I have to go through all this pain. Now, I say, I think going through ERP is as painful as doing rituals. One is just an end of rituals versus endless rituals. I hate to keep going back to this couple, but what I said initially, the only good thing about coping is it was better than not coping. I had told them how well they were coping somewhere in the middle. Again, the dad said, “Wow, I hate to see the other poor bastards,” which was cute. I said, “Yes, but you’ve been in support groups, you’ve seen them.” He suddenly realized, “Whoa, we are coping even though this really sucks.”

Kimberley: In this script—and maybe I’m wrong here, please tell me—I always think of the research around athletes and when they have an injury, there’s research to show that while they’re in the hospital bed with their new hip replacement and whatnot, the sports psychologists are coaching them through visual, imaginal, imagery of them doing the layup again and dunking the ball or turning the corner of the sprinting track or whatever. They’re doing that imagery work to help them play out how they would cope, how they would handle the pain, how they would return. Is that what this process is in step 3? 

Jon: No. Well, that guy or a woman who’s imagining that, does their injury permit that possibility?

Kimberley: Tell me more.

Jon: Are they so injured that they will never be able to do a layup?

Kimberley: No. In this example--

Jon: Or maybe somebody could say the odds are against them, so here’s what you can try to do, and here’s what to expect of how horrible it is to try.” But they might have to say, “You might not get there.” In a marriage, I don’t care how good the marriage is, I cannot say it will definitely work out. I can’t say you will definitely work out your problems. If I’m married for 20 great years, and then we have these three years at hell and I find out that you’ve been cheating on me the last two years, did I make a mistake? Or should I have left you four years ago, how would I know four years ago and should I have not tried, and all these questions that don’t have an answer. All I know is where I am now. 

THE THIRD STEP OF ACCEPTANCE SCRIPTS 

I like to say success is not making the right decision. It’s coping with the consequences of whatever decision you have made. I feel regret is cheating because regret is, again, I’m going into denial as soon as I have a regret. I should have done X. X would’ve been different. I don’t know if it would’ve been better. This failed. X being better is one possibility, but there are a whole lot of other ones where maybe it wouldn’t have been as good. All I can ever do is, what is next? That person in the relationship with ROCD, what do I need to do next? What have I learned? Somebody with ROCD did get divorced and gets into a relationship where they have the ROCD, but it’s such a better relationship. It’s not like you should have gotten out sooner because you know what, maybe if you didn’t go into that other relationship, maybe you wouldn’t have been ready for this one. Maybe you needed to go through your ROCD and go through all the crap to have this good one. Dumping that person sooner and getting into another relationship might have been better, or maybe you would’ve picked worse. We don’t get to know. All we know is what is from this moment on. 

Part of the exposure is, okay, X might happen. What are the possibilities of coping? Again, I think I said, in my scenarios, the person can’t do suicide. They’re condemned to life and say, why I kill myself? That’s just a way of not thinking in the present. I want you to be stuck thinking about how you would try to cope with this. A lot of times, people have been so distant from it that it just seems like a screaming wall. It is like getting a phone call that somebody you love died. The whole world stops, and that’s where people stop thinking. But in the real world, something happens after you get that information. 

Part of the exposure is to go through what happened next, what are some possibilities? I always say to somebody, “I don’t know if I can cope with the worst things that could happen to me, but I know that there are brave people who have. I don’t know if I can be like them, but they’re a model that I hope I will do that.” What if you don’t cope? Well, then I’ll be in deep trouble. My current plan is, the best I can do is I hope I will cope. I don’t want to be paralyzed and disfigured in a car crash. I hope I would cope. I don’t have to know that I’d cope because I’m going to wait till I get there to try to find out. But I might try to imagine it. 

We’re going to imagine what would you actually do. In this relationship, how will I live never knowing? I’m taking the ROCD, how will I live? What if this is wrong? It might be wrong. What’s decent right now? What do you like? Because again, no person is perfect. How do I get into the state of that? Do I ever send people to marital counseling? If I see actual problems, I will, but I am not sending them to marital counseling to get rid of the ROCD. I’m sending them to get rid of actual problems. With or without those problems, they still have ROCD. I’m just eliminating, okay, here’s some definite reasons to get out. But once they’re resolved, then you’re still stuck with the ROCD.

THE FORTH STEP OF ACCEPTANCE SCRIPTS 

Kimberley: Is there a fourth step of acceptance scripts? 

Jon: Kind of. It’s embedded in it, which is part of why I would take this risk, is what’s resulting from not taking this risk? What are the graphic horrible things that keep happening to you because you keep avoiding, including the torture you feel, the hours loss, humiliation from doing things? How are you actually hurting the people you think you love? Because a lot of times in ROCD, they can say they care about the person. I’ll always ask somebody, do you love your kids or love your spouse?” They’ll say, “Yeah.” “Will you do anything for them?” They’ll say yes. I’ll say, “I’m sorry, you’re a liar.” How do you hurt your family and loved ones with your ROCD? Not being present, yelling at them because they didn’t do something, and all the other ways that one might, asking for reassurance endlessly being in pain in the neck. I will point out, you have a choice in your relationship. I’m going beyond ROCD. But you get to pick between, are you going to serve your fear or your love? You keep choosing fear over love. 

Part of acceptance does have to do with what my values are. Who is the person I want to be? Here’s another reason I need to do acceptance, because here’s life without acceptance. Most people who we see, we can say, the idea of trying to not accept and do avoid, I think you’ve done an amazing experiment of checking out that method. I think the results are clear, it sucks, so it’s time to try this other method. It’s like, why am I doing acceptance? Because I think, again, in our society we just make acceptance sounds so wonderful. But that’s just an idea. Why would acceptance actually be worth it? I have to think about why would it actually be worth it. I have to be motivated to do it. And then I’m stuck with this in-between thing that a lot of the time I’m doing a separate, recognizing I am not there yet, which by the way, there’s this great book that this wonderful person wrote on self-compassion, because I need self-compassion during treatment because I’m not where I want to be. It’s like I’m doing this really hard work and it’s not there yet. The best I get to say is, I’m working hard, I see some improvement, but yes, I’m not there yet and mourning. 

Learning to live the second-best life takes time. I keep saying second-best life. I don’t actually mean it in some sense, but that is the feeling that when I’m working towards acceptance, that it is. I think in some cases, it’s not really a second-best life. I think a lot of times, if I overcome a fear, it’s like, this is great. Other times it is. I’ve had some people with a moral OCD about something they’ve done in the past and they’re going through all these contortions to try to convince themself that it’s not really bad even though they actually think it’s bad, but maybe here’s why it’s not bad. Part of the acceptance is, oh yeah, that was a bad shitty thing. You feel guilty about that. What is forgiving yourself mean? Shockingly, almost nobody knows what forgiving yourself means. How are you going to get to that point? But I have to accept, yeah, that was bad. That hurt people or whatever it is by whatever standards. Again, depending on who we’re talking about, it’s like, “Oh, I guess we have to have you accept being as bad as everyone else.” In some other cases, no, that was really bad.

WHAT HAPPENS IF I REFUSE TO ACCEPT? 

Kimberley: It’s great. The last part of the question is, what happens when I refuse to accept? What is the result of not taking this risk or even not accepting this, which is you have additional pain, right? The pain just keeps going and going and going.

Jon: Right. That’s right. End of pain. Endless pain.

Kimberley: Yeah. If they’ve used these somewhat prompts and people can go to your book and work through a lot of them, I know on your website there are a lot of worksheets as well. Once they’re writing these prompts, is there anything else you feel is important for them to know about this process or to be aware of or be prepared for in this process?

Jon: I am pausing. The next revision of the book might be your inspiration. Well, because I know that it is way, way, way, way easier said than done. The core treatment for all OCD is the same. However, I have a completely different set of things I say depending on the presentation, because they each have their own set of things that the individual has to be focused on working to accept and live with. Although I think in my book I attempt. When I talk about each presentation, I do try to go over those and I’ve seen that for many people as helpful. But I also see for many people who’ve read the book, and even though they’ve read it, it ends up different for them to actually have to discuss it out loud. Sometimes it’s because they haven’t been able to think about it without realizing they avoid thinking about it. Sometimes because I think not all the connections are obvious, which I know is a really vague statement. I think I can go on, but I have to wait for you to ask a question. 

Kimberley: Okay. We’re running out of time, so I want to make sure I’m respecting your time.

Jon: Don’t respect my time, by the way. I set aside way extra time. This is on you if we end.

Kimberley: Once you do those questions, you would then walk them through the four steps that you went through with scripting as well. 

Jon: Yes, and some other horrible things because the horrible show, that should have been illegal. Actually, it’s not on anymore. I think you can still find that on YouTube. Toddlers & Tiaras and the crazy mothers who make their little girls try to be in beauty pageants. You know what, if you look at the pictures of the kids, it’s like, oh my God, they’re sexualizing this eight-year-old. But when you say that word, that means you can see what they have done. You recognize the sexual aspect. You know what, if I go and take this picture apart, this horrifies people when I say it. It’s like, if you look at their legs, it’s like, yeah, they have good legs. Now, nobody wants to say that, and it’s like, “Oh.” That’s our first response. But if I have POCD, I see that, “Oh my god, what’s wrong with me?” It’s an acceptance that we can see something and recognize a piece of it. 

I think the most difficult POCD is the people who “I don’t want to be attracted to a 15-year-old.” I can say, if I show you this picture and tell you they’re 18, oh, that’s okay. If I show you the same picture and tell you they’re 15, no, that’s okay. It’s like somehow magically, I find that the picture, the attractive is the picture is right or wrong if I tell you the age, which of course makes no sense. The picture is attractive or not independent of that. It’s accepting, yes, I might find a whole lot of things. Again, what we think makes us accept or not do we act on it. 

Kimberley: It’s interesting because as you know, we just got a new puppy. It’s taking over all of the Quinlan family and our lives. I had a moment where our puppy loves his belly to be scratched and right there is his genitals. I can see the projection of my mind of like, “What if you just touched that? Or what if you pulled that back?” The imagery, I could see myself doing it. Thankfully I have all these skills where I’m able to go, “Oh, there’s a thought.” I did feel that hot, sticky anxiety flow going through.

Jon: If you don’t change diapers regularly, I’m sorry, it’s a weird experience and I don’t care who you are, you’re going to think about that. If you’re changing a little person and there you are, you’re pumping their genitals because you got to clean it up and wipe it, you know what you’re doing and the healthy thing is like, “Okay, weird thoughts. This is normal.” If I have OCD, it’s like, “Why would I even think that?” Well, it’s normal.

Kimberley: It’s funny because I was noticing myself going through some of these imaginal scripting steps myself. Instead of going, “No, no, no, no, no, you wouldn’t, you wouldn’t, you couldn’t. That’s terrible.” It was like, “All right.” This is the last question I want because you’ve given some great examples. As I was having this thought, I noticed the choice—I used the word “choice” on purpose—to get really edgy with it and try not to have it. My body language is all tight and I was gritting my teeth, or I was like, “Kimberley, just let it flow. Let the thoughts come.” As you’re doing this with your patients, is there any piece of you where you are bringing their attention to whether their shoulders are all tight and their jaw is all tight and their hands are all tight, or does that not matter?

Jon: Nothing not matters, maybe, but that’s not always true. I thought you’d enjoy that. I think it depends on how much that’s part of their conscious fear response. I mean, I think if they’re doing their dog and it’s like, “Oh my God, am I excited by this,” the answer I would be working on is, “I’m not really sure. Maybe I am in some deep way. I’m not going to play with the genitals now and that’s the best I get to know.”

Kimberley: Yeah. Agreed. I love this. Thank you. Again, I want you to say, where are the resources that people can go to get your concrete workbooks and your worksheets?

Jon: I love how you make me have so many more books and worksheets. All the paperwork that appears in my book appears for free for anybody on the site FreedomFromOCD.com. In the Kindle and audio version, they couldn’t have those, so I was obsessed to have the Kindle version so I made that available. My book has most of my repertoire except about 20 minutes. Those are the main places. I hate to do this, but most of the time, when it comes to OCD books, I will say to people, there are a bunch of books that I would recommend, I think, that are roughly equal. But I think the one that most agrees with me happens to be mine, so I mention a few of the other good books. There is only one other book seriously that I tell people to get because I think it’s different, and that is your book, which is amazing because generally, I hate books that label themselves “self-compassion” because it’s just a version of be nice to yourself in a lot of words. I feel your book gives these not easy-to-do steps that make it work. Although as I said to you last time, it is just you used too many exclamation points.

Kimberley: I will forever decline your opinion on my exclamation points and my emojis. If you ever text with me, you’ll know that I over emoji and I over exclamation points.

Jon: I’m okay with that in text. 

Kimberley: Thank you for that wonderful compliment. I do agree, yes, I have been blamed for the exclamation mark issue before, but I stand up and I stand with it.

Jon: I like to warn people because I want them to know, oh no, don’t worry. This isn’t as you would put it all flowers and unicorns. It’s a great book with too many exclamation points.

Kimberley: No, it’s funny because my mom helped me edit it while I was in a 14-day quarantine in a Sydney hotel for COVID. She would go through and she would add exclamation marks. She was adding e emojis and hearts and smiley faces and I was like, “Oh, we are going crazy here.”

Jon: Now I know where you got it from.

Kimberley: We’re all love. Thank you for that. It’s a very huge compliment. Thank you so much for being here and talking about this. Again, I love having you on talking just a little deeper into the topic and a bit more abstract, which I think is helpful too. Is there anything else you want to conclude on here?

Jon: I would love to have some really cool, all-summarizing conclusion. The truth is, I can just talk endlessly. I’m just going to thank you for having me on and I am always willing to come talk with you.

Kimberley: I would say, the point that I love that you made today, which I will add for you, is the word AND. The word AND is so important in this conversation.

Jon: That’s a great summary because I think so many of our ideas, it’s not like they’re new, they get refined with time. In a way, something we’ve been saying all along and suddenly there’s this very slightly different way of saying it, but it summarizes it in a way that makes it more understandable, and AND I think does that for a lot of understanding mindfulness and acceptance.

Kimberley: Yeah. Thank you so much.Jon: You take care.

Today we are talking all about ERP Scripting with Shala Nicely. Welcome back, everybody. We are on Week 2 of the Imaginals and Script Series. This week, we have the amazing Shala Nicely on the show. She’s been on before. She’s one of my closest friends and I’m so honored to have her on. 

For those of you who are listening to this and haven’t listened to any of the previous episodes, I do encourage you to go back to last week’s episode because that is where we introduce the incredible Krista Reed and she talks about how to use scripts and imaginals. I give a more detailed intro to what we’re here talking about if this is new for you.

This will be a little bit of a steep learning curve if you’re new to exposure and response prevention. Let me just quickly explain. I myself, I’m an ERP-trained therapist, I am an OCD Specialist, and a part of the treatment of OCD and OCD-related disorders involve exposing yourself to your fear and then practicing response prevention, which is reducing any of the safety behaviors or compulsions you do in effort to reduce or remove whatever discomfort or uncertainty that you feel. Now, often when we go to expose ourselves to certain things, we can’t because they’re not something we can face on a daily basis or they’re often very creative things in our mind. This is where imaginals and scripts can come in and can be incredibly helpful. 

If you want a more detailed understanding of the steps that we take regarding ERP, you can go to CBTSchool.com, which is where we have all our online courses. There is a course called ERP School that will really do a lot of the back work in you really understanding today’s session. You don’t have to have taken the course to get the benefits of today’s session because a lot of you I know already have had ERP or are in ERP as we speak, or your clinicians learning about ERP and I love that you’re here. Honestly, it brings me so much joy. But that is there for you if you’re completely lost on what’s going on today, and that will help fill you in on the gold standard treatment for OCD and the evidence-based treatment for OCD and OCD-related disorders. 

That being said, let’s get on with the good stuff. We have the amazing Shala Nicely. I am so honored again to have you on. You are going to love how applicable and useful her skills and tools are. Let’s just get straight over to Shala. 

Kimberley: Welcome, Shala. I am so happy to have you back. I know we have a pretty direct agenda today to talk about imaginals versus scripting in your way in which you do it. I’d love to hear a little bit about, first, do you call it imaginals or do you call it scripting? Can you give me an example or a definition of what you consider them to be?

SHALA’S STORY OF ERP SCRIPTING 

Shala: Sure. Well, thank you very much for having me on. Love to be here as always. I’ll go back to how I learned about exposure when I first became a therapist. I learned about exposure being two different things. It was either in vivo exposure, so in life. Meaning, you go out and do the thing that your OCD is afraid of that you want to do, or it was imaginals where you imagine doing the thing that you want to do that your OCD is afraid to do. Research shows us that the in vivo is more effective, but sometimes imaginals is necessary because you can’t go do the thing for whatever reason. But I don’t think about it like that anymore. That’s how I learned it, but it’s not how I practice it. 

To help describe what I do, I’ll take you back to when I had untreated OCD or when I was just learning how to do ERP for myself because I think that would help it make sense what I do. When I was doing ERP, I would obviously go out and do all the things that I wanted to do and my OCD didn’t want me to do. What I found was that I could do those things, but my OCD was still in my head, getting me to have a conversation about what we were doing in my mind. I might go pick up a discarded Coke can on the side of the road because it’s “contaminated,” and I would then go either put it in the trash, which would be another exposure because that would be not recycling. There are layers of exposures here. But my OCD could be in my head going, “Well, I don’t think that one is contaminated. It doesn’t look all that contaminated because it’s pretty clean and this looks like a clean area so I’m sure it’s not contaminated. What do you think, Shala?” 

“Oh, I agree with you.”

“Well, we threw it away, but I bet you, these people, they’re going to get wherever we threw it. They’re actually going to sort it out and it’s going to get recycled anyway.” There was this carnival in my head of information about what was going on. 

I determined what I was doing because I was doing the exposure, but I wasn’t really getting all that much better. I was getting somewhat better but not all that much better. What I realized I was doing is that I’m having these conversations in my head, which are compulsive. In my recovery journey, what I was doing was I was going to a lot of trainings, I was reading a ton of books, and I talk about this in Is Fred in the Refrigerator?, my memoir, because this was a pretty pivotal moment for me when I read Dr. Jonathan Grayson’s book, Freedom from Obsessive Compulsive Disorder. I know you’re having him on this series as well. I read his book and he talks so much in there about writing scripts to deal with the OCD—writing scripts about what might happen, the worst-case scenario, living with uncertainty, and all that kind of stuff. That really resonated with me and I thought, “Aha, this is what I need to be doing. I need to be doing ERP scripting instead of having that conversation in my head with the OCD. Because when I’m doing exposure and I’m having a conversation with OCD in my head, I’m doing exposure and partial response prevention. I am preventing the physical response, but I’m not at all preventing the mental response, and this was slowing down my recovery.”

The way I like to think of imaginals—you think about imagine like imagination—is that the way I do imaginal exposures, which I just call ERP scripting, is that I’m dealing with OCD’s imagination. People with OCD are exceptionally creative. If you’re listening to this and you think, “Well, not me,” for proof, all you have to do is look at what your OCD comes up with and look how creative it is. You guys share the same brain, therefore, you are creative too. All that creativity. When you have untreated OCD, it goes into coming up with these monstrous scenarios of how you’re harming others or harming yourself. You’re not ever going to be able to handle this anxiety or uncertainty or icky feeling or whatever, and it builds these scary stories that get us stuck. 

WHAT IS ERP SCRIPTING? 

What I’m trying to do with imaginal exposure or scripting is I’m trying to deal with OCD’s imagination because in the example I gave, I was picking up the Coke can and my OCD was using its imagination to try to reassure me all the ways this Coke can was going to be okay or all the ways this Coke can was going to eventually get recycled. I needed to deal with that. Really, the way I do ERP Scripting for myself and for my clients is I’m helping people deal with OCD’s imagination in a non-compulsive way. For me, it is not a choice of in vivo or imaginal; it is in vivo with imaginal, almost always, because most people that I see anyway are doing what I did. They are doing physical compulsions or avoidance and they’re up in their head having a conversation with their OCD about it. I’m almost always doing in vivo and imaginals together because I’m having people approach the thing that they want to do that OCD doesn’t want them to do, and I’m having them do scripts. The Coke can may or may not be contaminated. The fact that it’s sitting here and it looks pretty clean may or may not mean that it’s got invisible germs on it. I don’t know. The Coke can may or may not get recycled, it may or may not end up in recycling, but somehow contaminate the whole recycling thing that has to throw all that other recycling away because it touched it. I’m trying to use my imagination to make it even worse for the OCD so that we’re really facing these fears. 

That’s how I conceptualize imaginal exposure. It’s not an AND/OR it’s an AND for me. Some people don’t need it and if they don’t need it, fine. But I find it’s very helpful to make sure that people are doing full response prevention in that they’re permitting both the physical and the mental compulsive response.

DOES EVERYONE NEED ERP SCRIPTING? 

Kimberley: Does everyone need ERP scripting? When you say some people don’t need it, what would the presentation of those people be?

Shala: That for whatever reason, they are good at not having the conversation with OCD in their heads. This is the minority of people anyway that I work with. Most people are pretty good at having compulsive conversations with OCD because the longer you have untreated OCD, the more you end up taking your physical compulsions and pulling them inward and making the mental compulsion so that you can survive. If you can’t really do all that physical checking at your office because people are going to see you, you do mental checking. That’s certainly what I did. People become good at doing this stuff in their head and it becomes second nature. It can be going on. I talk about this a lot in Fred, I could do compulsions while I was doing anything else because I could do them in my head. Most people are doing that and most people have been doing that for long enough by the time they see somebody like me that if I just say, “Well, stop doing that,” I mean I’m never going to see them again. They’re not going to come back because they can’t stop doing that. That’s the whole reason they called me. 

I’m giving them something else to do instead. It’s a competing response to the mental compulsions because they don’t know how to stop that. They’re not aware of what they’re doing, they don’t know how to stop the process, so I’m giving them something to do instead of that until they build the mental muscles to be able to recognize OCD trying to get them to have a conversation and just not answer that question in their head. But it takes a long time to develop that skill. It took me a long time anyway. 

Some people, for whatever reason though, are good at that. If they don’t need to do the scripting, great. I think that’s wonderful. They don’t have to do it. The strongest response you can ever have to OCD is to ignore it completely, both physically and mentally. If you can truly ignore it in your head, you don’t even need to do the scripting. It’s a stronger response to just do what you want to do that upsets OCD and just go on with your day.

HOW TO DO ERP SCRIPTING? 

Kimberley: Amazing. So How do you do ERP Scripting? If you’re not one of those people and OCD loves to come up with creative ideas of all the things, what would be your approach? You talked about imaginals versus scripting. Can you play out and show us how you do it?

Shala: I mean, I guess imaginals in the traditional way that it is defined versus scripting. The way I would do it is we would design the client and I would design whatever their first exposure is going to be. Let’s say that it would be touching doorknobs. They’re going to be in their location and I’m going to be in my location. They’re going to be wherever we’ve decided they’re going to touch the doorknobs. Maybe it’s to the outside of their house, for instance. I’m there on video with them and we have them touch the doorknob. 

And then I asked them, “Well, what is OCD saying about that?” 

“Well, OCD says that I need to go wash my hands.” 

I will say, “Well, are you going to go do that?” 

“No.” 

I’m like, “Well, let’s tell OCD that.” 

“Okay, OCD, I’m not going to wash my hands.” 

“Now what’s OCD saying?” 

“Well, OCD is saying that I’m contaminated.” 

“Well, let’s say I may or may not be contaminated.” 

So far, we’ve got, “I’m not washing my hands and I may or may not be contaminated.” Okay, now I’ll ask them their anxiety level. When they say, “Gosh, I’m at a four,” I’ll say, “Is that good?” They’ll often say, “No, I wish it were zero.” I’ll be like, “I’m sorry, what? What did you say? You want your anxiety to be zero? I must have misheard that. Is four good?” Finally, they understand, “Oh, well, four is not good because we could be higher.” 

“What would be better than four?” 

“Anything above a four.” 

I’m working with them on that. We might start to throw some things in the script. I want to be anxious because this is how I beat my OCD, so bring it on. 

I’ll ask again, “What’s your OCD saying?” 

“Well, it’s saying that I’m going to get some terrible disease.” 

“Well, you may not get a terrible disease.”

I’m questioning back and forth the client as we’re working on this, until we’ve got enough of a dialogue about what’s going on in their head that we can then create a script. A script might look something like, “Well, I may or may not be contaminated. I may or may not get a dread disease, but I’m not washing my hands and I’m going to do this because I want my life back. It makes me anxious and I may or may not get a dread disease.” And then we’ll focus in on what’s bothering OCD most. Maybe it’s, at the beginning, the dread disease. “Well, I may or may not get a drug disease. I may or may not get a dread disease. I may or may not get a dread disease. I may or may not get a dread disease.” We might sing it, we say it over and over and over and over and over again, and look for what the reaction from the OCD is. If the OCD is still upset, then we still go after that. If it starts moving, “Well, what’s OCD saying now?”

“Well, OCD is saying now that if I get a dread disease, then I won’t be able to do this thing that I have coming up that I really want to do.”

“Well, okay, I may or may not get a dread disease and I may or may not miss this important event as a result.” We add that in. 

We do that and do that and do that and do that for whatever the period is that we’ve decided is going to be our exposure period. And then we stop and then we talk about it. What did we learn? What was that like and what did you learn? Really focusing on how we did more than we thought we could do. We withstood more anxiety than we thought we could withstand. What did we learn about what the OCD is doing? I’m not so concerned about what the anxiety is doing. I mean, I want it to go up. That’s my concern. I’m not all that concerned about whether it comes down or not. I do want it to go up. We talk about what we learned about the anxiety that gosh, you can push it up enough and you can handle a lot more than you thought you did. That would be our exposure. 

And then we would plan homework and then they would do that daily, hopefully. I have forms on my website that people can then send me their daily experience doing these exposures and I send them feedback on it, and that’s what we’re working on. We’re working on doing the thing that OCD doesn’t want you to do that you want to do, and then working on getting better and better at addressing all of the mental gymnastics in your head. 

Now, if somebody touches the doorknob and they’re like, “Okay, I can do this,” and then their anxiety comes up and comes back down and they can do it without saying anything, great, go touch doorknobs. You don’t need to do scripting. Often, I don’t know if somebody needs to do that until we start working on it. If they don’t need to do the scripting, great. We don’t do the scripting. Makes things easier. But often people do need to. That’s generally how I do it. Obviously, lots of variations on that based on what the client is experiencing. 

Kimberley: This is all thing, you’re not writing it down. Again, when you go back to our original training, for me, it was a worksheet and you print it out, you’d fill out the prompts. Are you doing any of this written or is this a counter to the mental compulsions in your head?

Shala: None of this is written. The only time I would write it out is after that first session. When you’re really anxious, your prefrontal cortex isn’t working all that well, so you may have trouble remembering what we did, remembering the specific things that we said, or pulling it up for yourself. When you’re doing your exposure, you’re so anxious. I might type out some of what we said, the main things, send it to the clients, and have that. But really to me, scripting is an interactive exercise and I want my clients to be listening to what the OCD is saying for the sole purpose of knowing what we’re going to say. Because when we start doing exposure, what we’re often trying to do is keep pace with the OCD because it’s got a little imagination engine running and it’s going to go crazy with all the things that it’s going to come up with. We’re trying to stay on that level and make sure we’re meeting all its imagination with our own imagination.

As we get better and better at this, then I’m teaching people how to one-up the OCD and how to get better than the OCD as it goes along. But it’s a dynamic process. I don’t have people read scripts because the script that we wrote was for what was going on whenever we wrote the script. Different things might be going on this time. What we’re trying to do is listen to the OCD in a different way. I don’t want people listening to it in a compulsive way. I want people listening to it in a, “I’ve got to understand my foe here and what my foe is upset about so I can use it against it.” That’s what we’re doing. There might be key things, little pieces we write down, but I’m not having people write and read it over and over. Now, there’s nothing wrong with that. It’s just not what I do. Everybody has a different way to approach this. This is just my way. 

Kimberley: Right. I was thinking as you were talking, in ERP School, I talk about the game of one-up and I actually do that game with clients before I do any scripting or imaginals or exposures too. They tell me what their fear is, I try and make it worse. And then I ask them to make it even worse, then I make it even worse, because I’m trying to model to them like, we’re going here. We’re going to go all the way and even beyond. If we can get ahead of OCD and get even more creative, that’s better. 

Let’s play it back and forward. You talked about touching a doorknob and all of the catastrophic things that can happen there. What about if someone were to say their thoughts are about harming somebody and they have this feeling of like, I’ve been trained, society has trained me not to have thoughts about harming people or sexual thoughts and so forth? There’s this societal OCD stigmatizing like we don’t think those things. We should be practicing not thinking those things. What would you give as advice to somebody in that situation? 

Shala: I would talk a lot about the science about our thoughts, that the more that you try to push a thought away, the more it’s going to be there. Because every time you push a thought away, your brain puts a post-it note on it that says, “Ooh, she pushed this thought away. This must be dangerous. Therefore, I need to bring it up again to make sure we solve it.” Because humans’ competitive advantage—we don’t have fur, we don’t have fangs, we don’t have claws, we don’t run very fast—our competitive advantage is problem-solving. The way we stay alive is for cave people looking out onto savannah and we can see that there are berries here, there, and yawn. But that one berry patch over there, gosh, you saw something waving in the grass by it and you’re like, “I’m going to notice that and I’m going to remember that because that was different, but I also don’t want to go over there.” Your brain is going to remember that like, “Hmm, there was something about that berry patch over there. Grass waving could be a tiger. We need to remember that. Remember that thing, we’re not going to go over there.” We’re interacting with thoughts in that way because that’s what kept us alive. 

When we get an intrusive thought nowadays and we go, “Ooh, that was a bad thought. I don’t know. I should stay away from that,” our brain is like, “Oh, post a note on that one. That one is like the scary tiger thought. We’re going to bring that up again just to make sure.” Every time we try to push a thought away, we’re going to make it come back. We talk a lot about that. We talk a lot about society’s norms are whatever they are, but a lot of society’s norms are great in principle, not that awesome in practice. We don’t have any control over what we think about. The TV is filled with sex and gore, and violence. Of course, you’re thinking those things. You can’t get away from those images. I think society has very paradoxically conflicting rules about this stuff. Don’t think about it but also watch our TV show about it. 

I would talk about that to try to help people recognize that these standards and rules that we put on ourselves as humans are often unrealistic and shame-inducing and to help people recognize that everybody has these thoughts. We have 40, 60, 80,000 thoughts a day. I got that number at some conference somewhere years ago. We don’t have control over those. I would really help them understand the process of what’s going on in their brain to destigmatize it by helping them understand really thoughts are chemical, neuronal, whatever impulses in our brain. We don’t have a lot of control over that and we need to deal with them in a way that our brain understands and recognizes. We need to have those thoughts be present and have a different reaction to those thoughts so your brain eventually takes the post-it note off of them and just lets them cycle through like all the other thoughts because it recognizes it’s not dangerous. 

HOW FAR CAN YOU GO IN ER SCRIPTING? 

Kimberley: Right. I agree. But how far can you go in ERP Scripting? Let’s push a little harder then. This just happened recently actually. I was doing a session with a client and he was having some sexual pedophilia OCD obsessions playing up, “I’ll do this to this person,” as you were doing like I may or may not statements and so forth. And then we played with the idea of doing one up. I actually went to use some very graphic words and his face dropped. It wasn’t a drop of shock in terms of like, “Oh my gosh, Kimberley used that naughty word.” It was more of like, “Oh, you are in my brain, you know what I’m thinking.” And then I had to slow down and ask him, “Are there any thoughts you actually aren’t admitting to having?” Because I could see he was going at 80% of where OCD took him, but he was really holding back with the really graphic, very sexual words—words that societally we may actually encourage our children and our men and women not to say. Do you encourage them to be using the graphic language that their OCD is coming up with?

Shala: Absolutely. I’m personally a big swearer.  That’s another thing I talk about in--

Kimberley: Potty mouth.

Shala: I’ll ask clients, “What’s your favorite swear word? Let’s throw swear words in here.” I want to use the language that their OCD is using. If I can tell that’s the language their OCD is using, well, let’s use that language. Let’s not be afraid of it. 

The other thing I do before I start ERP with anyone is I go through what I consider the three risks of ERP so they understand that what happens during our experience together is normal. I explain that it’s likely we’re going to make their anxiety worse in the weeks following exposure because we’re taking away the compulsions bit by bit, and the compulsions are artificially holding back the anxiety. I explained that their OCD is not going to roll over because they’re doing ERP therapy now. Nobody’s OCD is going to go, “Oh gosh, Shala is in ERP. I think I’ll just leave her alone now.” No, the OCD is going to ratchet it up. You’re not doing what you’re supposed to do, you’re not doing your compulsions, so let’s make things scarier. Let’s make things more compelling. Let me be louder. Your OCD can get quite a bit worse once you start doing ERP because it’s trying to get you back in line. When somebody is in an exposure session and their OCD is actually going places, they never even expected them to go, and I’ll say that’s what we’re talking about, “That’s just the OCD getting worse, that’s what we wanted. This is what we knew was going to happen.” We’re going to use that against the OCD to help normalize it.

Then I also explain to people that people with OCD don’t like negative emotions more than your average bear, and we tend to press all the negative emotions down under the anxiety. When you start letting the anxiety out and not doing compulsions, then you can also get a lot more emotions than you’re used to experiencing so that people recognize if they cry during the exposures, if it’s a lot scarier than they thought, if they have regret or guilt or other feelings, that’s just a normal part of it. I explain all that. When things inevitably go places where the client isn’t anticipating they’re going to go like in a first exposure, then they feel this is just part of the process. I think it makes it so that it’s easier to go those graphic places because you’re like, “Yeah, we expected OCD to go the graphic place because it’s mad at you.”

Kimberley: It normalizes it, doesn’t it? 

Shala: Yeah. Then we go to the graphic place too. I tell clients that specifically because this is a game and I really want them to understand this is what your opponent is likely to do so that they feel empowered so we can go there too and trying some to take the shame out of it. When you said the graphic word and your client had a look on their face and it was because how did you even know that was in my head, because you were validating that it’s okay to have this thought because you knew it was going to be there. I think that’s a really important part of exposure too.

HOW LONG DO YOU USE ERP SCRIPTING FOR? 

Kimberley: So, how long do you do ERP Scripting for? Let’s say they’re doing this in your session or they’re at home doing their assigned homework. Let’s say they do it for a certain amount of time and then they have to get back to work or they’re going to do something. But those voices, the OCD comes back with a vengeance. What would you have them do after that period of time? Would they continue with this action or is there a transition action or activity you would have them do?

Shala: That’s a great question. It depends a lot on really the stage of therapy that somebody is in and what is available to them based on what they’re going to be doing. Oftentimes, what I will ask people to do is to try to do the exposure for long enough that you’ve done enough response prevention that you can then leave the exposure environment and not be up in your head compulsively ruminating. Because if you were doing exposure for 20 minutes, you’ve done a great job, but then you leave that exposure and you are at a high enough anxiety level where it feels compelling. Now you have to fix the problem in your head even though you just did this great exposure. Then we’re just going to undo the work you just did. I try to help people plan as much as they can to not get themselves in a situation where they’re going to end up compulsively ruminating or doing other compulsions after they finish. But obviously, we can’t be perfect. Life happens. 

I think some of the ways you can deal with that, if you know it’s going to happen, sometimes they’ll ask people to make recordings on their phone and they just put in their earpieces or their earbuds or whatever and they can just listen to a script while they’re doing whatever they’re doing. Nobody has to know what they’re doing because so many people walk around with EarPods in their ears all the time anyway. That’s one way to deal with it. 

Another way to deal with it is to try to do the murmuring out in your head as best as you can. That’s really hard because they’re likely to just get mixed up with compulsive thoughts. You can try to focus your attention as much as you possibly can on what you’re doing. That’s going to be the strongest response. It’s hard for people though when they get started to do that. But if you can do that, I think that’s fine, and I think just being compassionate with yourself. “Okay, so I am now sitting here doing some rituals in my head. I’m doing the best I can.” If you’re not in a situation where you can fully implement response prevention in your head because you’re in a meeting and you got to do other stuff and you’ve got this compulsive stuff running in the background, just do the best you can. And then when you’re at a place where you can do some scripting, some more exposure to get yourself back on top of the OCD, then do that. But be really compassionate. 

I try to stress this to all my clients. We are not trying to do ERP perfectly because if you try to do it perfectly, you’re doing ERP in an OCD way, which isn’t going to work. Just be kind to yourself and recognize this is hard and nobody is going to do it perfectly. If you end up in a situation where you end up doing some compulsions afterwards, well, that’s good information for us. We’ll try to do it differently or better next time, but don’t beat yourself up.  

Kimberley: It’s funny you brought that up because I was just about to ask you that question. Often clients will do their scripting or their imaginal and then they have an obsession, “What if I keep doing compulsions and it’s not good to do compulsions?” Would you do scripting for that?

Shala: Oh yeah. I may or may not do more compulsions than I used to be doing. I may or may not get really worse doing this. I may or may not have double the OCD that I had when I started seeing trauma. This may or may not become so bad that they have to create a hospital just to help me all by myself. We try to just create stuff to deal with that. But also, I’m injecting one up in the OCD, I’m injecting some humor, how outlandish can we make these things? I try to have “fun” with it. Now I say “fun” in quotes because I know it’s not necessarily fun when you’re trying to do this, but we’re trying to make this content that OCD is turning into a scary story. We’re trying to make it into a weapon to use against the OCD and to make this into a game as much as we can.

Kimberley: I love it. I’m so grateful for you coming on. Is there anything that you want the listeners to know as a final piece for this work that you’re doing?

Shala: Sure. I think that there are so many different ways to do exposure therapy. This is the way that I do it. It’s not the only way, it’s not necessarily the right way; it’s just the way I do it and it’s changed over the years. If we were to record this podcast in five years or 10 years, I probably will be doing something slightly different. If your therapist is doing something differently or you’re doing something differently, it’s totally fine. I think that finding ERP in a way that works for you, like finding how it works for you and what works best for you is the most important thing. It’s not going to be the same for everybody. Everybody has a slightly different approach and that’s okay. 

One thing that people with OCD can get stuck on, and I know this because I have OCD too, is we can be black and white and say there’s one right way. Well, she does it this way and he does it that way and this is wrong and this is right. No, if you’re doing ERP, there are all sorts of ways to do it, so don’t let your OCD get into the, “Well, I don’t think you’re doing this right because you’re not doing this, that, or the other.” Just work with your therapist to find out what works best for you. If what I’ve described works well for you, great. And if it doesn’t, you don’t have to do it. These are just ideas. Being really kind and being really open to figuring out what works best for you and being very kind to yourself I think is most important.

Kimberley: Amazing. Tell us where people can get more information about you. Tell us about your book. I know you’ve been on the podcast before, but tell us where they can get hold of you.

Shala: Sure. They can get a hold of me on my website, ShalaNicely.com. I have a newsletter I send out once a month that they can sign up for called Shoulders Back! Tips & Resources for Taming OCD. In it, I feature blogs that I write or podcast episodes, other things that I’m doing. It’s all free where I’m talking about tips and resources for taming OCD. I have two books: Everyday Mindfulness for OCD that I co-wrote with Jon Hershfield and Is Fred in the Refrigerator? Taming OCD and Reclaiming My Life, which is my memoir. It is written somewhat like a suspense novel because as all of you know who have OCD, living with untreated OCD is a bit like living in a suspense novel. My OCD is actually a character in the book. It is the villain, so to speak. The whole book is about me trying to understand exactly what is this villain I’m working against. Then once I figure out what it is, well, how am I going to beat it? And then how am I going to live with it long term? Because it’s not like you’re going to kill the villain in this book. The OCD is going to be there. How do I learn to live in a world of uncertainty and be happy anyway, which is something that I stole from Jon Grayson years ago. I stole a lot from him. That’s what the book is about.

Kimberley: It’s a beautiful book and it’s so inspiring. It’s a handbook as much as it is a memoir, so I’m so grateful that you wrote it. It’s such a great resource for people with OCD and for family members I think who don’t really get what it’s like to be in the head of someone with OCD. A lot of my client’s family members said how it was actually the first time it clicked for them of like, “Oh, I get it now. That’s what they’re going through.” I just wanted to share that. Thank you so much for being on the show. I’m so grateful to have you on again.

Shala: Thank you so much for having me. It was fun.

Welcome back, everybody. Thank you for joining me again this week. I’m actually really excited to dive into another topic that I really felt was important that we address. For those of you who are new, this actually might be a very steep learning curve because we are specifically talking about a treatment skill or a tool that we commonly use in CBT (Cognitive Behavioral Therapy) and even more specifically, Exposure and Response Prevention. And that is the use of imaginals or what we otherwise call scripts. Some people also use flooding. 

We are going to talk about this because there are a couple of reasons. Number one, for those of you who don’t know, I have an online course called ERP School. In ERP School, it’s for people with OCD, and we talk about how to really get an ERP plan for yourself. It’s not therapy; it’s a course that I created for those who don’t have access to therapy or are not yet ready to dive into therapy, where they can really learn how to understand the cycle of OCD, how to get themselves out of it, and gives you a bunch of skills that you can go and try. Very commonly, we have questions about how to use imaginals and scripts, when to use them, how often to use them, when to stop using them, when they become compulsive and so forth. 

In addition to that, as many of you may not know, I have nine highly skilled licensed therapists who work for me in the state of California and Arizona, where we treat face-to-face clients. We’re actually in Los Angeles. We treat patients with anxiety disorders. I also notice that during my supervision when I’m with my staff, they have questions about how to use imaginals and scripts with the specific clients. Instead of just teaching them and teaching my students, I thought this was another wonderful opportunity to help teach you as well how to use imaginals and why some people misuse imaginals or how they misuse it. I think even in the OCD community, there has been a little bit of a bad rap on using scripts and imaginals, and I have found using scripts and imaginals to be one of the most helpful tools for clients and give them really great success with their anxiety and uncertainty and their intrusive thoughts. 

Here we are today, it is again a start of another very short series. This is just a three-week series, talking about different ways we can approach imaginals and scripts and how you can use it to help manage your intrusive thoughts, and how you can use it to reduce your compulsions. 

It is going to be three weeks, as I said. Today, we are starting off with the amazing Krista Reed. She’s been on the show before and she was actually the one who inspired this after we did the last episode together. She said, “I would love to talk more about imaginals and scripts.” I was like, “Actually, I would too, and I actually would love to get some different perspectives.”

Today, we’re talking with Krista Reed. Next week, we have the amazing Shala Nicely. You guys already know about Shala Nicely. I’m so happy to have her very individual approach, which I use all the time as well. And then finally, we have Dr. Jon Grayson coming in, talking about acceptance with imaginals and scripts. He does a lot of work with imaginals and scripts using acceptance, and I wanted to make sure we rounded it out with his perspective. 

One thing I want you to think about as we move into this series or three-part episode of the podcast is these are approaches that you should try and experiment with and take what you need. I have found that some scripts work really well with some clients and others don’t work so well with other clients. I have found that some scripts do really well with one specific obsession, and that doesn’t do a lot of impact on another obsession that they may have. I want you just to be curious and open and be ready to learn and take what works for you because I think all of these approaches are incredibly powerful. 

Again, in ERP School, we have specific training on how to do three different types of scripts. One is an uncertainty script, one is a worst-case scenario script, and the last is an acceptance script. If you’re really wanting to learn a very structured way of doing these, head on over to CBTSchool.com and you can sign up for ERP School there. But I hope this gets you familiar with it and helps really answer any questions that you may have. 

Alright, let’s get over to the show. Here is Krista Reed.

Kimberley: Welcome back, Krista Reed. I am so happy to have you back on the show.

Krista: Thank you. I am elated to be able to chat with you again. This is going to be great.

Kimberley: Yeah. The cool thing is you are the inspiration for this series.

Krista: Which is so flattering. Thank you. 

IMAGINAL OR SCRIPT?

Kimberley: After our last episode, Krista and I were having a whole conversation and you were saying how much you love this topic. I was like, “Light bulb, this is what we need to do,” because I think the beautiful piece of this is there are different ways in which you can do imaginals, and I wanted to have some people come on and just share how they’re doing it. You can compare and contrast and see what works for you. That being said, number one, do you call it an imaginal, do you call it a script, do you think they’re the same thing, or do you consider them different?

Krista: I do consider them differently because when I think about script, I mean, just the word script is it’s writing, it’s handwriting in my opinion. I mean, scripture is spoken. That’s something a little bit different, but scripting is writing. When I think of an imaginal, that is your imagination. I know that I already shared with you how much I love imaginals because in reality, humans communicate through stories. When we can, using our own imagination, create a story to combat something as challenging as OCD, what a powerful concept. That’s exactly why I just simply love imaginals.

Kimberley: I can feel it and I do too. There’s such an important piece of ERP or OCD recovery or anxiety recovery where it fills in some gaps, right?

Krista: Yes, because imaginals, the whole point, as we know, it’s to imagine the feared object or situation. It could evoke distress, anxiety, disgust. Yet, by us telling those stories, we’re poking the bear of OCD. We’re getting to some of that nitty gritty. Of course, as we know that, not every obsession we can have a real-life or an in vivo exposure. We just simply can’t because of the laws of science, or let’s be real, it might be illegal. But imaginals are also nice for some people that the real-life exposure maybe is too intense and they need a little bit of a warmup or a buy-in to be able to do the in vivo exposure. Imaginal, man, I freaking love them. They’re great. 

Kimberley: They’re the bomb. 

Krista: They really are. 

HOW TO DO IMAGINALS FOR OCD

Kimberley: You inspired this. You had said, “I love to walk your listeners through how to do them effectively. I think I remember you saying, but correct me if I’m wrong, that you had seen some people do them very incorrectly. That you were very passionate because of the fact that some people weren’t being trained well in this. Is that true or did I get that wrong?

Krista: No, you absolutely got it right. Correct and incorrect, I think maybe that is opinion. I’ll say that in my way, I don’t do it that way. That’s a preference. But this is an inception. We’re not putting stories into our clients’ minds. The OCD is putting these stories into our clients’ minds. If you already have a written-out idea of a script, of like fill in the blanks, you are working on some kind of inception, in my opinion. You are saying that this is how your story is supposed to be. That’s so silly. I’m not going to tell you how your story is supposed to be. I don’t know how your imagination works. When we think of just imagination, there’s so many different levels of imagination. 

Let’s say for instance, if I have somebody who comes into my office who is by trade a creative writer, that imaginal is probably going to be very descriptive, have a lot of heavy adjectives. Just the way it’s going to be put together is going to be probably like an art in itself because this is what that person does. If you have somebody who comes in and creativity is not something that is part of a personality trait, and then I have a written fill-in-the-blank thing for them, it’s not going to be authentic for their experience. They’re going to potentially want to do what I, the therapist, might want them to do. It’s not for me to decide how creative or how deep that person is to go. They need to recognize within themselves, is this the most challenging? Is this the best way that you could actually describe that situation? If that answer is yes, it’s my job as a therapist to just say okay.

Kimberley: How would one know if it’s the most descriptive they could be? Is it by just listening to what OCD has to say and letting OCD write the story, but not in a compulsive way? Share with me your thoughts. 

Krista: I think that that’s almost like a double-edged sword because that of itself can almost go meta. How do I know that my story is intense enough? Well, on the surface we can say, “Is it a hard thing to say.” They might say yes, and then we can work through. But if I’m really assessing like, “Is it hard enough, is it hard enough,” and almost begging for them to provide some type of self-reassurance, they might get stuck in that cycle of, is this good enough? Is this good enough? Can it be even more challenging? 

Another thing I love about imaginals is the limit doesn’t exist, because the limit is just however far your imagination can take you. Let’s say that I have a session with a client today and they’re creating an imaginal. I’m just going to give a totally random obsession. Maybe their obsession is, “I am afraid that I’m going to murder my husband in his sleep,” harm OCD type stuff, pretty common stuff that we do with imaginals. They do the imaginal and they’re able in session to work through it. It sounds like it was good. In the session, what they provided was satisfactory to treatment. And then they come back and say, “I got bored with the story,” which a lot of people think that that’s a bad thing. That’s actually a good thing because that’s letting you know that you’re not in OCD’s control of that feared response and you’re actually doing the work. However, they might still have the obsession. I was like, “Okay, so you were able to work through this habituate or get bored of that. Now, let’s create another imaginal with this obsession.” Because it’s all imagination, the stories, you can create as many as you possibly can or as you possibly want to. 

I’m actually going to give you a quote. He’s a current professor right now at Harvard. He is a professor of Cognitive and Educational Studies. If you look this guy up, his name is Dr. Howard Gardner—his work is brilliant. He has this fantastic quote that I think is just a bomb when it comes to imaginal stuff. His quote is: “Stories constitute the single most powerful weapon in a leader’s arsenal.” Think about that. What a powerful statement that is. Isn’t that just fantastic? Because we can hear that as the stories OCD tells us as being hard. Okay, cool story, bro, that is your weapon OCD, but guess what? I’m smarter than you and I brought a way bigger gun and this gun isn’t imaginal and I’m going to go ahead and one up you. If I come back that next week in my therapist’s office and I’m able to get bored with that, I can make a bigger gun.

Kimberley: I love that. It’s true, isn’t it? I often will say, “That’s a good story. Let me show you what I’ve got.” It is so powerful. Oh my gosh. Let’s actually do it. Can you walk us through how you would do an imaginal?

Krista: This is actually something that I created on my own taken from just multiple trainings and ERP learning about imaginals, because one of the things that I was realizing that a lot of clients were really struggling with is almost over-preparing just to do the imaginal. Sometimes they would write out the imaginal and then we would work through that. But what I was finding is sometimes clients were almost too fixated on words, reading it right, being perfect, that they were almost missing out on the fact that these are supposed to be movies in our mind.

Kimberley: Yeah. They intellectualize it.

Krista: Exactly. I created a super simple format. I mean, we really don’t have a lot of setup here. It’s basically along the lines of the Five Ws. What is your obsession and what is your compulsion? Who is going to be in your story? Who is involved? Where is your story taking place? When is your story taking place? And when is already one of those that’s already set because I tell people we can’t do anything in the past; the past has already existed. You really need to be as present as possible. But the thing is that you can also think. For instance, if my obsession is I’m going to murder my husband in his sleep tonight, part of that might be tonight, but part of that might also be, what is going to be my consequence? What is that bad thing that’s going to happen? Because maybe the bad thing isn’t necessarily right now. Maybe that bad thing is going to be I’m not going to have a relationship with my children and what if they have grandchildren? Or what if I’m going to go to hell? That might not necessarily exist in the here and now, but you’re able to incorporate that in the story. When is an interesting thing, but again, never in the past, needs to start in the present, and then move forward. 

And then also, I ask how. How is where I want people to be as descriptive as possible. For instance, if I say, and this is going to sound gritty, you’re fearful that you’re going to murder your husband tonight. Be specific. How are you going to murder your husband? Because that’s one of the things that OCD might want us to do. Maybe it is just hard enough to say, “I’m going to murder my husband.” But again, we’re packing an arsenal here. Do you want to just say that? Because I can almost guarantee you OCD is already telling you multiple different ways that it might happen. Which one of those seems like it might be the hardest? Well, the hardest one for me is smothering my husband with a pillow. Okay, that’s going to be it. That’s literally my setup. That’s literally my setup, is I say that.

Actually, I have one more thing that I have to include. I have all that as a setup and then I say, “Okay, at the very end, you are going to say this line, and it’s, ‘All of this happened because I did not do the compulsion.’” If I were going along with the story of I murdered my husband, I suffocated him with a pillow, and in my mind, the worst thing to happen is I don’t have a relationship with my kids and grandchildren, and the compulsion might be to pray—I’ll just throw that out—the last line might be, “And now, I don’t have a relationship with my children or grandchildren all because I decided to not pray when the thought of murdering my husband came up in my mind.” That is the entire setup. 

And then I have my clients get their phones out and push record. They don’t have to do a video, just an audio is perfectly fine. I know some therapists that’ll do it just once, but I actually do it over and over again. Sometimes it could be a five-minute recording, it could be a 20-minute recording, it could be a 40-minute recording. The reason for that being is if we stop just after one, we might be creating accommodation for that client, because I want my clients to be in that experience. That first time they tell that story after that very brief setup, they’re still piecing together the story. Honestly, it’s really not until about the third or fourth time that they’ve repeated that exact same story that they’re really in it. I am just there and every time they finish—I’ll know they finish because they say, “And this happened all because da da da da da”—I say, “Okay, what’s your number?” That means what’s your SUDS? And they tell me they’re SUDS. I might make a little bit, very, very minimal recommendations. For instance, if they say, “I murdered my husband,” I say, “Okay, so this time I want you to tell me how you murdered your husband.” Again, they say the exact same story, closing their eyes all over again, this time adding in the little bit that I asked for. We do that over and over and over again until we reach 50% habituation. Then they stop recording. That is what they use throughout the week as their homework, and you can add it in so many different ways. 

Again, keeping along with this obsession of “I’m afraid I’m going to kill my husband tonight,” I want you to listen to that with, as you probably have heard this as well, just one AirPod in, earbud, whatever, keep your other ear outside to the world. This is its way to talk back to OCD. Just something along the lines of that. I want you to the “while you’re getting ready for bed.” Because if the fear exists at night and your compulsions exist at night, I want you to listen to that story before you go to bed. It’s already on your mind. You’re already in it, you’re already poking the bear of OCD. It’s like, “Okay, OCD, you’re going to tell me I’m going to kill my husband tonight? Well, I’m going to hear a story about me killing my husband tonight.” Guess what? The bad thing’s going to happen over and over and over again. 

It’s such a powerful, powerful, powerful thing. Because it’s recorded, you can literally listen to it in your car. You can listen to it on a plane. You can listen to it in a waiting room. I mean, there’s no limit. 

Kimberley: It’s funny because, for those of you who are on social media, there was this really big trend not long ago where they’re like what they think I’m listening to versus what I’m actually listening to, and they have this audio of like, “And then she stabbed her with the knife.” It’s exactly that. Everyone thinks you’re just listening to Britney Spears, but you’re listening to your exposure and it’s so effective. It’s so, so effective. I love this. Okay, let’s do it again because I want this to be as powerful as possible. You did a harm exposure. In other episodes, we’ve done a relationship one, we’ve done a pedophile one. Let’s pick another one. Do you have any ideas? 

Krista: What about scrupulosity?

Kimberley: I was just going to say, what about scrupulosity?

Krista: That one is such a common one for imaginals. We hear it very frequently, “I’m going to go to hell,” or even thinking about different other religions like, “Maybe I’m not going to be reincarnated into something that has meaning,” or “It’s going to be a bad thing. Maybe I’m insulting my ancestors,” or just whatever that might be. Let’s say the obsession is—I already mentioned praying—maybe if I don’t read the Bible correctly, I’m going to go to hell. I don’t know. Something along the lines of that. If that’s their obsession, chances are, there’s probably somebody that maybe they have a time where they’re reading the Bible or maybe that we have to add in an in vivo where they’re going to be reading or something like that. A setup could potentially be, what is your obsession? “I’m afraid that any time I read my Bible, I’m not reading it correctly and I’m going to go to hell.” What is your compulsion? “Well, my compulsion is I read it over and over and over again and I reassure myself that I understand it, I’m reading it correctly.” Who’s going to be in your story? This one you might hear just, “Oh, it’s just me.” Really, OCD doesn’t necessarily care too much if anybody else is in this story. Where are you? “I’m in my living room. It’s nighttime. That’s when I read my Bible.” When is this taking place? “Oh, we can do it tonight.” Let’s say it’s tonight. 

Interestingly enough, when you have stuff that’s going to go to hell, that means, well, how are you getting to hell to begin with? Because that’s not just something that can happen. Sometimes in these imaginals, the person has to die in order to get there, or they have to create some type of fantastical way of them getting to hell. 

I actually had a situation, this was several years ago, where the person was like, “Well, death doesn’t scare me, but going to hell scares me,” because, in some cultures and some religions, it’s believed that there are demons living amongst us and so forth. “It’s really scary to think about, what if a demon approaches me and takes me immediately to hell and I don’t get to say goodbye to my family, my family doesn’t know.” Just even like that thought. We were able to incorporate something very similar to that. 

Just to make up an imaginal on the spot, it could be, I’m reading my Bible. I’m in my living room, I’m reading my Bible, and the thought pops up in my brain of, did you read that last verse correctly? I decide to just move on and not worry about reading my Bible correctly. Well then, all of a sudden, I get a knock at the door and there’s these strange men that I’ve never seen in my life, and they tell me that they’re all demons, and that because I didn’t review the Bible correctly, I’m going to go to hell. I would go on and on and probably describe a little bit more about my family not missing me, I don’t get to see my kids grow up, I don’t get to experience life, the travel, and the stuff that’s really important to me, incorporate some of those values. I don’t get to live my value-based life. And then at the very end, I was summoned and taken to hell by demons, all because I had the thought of reading my bible correctly and I decided not to.”

Kimberley: I love it, and I love what I will point out. I think you use the same model as me. We use a lot of “I” statements like “I did this and I did that, and then this happened and then I died,” and so forth. The other thing that we do is always have it in present tense. Instead of going, “And then this happens, and then that happens,” you’re saying as if it’s happening.

Krista: Yeah. Because you want it to feel real to the person. In all honesty, and I wonder what your experience has been, I find some of the most difficult people to do imaginals with our children. Even though you would think, “Oh, they’re so imaginative anyways,” one of the biggest things I really have to remind kids is, I want you to be literally imagining yourself in that moment. Again, I see this with kids more than adults, but I think it just depends on context and perspective. We’ll say, “Well, I know that I’m in my living room,” or “I know that I’m in your office, so this isn’t actually happening to me in this moment.” You almost have to really work them up and figure out, what’s the barrier here? What are you resisting?

Kimberley: That’s a good question. I would say 10 to 20% of clients of mine will report, “I don’t feel anything.” I’ll do a Q and A at the end of this series with common questions, but I’m curious to know what your response is to a client who reads like, “I kill my baby,” or “I hurt my mom,” or “I go to hell,” or “I cheat on my husband,” or whatever it is, but it doesn’t land. What are your thoughts on what to do then?

Krista: A couple of things pop up. One, it makes me wonder what mental compulsions they’re doing. And then it also makes me wonder, are we going in the right direction with the story? Because again, like I mentioned before, if a client comes back and they’ve habituated to one thing, but they’re still having the obsession, well, guess what? We’re just telling stories. Because the OCD narrative is typically not just laser-focused—I mean, it can be laser-focused, but usually, it has branches—you can pick and choose. I’m going to go ahead and guarantee, that person who is terrified of killing their husband ensure they’re not going to see their grandchildren and children. I’m going to go ahead and waiver that there’s probably other things that they’re afraid of missing. 

Kimberley: Yes. That’s what I find too, is maybe we haven’t gotten to the actual consequence that bothers them. I know when I’ve written these for myself, we tend to fall into normal traps of subtypes, like the fear that you’ll harm somebody or so forth. But often clients will reveal like, “I’m actually not so afraid that I’ll harm somebody. I’m really afraid of what my colleagues and family would think of me if I did.” So, we have to include that. Or “I’m afraid of having to make the call to my mom if I did the one thing.” I think that that’s a really important piece to it, is to really double down on the consequence. Do you agree?

Krista: Oh, I agree a hundred percent. You got to figure out what is that core fear. What are you really, really trying to avoid? With harming somebody, is it the consequences that might happen afterwards? Is it the feeling of potentially snapping or losing control? Or is it just knowing that you just flat out, took the life of somebody and that that was something that you were capable of? I mean, there’s so many different themes, looking at what does that feared self like, what does that look like, and maybe we didn’t hit it last time.

Kimberley: Right.

Krista: I know this is going to sound silly and I tell my clients this every once in a while, is I’m not a mind reader. What I’m asking you, is that the most challenging you can go and you’re telling me yes, I’m going to trust you. I tell them, if you are not pushing yourself in therapy to where you can grow, I’m still going to go to bed home and sleep tonight just fine. But I want you to also go home and go to bed and sleep just fine. But if you are not pushing yourself, because we know sleep gets affected super bad, not just sleep, but other areas, you’re probably going to struggle and you might even come back next week with a little bit more guilt or even some shame. I don’t want anybody to have that. I want people to win. I want people to do well in this. I know this stuff is scary, but I’m going to quote somebody. You might know her. Her name is Kimberley Quinlan. She says, “It’s a beautiful day to do hard things.” I like to quote her in my practice every once in a while. 

Kimberley: I love her. Yes, I agree with this. The way you explained it is so beautiful and it’s logical the way you’re explaining it too. It makes sense. I have one more question for you. Recently, I was doing some imaginals with a client and they were very embarrassed about the content of their thoughts. Ashamed and guilty, and horrified by their thoughts. I could see that they were having a hard time, so I gave them a little inch and I went first. I was like, “Alright, I’m going to make an assumption about what yours is just to break the ice.” They were like, “Oh yeah, that’s exactly what it is.” There was a relief on their face in that I had covered the bases. We did all of the imaginal and we recorded it and it was all set. And then at the end I said, “Is there anything that we didn’t include?” They reported, “Yeah, my OCD actually uses much more graphic words than what you use.” I think what was so interesting to me in that moment was, okay, I did them the favor by starting the conversation, but I think they felt that that’s as far as we could go. How far do you go?

Krista: As far as we need. 

Kimberley: Tell me what that means.

Krista: Like I mentioned before, the limit does not exist and I mean, the limit does not exist. This is going to sound so silly. I want you to be like a young Stephen King before he wrote his first novel and push it. Push it and then go there. Guess what? If that novel just doesn’t quite hit it, write another one, and then another one, and let’s see how far you can go. Because OCD is essentially a disorder of the imagination, and you get to take back your imagination by creating the stories that OCD is telling us and twisting it. I mean, what an amazing and powerful thing to be able to do. I’m sure you’re the same in that you know that there’s a lot of specialists that don’t believe in imaginals, don’t like imaginals, especially when it comes to issues with pedophilia OCD. I think we also need to not remind our clients because that would be reassurance, but to tell these specialists, we’re not putting anything into our client’s heads that aren’t there to begin with. Just like you said, if your client is thinking like real sick, nasty core, whatever, guess what? We’re going to be going there. Are you cutting off the heads of babies in your head? Well, we’re going to be talking about stories where you’re cutting off the heads of babies. If that’s what’s going on, we’re going to go there.

Kimberley: What’s really interesting, and this was the example, is we were talking about genitals and sexual organs and so forth. We’re using the politically correct term for them in the imaginal. Great. Such a great exposure. Vagina and penis, great. Until again, they were like, “But my OCD uses much more graphic words for them.” I’m like, “Well, we need to include those words.” Would you agree your imaginals don’t need to be PC?

Krista: I hope my clients watch this, and matter of fact, I’m going to send this to them, just to be like, no, no. Krista’s imaginals with her clients. Well, not my imaginals. Imaginals that are with my clients. Woah, sometimes I’m saying bye to my client. I’m like, “I think I need a shower.”

Kimberley: Again, when people say they don’t like imaginals or they think that it’s not a good practice, I feel like, like you said, if OCD is going to come up with it, it gives an opportunity to empower them, to get ahead of the game, to go there before it gets there so that you can go, “Okay, I can handle it.” I would often say to my clients, “Let’s go as far as we can go, as far as you can go, so that you know that there’s nothing it can come up with that you can’t handle.”

Krista: I think that where it gets even more complex is when we’re hitting some of the taboo stuff. Not only pedophilia, but something like right now that I’m seeing a lot more of in my office is stuff relating to cancel culture. This fear that what if I don’t use somebody’s pronouns correctly? What if I accidentally say an inappropriate racial slur? I will ask in session and I’ll be super real. It’s hard for me to hear this stuff because this goes outside of my values. Of course, it goes outside of their values. OCD knows that. That’s why it’s messing with them. I’ll say, “Okay, so what is the racial slur?” My clients are always like, “You really want me to say it?” I said, “We’re going to say it in the imaginal.” I realized how hard that is to stomach for therapists. But in my brain, the narrative that OCD is pushing, whether it is what society views as OCD or taboo OCD, it doesn’t matter. We still have to get it out. It is still hard for that client. If that’s hard for that client to think of an imaginal or a racial slur, it is almost the exact same amount of distress for somebody maybe with an imaginal that I’m afraid I’m getting food poisoning. 

We, as clinicians, just because we’re very caring and loving people, sometimes we can unintentionally put a hierarchy of distress upon our clients like, okay, I can do this imaginal because this falls with my values, but I don’t know if I can do this imaginal because pedophilia is something that’s hard for me to do and I don’t want to put my client through that. Well, guess what? Your client is already being put through that, whether you like it or not. It’s called OCD.

Kimberley: Right. Suppressing it makes it come on stronger anyway. Love that. I think that the beauty of that is there is a respectful value-based way of doing this work, but still getting ahead of OCD. Is that what you’re saying?

Krista: Absolutely. OCD tries to mess with us and think, what if you could be this person? Well, like I mentioned before, if a story is like a weapon, well, I’m going to tell a story to attack OCD because it’s already doing it to me.

Kimberley: Yeah. Tell us where people can hear more from you, get your resources because this is such great stuff.

Krista: Thank you. I’d say probably the best way to find me and my silly videos would be on my Instagram @anxiouslybalance.

Kimberley: Amazing. And your private practice?

Krista: My private practice, it’s A Peaceful Balance in Wichita, Kansas. The website is apbwichita.com.

Kimberley: Thank you so much. I’m very grateful for you for inspiring this whole series and for also being here as a big piece of the puzzle.

Krista: Thank you. I’m grateful for you that you don’t mind me just like this. I’m grateful for you for letting me talk even though clearly, I’m not very good at it right now. You’re amazing.

Kimberley: No, you’re amazing. Thank you. Really, these are hard topics. Just the fact that you can talk about it with such respect and grace and compassion and education and experience is gold. 

Krista: Thank you. At the end of the day, I really truly want people to get better. I know you truly want people to get better. Isn’t that just the goal?

Kimberley: Yeah. It’s beautiful. Krista: Thank you. 

Welcome back, everybody. Today, we are going to have a discussion, and yes, I understand that I am here recording on my own in my room by myself, so it’s not really a discussion. But I wanted to give you an inside look into a discussion I had, and include you hopefully, on Instagram about a post I made about being busy. 

Now, let me tell you a little bit of the backstory here. What we’re really looking at here is, is being busy a compulsion or an effective behavior? Here’s the backstory. I am an anxious person. Nice to meet you. Everybody knows it, I’m an anxious person. That’s what my natural default is. I have all the tools and practice using all the tools and continue to work on this as a process in my life. Not an end goal, but just a process that I’m always on, and I do feel like I handle it really, really well. In the grand scheme of things, of course, everyone makes mistakes and recovery is an up-and-down climb. We all know that. But one thing I have found over and over and over and over again is my inclination to rely on busyness to manage my anxiety. 

The reason I tell you this over and over is it’s a default to me. When I’m struggling with anything, I tend to busy myself. Even when I had the beginning of an eating disorder, that quickly became a compulsive exercise activity because trying to manage my eating disorder created a lot of anxiety, and one way I could avoid that anxiety and check the eating disorder box was to exercise, move my body. Even though I fully recovered from that, and even though I consider myself to be doing really well mentally overall, I still catch myself relying on work and busyness as a compulsion, as a safety behavior to reduce or remove or avoid my anxiety. 

I made a post on this and it had overwhelming positive responses. Meaning, I agree, there was a lot of like, “Oh, I feel called out or hashtag truth.” A lot of people were resonating with this idea that being busy can be a very sneaky compulsion that we do to run away from fear or uncertainty or discomfort or sadness and so forth. But then some of my followers, my wonderful followers came in hot—when I say “hot,” like really well—with this beautiful perspective on this topic and I really feel like it was valid and important for us to discuss here today.

Let’s talk about that, because I love a good discussion and I love seeing it from both sides. I love getting into the nitty gritty and determining what is what. Let’s talk about me just because it’s easy for me to use an example. Let’s say I have a thought or a feeling of anxiety. Something is bothering me. I’m having anticipatory anxiety or uncertainty about something. My brain wants to solve it, but because I have all these mindfulness tools and CBT tools, I know there’s no point in me trying to solve it. I know there’s no point in me ruminating on it. I’m not going to change it or figure it out. I have that awareness, so I go, “Okay, now I’m going to get back to life,” which is a really wonderful tool. But what I find that I do is I don’t just get back to life. I, with a sense of urgency, will start typing, cleaning, folding laundry, whatever it is, even reading. I will notice this shift in me to do it fast, to do it urgently, to try and get the discomfort to be masked, to be reduced. 

And then, of course, I want to share with you, what I then do is when I catch that is I go, “Okay.” I feel the rev inside me and then I ease up on it. I pump the brakes and I try to return back to that activity without that urgency, without that resistance to the anxiety, or without that hustle mentality. But it is a default that I go to that often I don’t catch until later on down the track. It’s usually until I start to feel a little dizzy, I feel a little lost, a little bit overwhelmed. And then I’m like, “Oh, okay, I’m overusing busyness to manage my anxiety.”

The perspective that I loved was people saying, and one in particular said, “I want us to be really careful around that message because I think that some people can hear this idea that being busy is a compulsion and then start to question their own normal busyness throughout the day.” I’ll use the exact terms because I thought it was so beautifully said. They said, “You have to be pretty careful with how you explain this to some people with OCD because we’re told to lean into our values or live a ‘value-based’ life, and that does require us to be busy,” and I wholeheartedly agree. 

I think that’s where I’m coming from. I want to offer to you guys that I want you to just check in and see if you’re using busyness, this urgent, rushing movement, or frantic experience in your body to avoid discomfort. And if so, that’s good to know. Let’s not judge that. Let’s not beat you up. Let’s not be unkind. Let’s just acknowledge that that is a normal response to having anxiety. In fact, it’s a big part of what’s kept us alive for all these years. That’s true. And we can return back. Once we catch that we’re doing those behaviors, we can return back to staying effective in our skills. But I don’t want you guys to worry that you are overusing busyness. 

I think that the discussion I had online was to say, isn’t this a wonderful opportunity for us to see how anxiety or OCD or any anxiety disorder can make a really healthy behavior into a compulsive behavior? You might flip between the two, it mightn’t be all or nothing. An example of that might be prayer. Prayer is a beautiful practice for those who are spiritual. However, we can sometimes overuse prayer in a compulsive manner in this urgent, frantic, trying to get anxiety to go away manner, and then it’s being misused. 

There may be sometimes you use prayer in this beautiful non-compulsive way and there’ll be other times when you’re absolutely using it as a safety behavior. Same goes for cleaning, same goes for thinking through your problems. There will be times when thinking through problems and solutions is a very effective behavior. However, there will be other times if you’re doing it with a sense of urgency to make the discomfort go away or you’re doing it to try and figure out something that you know you won’t figure out because there’s really no solution to it—that’s something for us to keep an eye out for.

There are so many ways in which this can get blurred. Asking for help and reassurance. It’s not a problem to go to your loved ones and say, “I have this really huge presentation at work, would you let me rehearse it to you and you can give me feedback?” That’s an effective behavior. However, if we are doing that repetitively and we are doing it coming from this desperate place of urgency to get certainty and removal of discomfort, that’s how we may determine whether the behavior is a safety behavior that we want to start to reduce.

I want to just offer this to you. If we’re being honest, this episode isn’t really about just the busyness. It’s being able to, again, for yourself, determine are the behaviors you’re doing being done because they line up with your values? Are they being done with a degree of willingness to also bring anxiety with you? I think that’s a huge piece of the work that I have to catch, which is, okay, I’m rushing, I’m hustling, I’m engaging in busyness just for the sake of trying to get rid of that discomfort. Can I pause and return back to that behavior? Because it might be a behavior or an activity I need to get done. But can I do it with an increased sense of willingness to bring anxiety along for the ride? Can I do it with a sense where I’m not trying to train my brain that anxiety is bad? Can I just say, “Yeah, it’s cool. Anxiety is here, let’s bring it along”? 

I want to, again, reinforce to you guys, it’s okay that you haven’t figured this out because it’s probably ever-changing. There will be times when you are engaging in compulsive busyness and there’ll be other many times in which you’re not. What I would encourage you to do is not to spend too much time trying to figure out which is which, because that can become a compulsion as well. A lot of this is just accepting that nothing is perfect and just moving one step at a time moving forward as you can kindly and compassionately. 

The only other thing I want to address here is this idea of a good distraction and a bad distraction. I think that this has been an argument or a complex discussion in the anxiety field for a long time. When I first was trained as an anxiety specialist, there were all these articles that talked about bad distraction, that distraction is bad and we shouldn’t do it, and we should just have our anxiety and let it be there and then focus on it and so forth. I actually don’t agree with that. In fact, I would go as far as to say, a real mindful practice would be taking the judgment out of destruction in general and saying that distraction is neither good nor bad. What distraction is, is up to you to decide whether it’s helping you and is helpful behavior that brings you closer to your recovery goals or not. I don’t want you to spend too much time trying to figure it out either, again, because I think it gets us caught in this mental loop of, am I doing recovery right? Am I doing my treatment right? Am I using the skills perfectly? 

I think when we get to that point, we’re too far in the weeds and we have to pause and let it be imperfect and let it be uncertain and do our best not to try and solve that one, because often how would we know? There isn’t actually an answer to what’s bad and what’s good. I wouldn’t encourage you to place good and bad labels on those kinds of things because that usually will just keep you in a loop of anxiety anyway. 

That’s just a few ideas on this idea of being overly busy being a compulsion. I really want to make sure I say one more time. I think there is absolutely an opportunity for us to consider that busyness is also neither good nor bad. It just is, and that you for yourself can determine whether it’s helpful for you to stay busy or not. What I will say—and I will use this as an example, I think I actually did a podcast episode on this—not long ago, my parents were voyaging across the Drake Passage, which is a very dangerous body of water that takes you from South America to Antarctica. It’s usually very, very calm or it can be incredibly dangerous to pass the Drake Passage. For the 18 hours that they were passing that, I engaged in a lot of busyness. I would say it wasn’t compulsive either. It was, I knew they were doing something scary. I knew that it would be probably fine, but it was still uncertain. I knew that there was nothing I would do to make my anxiety go down during that 18 hours. I knew I probably wouldn’t get a good sleep because I love them dearly and I want them to have a safe trip. I just said to myself, “I’m going to mindfully go from one activity to another. Because I don’t want to engage in a bunch of mental rumination, I’m just going to gently stay busy.” I think that’s fine. I think that that is effective. In fact, I was very proud of how I handled that. I was able to resist the urge to text them at two in the morning and be like, “Take a photo of the waves. I want to see that you’re okay.” You know what I mean? 

I want to just offer to you that to check in whether your busyness is compulsive, be gentle with yourself either way to discuss with your mental health provider on what is a great way for you to engage in this kind of behaviors and for you to come up with your own protocol on how to determine when you’ve crossed over from being busy into compulsive busyness. That’s it. I think that from there, you can be gentle with yourself and practice being uncertain about what’s right and wrong. 

I hope that was helpful. I’m very much just chatting to you. I didn’t do a whole ton of prep for this. I just wanted to include you in the conversation on “Is being overly busy a compulsion?” I wanted to give you some ideas and things to look out for and I hope that it helps you move forward towards the recovery that you’re looking for. Have a wonderful, wonderful day. If you guys want additional resources from me, you can head over to CBTSchool.com. We have all kinds of online options there for you. If you’re looking for one-on-one therapy, if you live in the state of California or Arizona, you can go to www.kimberleyquinlan-lmft.com and I look forward to chatting with you next week.

Hello and welcome back, everybody. We have an amazing guest today. This is actually somebody I have followed, sort of half known for a long time through a very, very close friend, Shala Nicely, who’s been on the show quite a few times, and she connected me with Dr. Ashley Smith. Today, we are talking about happiness and what makes a “good life” regardless of anxiety or of challenges you may be going through. 

Dr. Ashley Smith is a Licensed Clinical Psychologist. She’s the co-founder of Peak Mind, which is The Center for Psychological Strength. She’s a speaker, author, and entrepreneur. She has her own TED Talk, which I think really shows how epic and skilled she is. 

Today, we talk about how to be happy. What is happiness? How do you get there? Is it even attainable? What is the definition of happiness? Do we actually want it or is it the goal or is it not the goal? I think that this is an episode I needed to hear so much. In fact, since hearing this episode as we recorded it, I basically changed quite a few things. I will be honest with you, I didn’t actually change things related to me, but I changed things in relation to how I parented my children. I realized midway through this episode that I was pushing them into the hamster wheel of life. Ashley really helped me to acknowledge and understand that it’s not about success, it’s not about winning things, it’s not about achievement so much, while they are very important. She talks about these specific things that science and research have shown to actually improve happiness. 

I’m going to leave it at that. I’m going to go right over to the show. Thank you, Dr. Ashley Smith, for coming on. For those who want to know more about her, click the links in the show notes, and I cannot wait to listen back to this with you all. Have a great day, everybody. 

Kimberley: Welcome, Dr. Ashley Smith. I’m so happy to have you here.

Dr. Ashley: I am excited to be here today. I’ve wanted to be on your podcast for years, so thank you for this.

Kimberley: Same. Actually, we have joint friends and it’s so good when you meet people through people that you trust. I have actually followed you for a very long time. I’m very excited to have you on, particularly talking about what we’re talking about. It’s a topic we probably should visit more regularly here on the show. We had discussed the idea of happiness and what makes a good life. Can you give me a brief understanding of what that means or what your idea about that is?

Dr. Ashley: Yeah. Oh, this is a topic that I love to talk about. When I think about it, I have a little bit of a soapbox, which is that I think our approach to mental health is broken. I say that as someone who is a mental health practitioner, and I really love my job and I love working with people and helping. But what I mean by that is our traditional approach has been, “Let’s reduce symptoms. Let’s correct the stuff that’s ‘wrong’ with someone.” When it comes to anxiety or depression, it’s how do we reduce that? And that’s great. Those are really important skills, but we’ve got this whole other side that I think we need to be focusing on. And that is the question of how do we get more of the good stuff. More happiness, more well-being. How do we create lives that are worth living? That’s not the same as how do we get rid or reduce anxiety and depression.

In the field of psychology, there’s this branch of it called Positive Psychology. I stumbled on that 20 years ago as a grad student and thought, “This is amazing. People are actually studying happiness. There’s a science to this.” I looked at happiness and optimism and social anxiety and depression and how those were all connected. Fast forward, 15 years or so, I really hit a point with my professional life and my personal life where I was recognizing, “Wait a minute, I need more. I need more as an individual. The clients I work with need more. How do we get more of this good stuff?” This is the longest preamble to say, I did a deep dive into the science of happiness and learned a lot over the years, and I want to be really clear about a couple of things.

When we talk about happiness, a lot of people think pleasure. “I want good experiences, I want to enjoy this.” That’s a part of it, this positive emotion that we all call happiness or joy. But that’s only a piece of it. There’s actually this whole backfiring process that can happen when we chase that. If I’m just chasing the next pleasant event, what that actually does is set me up to not have a happy life. Think about it. I mean, I love chocolate, and if I eat that unchecked because it brings me pleasure, at some point, it’s going to take a toll on my health. What does that actually do to my well-being and happiness? 

What was really interesting getting into this area was, it’s not just this transient state of pleasure or enjoyment, but they’re the other factors that contribute to a good life. It’s things like relationships. It’s things like meaning and purpose. It’s engagement. It’s achievement even. It’s these things that are not always pleasant in the moment, but that really contribute to this sense of satisfaction with life or contentment with life. I think it’s really important that we need to be looking at what are the ingredients that really make a good life. 

WHAT IS CONSIDERED A GOOD LIFE? 

Kimberley: I love this, and I love a good recipe too. I like following recipes and ingredients. It’s funny, I’m actually in the process of getting good at cooking and I’m realizing for the first time in my life that following instructions and ingredients is actually a really important thing, because I’m not that person. First of all, what is a good life? When I looked at that, I actually put it in quote marks. What is a good life? What do you think? You explained it; it’s not chasing pleasure. We know that doesn’t work, otherwise, you just buy a bunch of stuff you don’t want and behave in ways that aren’t helpful. Not to also villainize pleasure, it’s a great thing, but what would you describe as a good life?

Dr. Ashley: On the one hand, it’s the million-dollar question. Philosophers and scientists and religious leaders and all kinds of people have been trying to answer that question for eons. I don’t know that I have it nailed down. I think I’m humble enough to say I have my own ideas about it. To me, what makes a good life, it’s really when the way we spend our time lines up with what’s important to us, when we’re living in accordance with our values to use some psych buzzwords, but when we’re doing the things that really matter. I think also part of a good life is having daily rhythms and lifestyle habits that support us as biological creatures. I want to contrast that with the demands of modern life, which are that we should be productive 24/7, that we should be multitasking. People sacrifice sleep and movement and leisure time and stillness. I think all of that compromises us. It impacts us on a neurological level. Our brains are part of our system. If we’re not taking care of our system, they’re not going to function optimally. That gets in the way of a good life. 

When we’re sacrificing relationships, when I look at all of the research, when I look at my own experience, a huge component of a good life is having quality relationships. Not quantity, quality. Trusting ones that are full of belonging and acceptance that are two-way support streets, those are really important. I think a lot of times, modern life compromises that. We get pulled in all of these other directions.

Kimberley: Yeah. Oh my gosh, there’s so many things. I also think that anxiety and depression pull us away from those things too. You are anxious or you’re depressed and so, therefore, you don’t go to the party or the family event or the church service. That’s an interesting idea. I love this. Tell us about this idea of meaning. How do we find meaning? I’ll just share with you a little bit of my own personal experience. I remember when I was actually going through a very difficult time with my chronic illness and I know I was depressed at the time. It was the first time in my life where I started to have thoughts like, “What’s the point?” Not that I was saying I was suicidal, but I was more like, “I just don’t understand why am I doing all this.” I think that that’s common. What are your thoughts on this idea of the meaning behind in life?

Dr. Ashley: That’s a fantastic question. I have a vision impairment, so I’m legally blind. It’s a really rare thing and it’s unpredictable. I don’t know how much sight I will lose. Ultimately, the doctors can’t tell me there’s no treatment options. It’s just I go along and every so often, there’s a shift and I see less. For me, I hit that same point you were talking about back in 2014 when I had to stop driving. I was anxious and I would say depressed and really wallowing in this, “What does this mean for my life? I can’t be independent. People aren’t going to associate with me personally or professionally when they see this flaw.” It was a dark point. For me, that’s when I went back to the science of happiness when I finally got tired of being stuck and I realized my anxiety skills and my depression skills. They’re helpful and I practice what I preach, but it wasn’t enough. And that’s really what propelled me back into this science of happiness where I figured, you know what, someone has to have done this. 

I did come across this theory of well-being called the PERMA factors. These are like the ingredients that we need. I’m getting back to that because the M in this is meaning. With this, the PERMA factors, P is positive emotion. That’s the pleasure, the joy, the happiness. Cool. I know some strategies for boosting that. E is engagement. Are you really involved and engaged in what you’re doing? Are you present? Are you hitting that state of flow? R is the relationships, A (skipping ahead) is achievement, but M is this meaning, and it’s a hard one to figure out. 

I remember then, this started what I was calling my blind quest for happiness where I started to think about, what do I need to do? How do I experiment? How do I live a happy life despite these cards I’ve been dealt? We don’t get to choose them. You’ve got a chronic illness, I have a vision impairment, listeners have anxiety and depression, and we get these cards. I think of it like if life is a poker game, we don’t get to choose the cards we’re dealt, but by golly, we get to choose how to play them, and that’s important. I think a lot of times people can turn adversity into meaning.

For me, I’m now at a point where it’s not that I don’t care about my vision, it’s just I really accepted it. It is what it is, it’s going to do what it’s going to do, and I’m focusing on the things I can control. That has given me a sense of meaning. I want to help other people live better lives. I want to help other people crack the code of how our brains work against us and how do we play our cards well.

If we go to all of this, “meaning” is really just finding something that’s bigger than you are, finding something to pursue or contribute to that’s bigger than you. I think when we look at anxiety and depression, the nature of those experiences is that they make us very self-involved. I mean, people with anxiety and depression, in my experience, have giant hearts, tons of empathy, but it locks our thinking into our experience and what’s going on in these unhelpful thoughts. 

When we can connect with something bigger than us, it gets us outside of that. 

If I go back to grad school, writing my dissertation was decidedly not a fun experience. Would I do it again? Yes. Because it was worth it on this path to my reason for being—helping people live better lives. Sometimes I think when we have this meaning, this purpose, this greater good, it helps us endure the things that I want to say suck.

Kimberley: You can say suck.

Dr. Ashley: Yeah. That’s where it’s not just about how do I get rid of anxiety or depression. Sometimes we can’t. Chronic health conditions, anxiety is chronic. My vision is chronic. I’m not getting rid of this, but how do I live a good life despite that? I think there are a ton of examples throughout history and currently of people doing amazing things despite some hardship. 

Kimberley: Yeah. I love this idea. It’s funny, you talk about being outside yourself. When I’m having a bad day, I usually go, there’s like a 10 minutes’ drive from us that looks over Los Angeles. If let’s say I’m having a day where I’m in my head only looking at my problems, and then I see LA, I’m like, “Oh honey, there is a whole world out there that you haven’t thought about.” I’m not saying that in a critical way, just like it gives me perspective.

Dr. Ashley: I think that’s so important, to realize there’s so much more. When it does shrink our problems, all of a sudden, it’s manageable.

Kimberley: Right. Let’s talk about just one more question about meaning. I’m guessing more about people finding what’s your why and so forth. What would you encourage for people who are very unhappy, have been chasing this idea of reducing anxiety, reducing depression, chasing pleasure, and feeling very stuck between those? Let’s say I really have no idea what my meaning is. What would be your advice to start that process? 

Dr. Ashley: Experimentation. I think experimenting is a lifestyle that I wish everyone would adopt, because what happens is we want to think. We are thinkers. That’s what our minds were designed to do. That’s awesome and sometimes it’s really helpful, but I don’t think we’re going to think our way into passion or meaning or a good life. I think we have to start trying things. What will happen, if you notice, is your mind is going to have a lot of commentary. It’s going to say, “That’s dumb. That’s not going to work. Who are you to try that? You can’t do that.” It’s all just noise that if we look at what is it doing, it’s keeping you stuck. With the experimentation, I’m just a big fan of go try it. Whether you think it’s going to work or not, you don’t know. We want to trust our experience, not what our mind tells us. Trust your actual experience. 

For me, I remember getting my first self-help book. It was actually called Go Find Your Passion and Purpose. Because I was at this crossroads, I had been doing anxiety work for a long time, had plateaued, and was feeling a little bored, and that coincided with the stopping driving. My whole personal world was just in disarray and I was like, “I’m going to go hike part of the Appalachian Trail while I can. While I do that, I’m going to find my purpose in life.” I did not find it, but it was an experiment. I go and I get this experience and I can say, “Okay, I’m not going to be someone who does a six-month hike. I made it four days. Awesome.” But go and experiment with things. I never thought that I would really want to write and I started a blog, and that has turned out to be such a positive experience. Prior to that, my writing experience had been very academic where it was a chore. Now, this is something I really enjoy, or talking to people. 

I would say experiment and continue to seek out those new experiences. One, seeking out new experiences helps on the anxiety side because you’re continually putting yourself into uncertain and new, so your confidence level is going to grow, your tolerance for not knowing grows, and your tolerance for awkward grows. That’s my plug for go try new things, period. Somewhere along the way, you’re going to find something that sparks an interest or that sparks this sense of, “Yeah, this is me.” Notice that. I know you talk a lot about mindfulness, we need to notice what was my actual experience, not what did my head tell me. What did I actually feel? And keep experimenting until you find something. I think that’s really the key.

Kimberley: I love that you said your tolerance for awkwardness. I think that is a big piece of the work because it is a big piece. We talk about tolerating discomfort, tolerating uncertainty, but I think that’s a very key point, especially when it comes to relationships, which I know is one of the factors. Tolerate the awkwardness is key.

Dr. Ashley: Yeah. I think it’s huge. I’ve been seeking out new experiences since 2017. This is going to be my New Year’s resolution. It was such a transformational experience over the course of the year that I’ve just continued it, and I’m trying to get everybody to join me because it’s such an expansive practice. I think it’s great for anxiety and depression, it’s great for humans, it’s been great for me on this quest for a good life. But with this, it means I have put myself into some awkward situations on purpose. Sometimes I know going into it, sometimes I don’t. 

I went to this one, it was called Nia. I practice yoga. That’s cool. That’s very much in my comfort zone. This was yoga adjacent, but it was also an interpretive dance with sound effects. You had to make eye contact with people and dance in these weird ways. I distinctly remember having this conversation with myself when I showed up, “What did you just get yourself into?” And then it was immediately, “Okay, you have two choices here. You can grit your teeth and hate the next hour, or you can embrace the awkward and dance at a three. Because she said, you can dance at a one, itty bitty, at a two or at a three and really go for it.” That for me was my, “All right, let’s just do this.” I embrace the awkward, and that was a turning point. That was amazing. And then now, when I think about good life, I feel like so many doors are opened because I’m not afraid of, “This is going to be awkward.” It’s going to be and you’re going to be okay or it’s going to make a hilarious story. I said, “Go for it.”

Kimberley: You’re here to tell the story. I love it. You didn’t die from awkwardness.

Dr. Ashley: No.

Kimberley: Can you tell me about the P? Can you go through them and just give us a little bit more information? Because I think that’s really important.

Dr. Ashley: Yeah. I love this theory because you can think about it as like, how are my PERMA factors doing? When you’re low, raise them. You know that those are the ingredients for a good life. The P is positive emotion. That is, we do need to spend time in positive emotional states. The more time we’re in the positive emotional states, the better compared to the negative ones like anxiety or sadness, or anger. Now that said, we know if we try to only pursue pleasure, it’s going to backfire. If I’m trying to avoid anxiety, I’m actually going to get more anxiety. But this is where behavioral activation comes in. Do things that are theoretically enjoyable and see if it puts you in a positive state. Again, theoretically enjoyable, because if you’re in the throes of depression, nothing feels enjoyable, do it anyways. And then notice, did it bring on a pleasurable emotional state? Cool. We want to do those things. 

E is engagement. This is when people talk about finding flow or being in the zone. These are the activities that you’re fully engaged in it. Self-consciousness goes away. You lose track of time because you’re just in it. We know that the more consistently we are able to put ourselves in states of flow, the higher our well-being tends to be. Athletes will talk about this a lot. When they’re on the field, they’re in the zone. Musicians, artists. But there are other ways to do this. This is a place for me personally, I didn’t know. I was like, “Well, okay, great. I need E, I need engagement. What puts me in a state of flow?” It took experimentation and noticing. For me, writing does it. Web design, I’m not techy, but when I start to do design projects, I get in that state of flow. It has to be this perfect apex, this perfect joining of skill and pleasure, like enjoyment. If it’s too easy, you will not go into a state of flow. That’s just the P. If it’s too hard, we go into a state of stress or anxiety, so that’s not flow. We have to be right on the cusp of our skillset. It’s hard work, but we’re into it. That’s the E.

R is relationships. We need quality relationships where we are being open, where we are being vulnerable, we’re really connecting with other people. That is huge. I mean, if we look at what’s the best predictor of life satisfaction, it’s quality relationships. This also is doing things for other people. Altruism, ugh, I love this side note. The act of kindness thing hits on three different factors. It feels good to do something good for other people. If you want a mood boost, go do an act of kindness. That reliably boosts our mood. It also improves relationships and it can tap into that meaning. I love that as just a practice. 

The M we talked about, that’s meaning. And then the A, that’s achievement for achievement’s sake. As humans, it feels good to conquer goals. It feels good to accomplish things. And that contributes to our well-being independently of the positive feelings that we get from it, or the meaning in the relationships or the engagement. I’m also a really big fan of set goals and then crush them. It can be silly little things like, I’m going to hold my breath for two minutes. Okay, cool. That’s a silly little thing, but then it feels good to do it. Or it could be something huge like crossing those bucket list things off your list.

Kimberley: You know what’s funny around achievement? I’ve got a couple of questions, but first I want to tell you your stories. Last year, I was struggling to do a couple of things that were really important to me for my medical health. I found an app called Streaks. Have you heard of Streaks? It’s a $5 app. But when you do the action, and for me it was taking my medicine, it does this little spiral and then it’s like, “You’ve done this for three days in a row.” And then tomorrow you click it and then it says, “You’ve done it for four days in a row.” You would think that the benefits of taking my medicine would be enough. But for me, it’s actually knowing I get that little positive reinforcement of like, “Look at me, I’ve taken my medicine for 47 days in a row, or now are like 300 days in a row.” I don’t think I deserve a medal for being able to take my medicine. But for me, that little bit of reward center on the achievement was a huge shift for me. And then it became, how many days did you practice your Spanish in a row? Even like, how many days did you do your Kegels? I’ve got all of the streaks happening and it’s really incredible how that little achievement piece does boost your mood.

Dr. Ashley: Yeah. But what I love about this is you’re also talking about how to hack the system. We’re talking about our brains and this is the stuff that just lights me up, because oftentimes our minds will say, “Well, you should just take your medication. You should just do these things.” Well, that’s not how it works. There’s a million reasons why we don’t do the things we know we should do. But can we figure out how to hack the system? Yeah. Our brains love streaks. They love streaks.  it taps our reward centers, like you’re saying, and so let’s use the tools that work. That got you if your goal is to take your medication consistently. Using our brain’s glitchy wiring to our own advantage is something that’s huge. That did it. And then it does feel good. And then you get some momentum going and then you create a habit around that and it’s fantastic.

Kimberley: Yeah. What about those who are overachieving to the point that it’s bringing their happiness down? What would we do there? 

Dr. Ashley: Yeah. I think that’s a great question and it’s something that comes up a lot, especially when we look at anxiety and perfectionism. At least the way I think about it is coming back to what’s driving this. Is this being driven by fear? Is this being driven by values? For me, I almost think of it as—I’m going to try to make sense with it—is it the -ing or the -ed? Meaning, the doING (I-N-G) or the -ed as in I did this past tense. What I mean by this is, I notice for me when I’m approaching something, say a big goal, like I want to write a book this year. If I can approach that from a place of, “I am doing this because this is important to me, I feel driven to get this message out into the world,” the -ing, the process of doing it, that feels like it’s going to boost my wellbeing when I start to get pulled into the thoughts of the outcome. I’m going to write this book and how many people are going to read it and is it going to sell? I’m really looking at all of this, and underneath that is fear. What if it doesn’t sell? What if people judge it? What if they think it’s stupid? Then I’m focusing on the outcome, kind of when it’s done. That I think is actually going to detract from my well-being because it’s not coming from a valued place; it’s coming from this feared place. 

A lot of times with overachieving, we’re chasing this other people’s expectations or we’re chasing this promise of happiness. When you do this, then you’ll be happy. It’s not going to work like that. It may be for a moment and then the bar just changes again. Now you’ve got another target. We have to come back to this, I think the process or the journey. Are you doing this because it matters to you, or are you doing this because some sort of fear is compelling you? 

Kimberley: Right. I’m just asking questions based on the questions I would’ve had when I was struggling the most. I remember hearing something that blew my mind and I actually want your honest opinion about it. I remember I used to chase happiness, like you talked about, even though I was doing all these things. I was doing all these things, but there was that anxious drive behind it. I remember hearing somebody saying life is 50/50. Even though you’re doing all these things, you’re still going to have 50% great and 50% hard. For me, that was actually very relieving. I think I was caught in and I think a lot of people experienced this like, “Okay, I’m at 50%, how can I get to 55? How can I get to 56?” What are your thoughts on also accepting that you won’t be happy all the time, or what are your thoughts on balancing this goal for happiness or this lifelong playfulness around happiness? 

Dr. Ashley: I agree with you completely. I think we have this cultural myth that we should be happy all the time. If you’re not happy, there must be something wrong. You’re doing something wrong. It sets up even this idea that being happy all the time is possible. It isn’t. If we look at, again, happiness, what people mean by that is a pleasurable or enjoyable state, an emotion that we like. Humans are wired. Two-thirds of our emotions would be under that negative category. Just by the way we’re wired, we’re more likely to have negative emotions, and they’re just messengers. They’re just designed to give us information about a situation. Some of them are going to be dangerous, so we’re going to feel anxious. Or we’re going to lose something we care about, so we’re going to be sad. We’re going to mess up, so we’re going to feel guilty. It’s unrealistic to expect to not have those emotions. I think that is a hundred percent something that we need to work on, just accepting happiness all the time is not possible and pursuing it is like playing a rigged game. 

The other thing, you know how on the anxiety side we talk about facing fears because then you habituate or you get used to them. But that habituation process happens on the pleasurable side too. This is why when we chase happiness, we end up on this hedonic treadmill where it’s, “Oh, I’m going to go buy this thing. And then I’m going to feel really happy,” and you are. And then you’re going to habituate. Your body goes back to baseline so that happiness fades. If you’re looking to an external source, you’re going to get caught up in this always chasing something bigger and better, not sustainable. 

I like to look at happiness as the side effect of living a good life. Do the things that we know matter. Take care of your health and wellbeing. Sleep, eat well, move your body, practice mindfulness, the PERMA factors that we talked about, and live in line with your values. If you’re doing those things, happiness is the side effect of that.

Kimberley: To make that the goal, not happiness the goal. 

Dr. Ashley: Yeah. 

Kimberley: I think that’s very, very true. Again, for me, it was a massive relief. I remember this weight falling off of like, “Oh,” because I think social media makes it so easy to assume that everyone is just happy, happy, happy content, to feel all the things. It was delightful to be like, “Oh no, everyone’s got a 50/50.”

Dr. Ashley: Exactly. When we know that’s normal, then all of a sudden, you can accept it. Like, I’m anxious for now, I’m sad for now. To do that, it does keep us from piling on extra. I have this saying that I love, “Just because life gives you a cactus doesn’t mean you have to sit on it.” A lot of times, we sit on it because we’re ruminating or I don’t want to feel this way and we’re fighting it. And that’s just amplifying it and making it a lot harder. When we can say, “Oh, this is where I’m at today. I’m still going to choose to do the things that I know are good for me, that are part of me, living a good life by my standards or my terms,” that’s going to be the side effect, is I’m going to end up with more happiness down the road, but not chasing it in that moment.

Kimberley: I love this. Thank you for coming on and talking about this. I think this has been enlightening and so joyful to have these conversations. I feel a little lighter, even myself, after chatting with you, so thank you. Tell me how people can hear from you, get in touch with you, learn about your work.

Dr. Ashley: Yeah, absolutely. I have a blog that I publish every week, so if you’re interested in that, you can subscribe at PeakMindPsychology.com/subscribe, o you can just check out all of the blog posts. That’s probably the best way to follow me and follow my work. I also have a TEDx Talk that came out pretty recently and you can watch that as well. It’s called Is Your Brain Deceiving You, and talk a little bit about learning to play my cards well.

Kimberley: I love the TED Talk. Congratulations on that. It was so cool. 

Dr. Ashley: Thank you. 

Kimberley: Thank you again for coming on. This has been just delightful. Really it has.

Dr. Ashley: I appreciate you having me.

Hello and welcome back, everybody. I’m so happy to be here with you. This is not the normal format in which we do Your Anxiety Toolkit podcast, but I wanted to really address a question that came up in ERP School about how to manage 10 out of 10 anxiety. 

For those of you who don’t know, over at CBTSchool.com, we have a whole array of courses—courses for depression, generalized anxiety, panic, OCD, hair pulling, time management, mindfulness. We have a whole vault of courses. In fact, we have a new one coming out in just a couple of weeks, which is a meditation vault. It will have over 30 different meditations. The whole point of this is, often people say to me that the meditations that they listen to online can become very compulsive. It’s things like, “Oh, just let go of your fear or make your fear go. Cleanse away and dissolve,” and all the things. That’s all good. It’s just, it’s hard for people with severe anxiety to conceptualize that. That whole vault will be coming out very, very soon. 

But this is actually a question directly from ERP School. Under each video of all the courses, there is always a place you can ask questions, and I do my best to respond to them as soon as I can. But I did say to this student, I will actually do an entire podcast on your question because I think it’s so important. 

Here is what they said: “Hi Kimberley, I love all the information you give us. I get so much more out of this than I do with a therapy session for one hour once a week. That being said, I’m feeling a little bit overwhelmed. There is just so much information and so many tools.” 

Yes guys, I admit to that. I do tend to heavy-dose all of my courses with all the science. I can bring in as many tools as I can with the point being that I want you to feel like you have a tool belt of tools, in which you can then choose which one you want to use, so I totally get what they’re saying here. 

They said: “When I’m at a 10 out of 10, I’m hardly able to function and it all seems to go out the window. It either seems that noticing works as I run through my list of tools or I can’t even think straight enough to check in with myself or even think about the tools I could use. So, where do I even start in those terrible moments?”

This is a really good question, and I think every single one of my clients in my history of being a therapist has asked this question. I know I have asked this question to my therapist because even as a therapist who has all the tools in those moments, it can feel overwhelming.

What I did here is I pulled all of my followers on Instagram and asked them to give me their tools that they find helpful, and then I’m going to weigh in myself, and then I’m going to encourage you to just practice any of them. Now, often what happens—and this is the case for what obviously someone’s bought a course from me—is when you have all of these options, we fall into the trap of thinking there is a “right” tool to use, and I want to reframe that. In addition, there’s another myth that that one tool will make all your discomfort go away or that will be the tool of all tools for recovery. I want to really normalize that there is no one tool. 

The whole reason that I do Your Anxiety Toolkit is to remind you that you’re going to have to practice multiple different things, you can’t put all your eggs in one basket, and it’s okay if it’s not a 10 out of 10 win. Meaning, it’s okay if it’s not perfect. Often I’ll say to clients, use the tools, even if it’s 50% effective. That’s still 50% effective more than what it would be in the past, which might be 0% effective or 1% effective. We take any wins we can take and we use it not as a fact that you’re a failure if it didn’t work, but more as just data on what to use for the next time.

At the end of the day, the goals are: Did it give me a 1 or 2% improvement on how I handled it the last time? 1 or 2%, folks. That’s all I’m goaling for here. Was I kind as I practiced it? And, did it move me towards the five-year you, or the three-year you, or the one-month you? The you who’s in one month, does it move you towards that person that you’re trying to be? I often will think about me through the terms of, what would the five-year me do in this situation? What would the three-year me do? What would the three-month me do? It might be different, and then I just pick one. Knowing it’s probably not perfect, but that’s okay. 

I have polled a whole bunch of people on Instagram because I honestly feel like folks who were in the thick of it actually are better at giving tools than even I am as a trained clinician who’s been through it. Of all of the different responses we got, I’ve actually broken it down into two separate sections per se. We’ve got mindset shifts and tools and actions. Again, these may actually feel again like, “Oh my gosh, now I have even more tools,” which is not a bad problem. 

TAKE ONE MOMENT AT A TIME 

But I want you in the moment that you’re at a 10 out of 10 to just pick one and be curious about it. I’m going to say here that the one I loved the most—I’m going to just actually give you one of the tools and actions first—is somebody (multiple people wrote this, in fact) said, just take one moment at a time. I have to say at a 10 out of 10 anxiety, that has been the most helpful for myself and for my clients. That when you slow down and you make it really simple, that’s actually the best way to respond. 

We have these bigger concepts like ERP and habit reversal training and mindfulness and all these big concepts. What’s the saying? The rubber hits the road or something like that. When it gets really hard, simplify things, go back to basics, slow down, and just go, “Okay, all I have to do is get through this minute. What can I do in this one minute?” Slow it down. That’s one of the tools and actions. 

BE AN OBSERVER 

The second tool and action is somebody says, “I notice my five senses,” which is a more tactical skill of being present (be an observer) and in the moment, which is your mindfulness skill. For them it might be: What do you see? What do you smell, what do you taste? Some people play games with this. A lot of my clients have said, “When I’m at a 10 out of 10 and I’ve just faced my biggest fear, or I’ve been triggered, I find six different colors.” You’re not doing that to suppress your thoughts or make the fear go away. You’re doing it because that’s response prevention. You’re not engaging in catastrophization and mental rumination. Instead, you’re just being an observer of what’s in your present moment. 

BREATHE

A lot of you folks said, “Breathe, that the only thing I do is breathe.” Again, I love this because it’s simple. Now, does that mean we have to breathe a certain way? A lot of people said three breath-in and four counts out, or box breathing. It doesn’t matter. Please don’t put pressure on yourself. For me, I just really put attention on my breath in and my breath out. I say to myself, “I’m breathing in knowing that I’m breathing in and I breathe out knowing I’m breathing out.” Very, very simple. 

DO NOTHING! ACCEPT IT IS HERE

A next person said, “It feels awful, but I do nothing more than just talk to it, accept that it’s here, and breathe.” Again. These are really simple things. What I’m going to encourage you guys to do is just pick one of these things and play with it for a day or a couple of days, whatever it feels good. And then check in and be like, “How did that work? Was that successful at helping me stay present and reduce behaviors that actually create more problems?” 

FEEL YOUR FEET ON THE FLOOR

Someone says, “I just feel my feet on the floor.” Again, these are so basic, but almost everybody’s response wasn’t like, “I practice these very complex skills.” They’re just talking about simple, really basic things. “I put my feet on the floor.”

USE TEMPERATURE

Someone says, “I splash cold water on my face.” Again, simple. They’re just bringing their attention to sensations in the present. 

CONNECT WITH YOUR SPIRITUALITY

Someone said, “I pray.” I love that some of you bring your religion into it or your faith. “I pray and I be quiet.” Some of you might call that a form of meditation. 

FEEL YOUR EMOTIONS & CRY

This one I really love. Someone said, “I cry. I embrace crying. It’s such a good emotional release.” This one’s really hard for me, you guys. I’m a crier, but when I’m at a high level of anxiety, I feel like there are no tear ducts in my eyes, like I can’t get myself to cry. But really when I do allow myself to cry, it is such a cathartic experience, especially if I do it kindly. 

EXERCISE

Someone says they work out. I think that there’s some interesting piece to that. Let me just bring a little nuance to that. When we work out, really what I think we’re doing is we’re putting our attention on something that is very strategic, like 15 bicep curls. Or you get on the treadmill, you listen to some music, and so forth. I love this tool. 

SOMETHING TO THINK ABOUT (IF YOU ARE PRONE TO EATING DISORDERS)

One thing to think about, and the only reason I’m telling you this is just because I myself used to use working out as a skill and it was very helpful. But if you are someone who’s prone to an eating disorder or compulsive exercise, just keep an eye out for that because, for me, my healthy practice of working out ended up becoming a compulsive eating disorder compulsion. Now, for most of you, that’s probably not the case, but I think with any of these things, like any time we overdo it or we do it to make the fear go away or to avoid the fear, we can get ourselves a little bit into trouble there. So just keep an eye out for that. For me, when I heard that, I was like, “Oh gosh, no, I couldn’t do that.” But I think for most of you and many of you, that is a really effective tool. We do have research that exercise is a very, very helpful way of managing anxiety. I do still work out for that exact reason, but we have to be careful of becoming compulsive

VALIDATE YOURSELF

Now, of the last of the tools, P.S. It’s actually mine. I did weigh in on the end. My tool and action that I would weigh in, in addition to all of these great ideas, is validate, validate, validate. One of the things I think we miss is when we’re at a 10 out of 10, whether that be anxiety, sadness, depression, stress, panic, whatever it may be, we forget to validate ourself by going, “This is really hard.” It makes complete sense that you can’t think about what tools. You’re at A 10 out of 10. It makes complete sense that this is something that is rocking your world. You could say, “Anybody in this position would struggle to find tools.” 

Validate, validate, validate. That’s a self-validation, guys. A self-validation. It might be simply as much as you saying, “It’s okay that you’re struggling, I got you,” which moves me to the mindset shifts. There’s only four of them, but I thought they were beautiful. The reason I separated them is sometimes when we are in the 10 out of 10, naturally, our brain will send us to get away from here, fight, flight, freeze, and fawn. How can we make the fear go away and get out of this “dangerous” situation? If you can, often you won’t be able to. Again, there is some research that when you’re at a 10 out of 10, it’s very hard to actually have a mindset shift. But on the lower 6s, 7s, and 8s out of 10s, if you practice it, I think it gets a little easier. 

Here are some of the things that a lot of the folks did weigh in on and say. 

MINDSET SHIFTS TO CONSIDER

Number one mindset shift is, “I remind myself that I don’t have to solve the thoughts I’m having.” Great mindset shift because in those moments, we’re like, “What is the answer? What is the answer? We need to figure it out,” and so forth. I love that. 

The second one is, “I remind myself that I’m resilient and strong.” Total shift, away from, “I can’t handle this, what do I do” to “I’m resilient and strong.” For me—I’ll weigh in here—I often say, “Everything is figureoutable. I’ll figure this one out.” That sentence has changed my life because it takes away the pressure of having to find solutions right now and says, “I’m in a process now. I’ll figure it out. We’ll get to the end of it. It might take some bounces and bumps.”

The third one is of course my all-time favorite, which is, “I can do hard things.” Today is a beautiful day to do hard things. So good. It can remind you that this is a moment to lean into. 

I think this last one here is really important. someone weighed in and said, “I remind myself that being uncomfortable doesn’t mean dangerous.” This is gold, you guys. 

There are some ideas of the people who weighed in and the most common responses. Let me also say, to be honest, a lot of people wrote, “I totally can’t handle it and I just fall apart.” A lot of people were making jokes like, “I throw a tantrum on the floor.” They were basically saying, “I haven’t figured it out yet.” I want to just really emphasize again the importance that it’s okay if you don’t have the 10 out of 10s figured out. We are not here to win all of the challenges. 

I have been thinking about this a lot lately and I’ll actually use this as the final point. In our society and even in the community that I have built here, I have to also acknowledge that we can sometimes overdo the “Face your fears, use the tools, fix yourself, get better.” That message can be very, very helpful but also sometimes a little overachieving, a little condescending, a little pressured. 

I want to just conclude here, if you are early in your recovery and you’re working on the 4s, 5s, and 6s out of 10, you’re doing enough. If you’re in the middle of your recovery or you’re accelerating in your recovery and you’re doing the 7s, 8s, and 9s, it’s okay that you don’t yet have the skills to do the 10s. Don’t focus too much on that. Just keep the expectations realistic. I don’t want you to leave today thinking, “Okay, now I have to go do those tools and I have to handle 10 out of 10s well.” That’s a lot to ask. I don’t handle the 10 out of 10s perfectly. Nobody does. I know so many anxiety specialists who also don’t handle the 10 out of 10s perfectly. Let’s not fantasize that or let’s not make that a thing so that you are constantly feeling like you have to be doing this perfectly. 

Again, do what you can. Practice. This is trial and error. If it does work, great. If it doesn’t work, well good to know. Let’s just try again next time. It mightn’t work next time, that’s fine. Just good to know. We’re not here to always win every battle, but the fact that you asked this question, the fact that your inquiring shows me how much you value your recovery and how much you want to overcome this problem. For that, I applaud you. I applaud everyone listening. I hope that today was helpful for you. 

Again, for those of you who are interested, go to CBTSchool.com. We have a whole vault of different courses you can take. We do have some new ones coming out here this year, which I’m super excited about. We’ve got courses for depression, all the things. You can go and listen to those. They are on demand. You have unlimited access. You can watch them as many times as you want. Take notes. Just listen, whatever you want to do, and I hope that you find them helpful. 

Have a wonderful day, everybody, and I will see you next week.

Welcome back, everyone. I am so happy to do the final episode of our Sexual Health and Anxiety Series. It has been so rewarding. Not only has it been so rewarding, I actually have learned more in these last five weeks than I have learned in a long time. I have found that this series has opened me up to really understanding the depth of the struggles that happen for people with anxiety and how it does impact our sexual health, our reproductive health, our overall well-being. I just have so much gratitude for everyone who came on as guests and for you guys, how amazing you’ve been at giving me feedback on what was helpful, how it was helpful, what you learn, and so forth. 

Today, we are talking about PMS and anxiety, and it is so hopeful to know that there are people out there who are specifically researching PMS and anxiety and depression, and really taking into consideration how it’s impacting us, how it’s affecting treatment, how it’s changing treatment, how we need to consider it in regards to how we look at the whole person.

Today, we have the amazing Crystal Edler Schiller on. She is a Psychologist, Assistant Professor, and Associate Director of Behavioral Health for the University of North Carolina Center for Women’s Mood Disorders. She provides therapy for women who experience mood and anxiety symptoms across the lifespan. She talks about her specific research and expertise in reproductive-related mood disorders. She was literally the perfect person for the show, so I’m so excited. 

In today’s episode, we talked about PMS, PMDD, the treatments for these two struggles. We also just talked about those who tend to have an increase in symptoms of their own anxiety disorder or mood disorder when at different stages of their menstrual cycle. I found this to be so interesting and I didn’t realize there were so many treatment options. We talked about how we can implement them and how we may adjust that depending on where you are in terms of your own recovery already. 

I’m going to leave it there and get straight over to the show. Thank you again to Crystal Schiller for coming on, and I hope you guys enjoy it just as much as I did.

Kimberley: Thank you so much for being here, Crystal. This is a delight. Can you just share quickly anything about you that you want to share and what you do?

Crystal: Sure. I’m a clinical psychologist at UNC Chapel Hill. I’m an Associate Director of the UNC Center for Women’s Mood Disorders, where we provide treatment to people with reproductive hormones across the lifespan—starting in adolescence, going through pregnancy, postpartum, and all the way up through the transition to menopause. We also do research. My research focuses on how hormones trigger depression and anxiety symptoms in women. I do that by administering hormones, so actually giving women hormones and looking at the impact on their brain using brain imaging and then also studying specific symptoms that they have with that treatment. We’ve given hormones that mimic pregnancy and postpartum, and we also use hormones to treat symptoms as women transition through menopause and look at, like I said, how that impacts how their brain is responding to certain kinds of things in the environment and also how they report that changes their mood. 

WHAT IS PMS?  AND WHAT IS THE DIFFERENCE BETWEEN PMS AND PMDD?

Kimberley: Wow. You couldn’t be more perfect for this episode. You’ve just confirmed it right there. Thank you for being here. Before we get started, mostly we’re talking about what we call PMS, but I know that’s actually maybe not even a very good clinical term and so forth. Can you share with us what is PMS and What is the difference btween PMS and PMDD? 

Crystal: Yeah. PMS stands for premenstrual syndrome. It actually is a medical diagnosis and it includes a host or a range of physical symptoms as well as some mild psychological symptoms. It can be things like breast tenderness or swelling, bloating, cramps, menstrual pain, as well as some anxiety, low mood, mood fluctuations. But those tend to be mild in a PMS diagnosis. PMS is really common in the general population. Some studies estimate 30, 40, 50% of women experience these symptoms. Very, very common. On the other hand, premenstrual dysphoric disorder is a condition that is associated with more severe depression and anxiety symptoms. The mood symptoms are more at the forefront, although those physiologic symptoms like the breast tenderness, swelling, pain, cramps can certainly be a part of it. 

HOW CAN WOMEN DISTINGUISH BETWEEN NORMAL PREMENSTRUAL SYMPTOMS AND THOSE ASSOCIATED WITH PMS OR PMDD?

Most women with PMDD do have those physical symptoms as well. Pain is a commonly reported symptom in folks with PMDD, but the mood fluctuations are more severe. People spend about half their menstrual cycle usually with pretty severe symptoms. And then once the period starts, those symptoms go away in PMDD. That’s actually part of the criteria for the disorder that the symptoms have to what we call clear out or remit soon after menstrual bleeding starts. So, that’s for the formal diagnosis of PMDD. 

But then all sorts of people with anxiety or depression have what we call a premenstrual exacerbation of symptoms, so it’s also possible to have, let’s say generalized anxiety disorder or panic disorder, OCD, and have those symptoms get worse during certain periods of the menstrual cycle. We wouldn’t say that that person has PMDD; they just have a premenstrual worsening of symptoms. For some women, that occurs during that time, the week or two leading up to a period, but others have symptoms that are more around ovulation. Other women have symptoms that persist through the period. That’s the interesting thing. But also, the really complicated thing about this space is that there’s so many individual differences where some people have symptoms that sometimes, but not others. And then if you look at symptoms across the menstrual cycle and the next person, it may show a totally different pattern. But then over time, that pattern is maintained. It is clearly a pattern and a function of hormone change, but it can look different between different people.

PMS SYMPTOMS VS PMDD SYMPTOMS?

Kimberley: Why is it so different for different people? Do we understand that yet, or do we not have enough research?

Crystal: We don’t have enough research. This is a relatively new area that one of my colleagues, Dr. Tory Eisenlohr, has been working on at the University of Illinois at Chicago. What she has been finding is that there are different subgroups or subtypes of people with this premenstrual worsening where, like I said, some people have it right before their period; others more around ovulation. Some people seem to have worsening symptoms when their hormone levels are going up. Other people have worsening symptoms when their hormone levels are going down. Some people have worsening symptoms anytime there’s a fluctuation or change. That’s what we see in my research as well. When I start administering hormones in some women, they almost immediately start experiencing anxiety and irritability. And then as soon as I take the hormone away, they feel better. Whereas other women feel terrible until their hormones even out again, and I’ve stopped messing with them so much. It’s really individualized and it probably has something to do with genetic predisposition as well as early environment. It’s this combination of factors.

DOES ANXIETY INCREASE DURING PMS?

Kimberley: Right. I could be so off base here, and please just tell me if I am. While we know it’s chemical, hormonal, biological, and genetic, is there also a small percentage of people who have these shifts from a cognitive component to where they’ve maybe had some depressive symptoms in the past, and so that when it comes on, they’re anxious about the symptoms coming on? Does anxiety increase during PMS? Is it as cognitive as well, or are you more looking at just the physiological piece?

Crystal: Both, for sure. First of all, you’re not way off base. That’s totally what I see in the clinic, that as folks have had these experiences with hormonal shifts and they had some anxiety or symptoms of depression during those times, it raises concern as they go through those similar hormonal shifts in the future. It becomes, in some ways, a self-fulfilling prophecy. Like, “Oh my gosh, this time is going to be so horrible, I must prepare for it. Oh no, here it comes.” And then it is terrible because you’re expecting it to be terrible on some level. 

TREATMENT OPTIONS FOR PMS AND PMDD

Crystal: There are great treatment options for PMS and PMDD. That’s what we do in cognitive behavioral therapy for these very symptoms, is working through some of those expectations about how things are going to be and what we can actually do to prepare for it so that it doesn’t end up being bad just because we think it’s going to be bad.

But that’s not to say that there isn’t also a hormonal driver because for some people, there clearly is. Again, that’s what makes this work so interesting and complicated, is that it’s both for so many people. And that’s what makes treatment somewhat complicated. CBT can go a long way toward helping with these symptoms. Not everybody, of course, can afford to access CBT. There are medication options as well, but the combination of these treatments seems to work the best for that reason.

Kimberley: Yeah. CBT is good for so many things, isn’t it? 

Crystal: Yeah. 

Kimberley: This is a perfect segue into questions I commonly get. I’m not a medical professional, everybody knows that. I’m a therapist. But people will often report to me that their doctor said, “There’s nothing you can do. It’s your hormones, it’s your cycle. You have to ride it out and ride the PMDD or ride out your OCD or ride out your anxiety or your panic and just wait.” Would you agree with that? If so, or if not, what treatments would you encourage people to consider?

Crystal: Okay, I want people to know that that is absolutely not true. If a medical provider tells you that, go see someone else because it’s just not true. I actually hear the same thing all the time from my own patients and from our research participants too. They raised this concern with their physician; it wasn’t taken seriously. That’s why I do this work because I think it’s really important. We do have good treatments that work. There are a whole bunch of different things that people can try. 

MEDICATIONS FOR PMDD + PMS

Crystal: Because I mentioned there are different ways in which hormones influence mood symptoms across individuals, the unfortunate news is that we have certainly different medication for pmdd + pms treatments that work for a lot of people, but you have to work with a physician that you like to find the combination or the exact right treatment for you. It’s not like a one-and-done where you would go in and say, “Okay, great, you’re going to put me on this low-dose antidepressant and I will feel better and it will completely take care of this.” The thing that I would really encourage people to do is find a physician who’s willing to work with them and see them regularly in the beginning, once every few weeks, or even more often as they try these different treatments to see what’s going to work. I already mentioned cognitive behavioral therapy. That’s a first-line treatment option for PMDD as well as for this premenstrual exacerbation or cyclic exacerbation of underlying anxiety or depression. 

The other thing that works well for PMDD is selective serotonin reuptake inhibitors. SSRIs that are used to treat depression and anxiety work well for PMDD but the mechanism is different, which is really interesting. A lot of people I hear from are reluctant to take SSRIs because they’ve heard that they’re difficult to come off of eventually if they wanted to, that you can become dependent on them. The good news for PMDD, for people who are worried about those studies, is actually, you don’t have any dependence on it because you only take it during that period of the menstrual cycle that’s problematic for you. You can take it just those two weeks leading up to the beginning of your period and then stop taking it once the period starts. That has been shown to fully prevent PMDD symptoms in some women. And then some other people take it all the time, like around the whole menstrual cycle just because it’s hard to remember to start it, or because they’re not exactly sure when their period is going to start. If you’re not super regular, it’s hard to know and you might miss that window of opportunity to start it before the mood symptoms. That’s another option. But SSRIs are another first-line treatment option. 

And then some women have really good success with oral contraceptives. Low-dose combined estrogen-progestin contraceptives are what’s recommended. Yaz is the only one that’s FDA-approved to treat PMDD, but it’s not all that dissimilar from any other low-dose combined oral contraceptive. Sometimes it isn’t covered by all insurances. If that one is not covered, I tell people to ask their doctor about what are the other alternatives because you shouldn’t be paying tons and tons of money for your oral contraceptive. 

And then the other thing that often helps, for women who have some symptom relief with Yaz or other oral contraceptives, is to take it continuously because, as I mentioned, it is often that hormone change that seems to provoke symptoms in folks. If you don’t have a period, then you don’t have any hormone change. It’s those placebo pills that cause a period, it’s the switching from a low-dose hormone to then having that withdrawal of progestin that causes a period. But you don’t medically need one. You can ask your doctor to prescribe the hormone continuously and not have a period at all. And that works well for a lot of folks with PMDD as well. And then you can combine all these different treatments. 

LIFESTYLE CHANGES TO HELP PMS ANXIETY + PMDD 

And then, in addition, some other non-pharmacologic lifestyle changes to help PMS anxiety and PMDD. Exercise has been shown to help. Regular exercise I think enhances all of our moods. It has the same effect within PMDD. There’s some studies showing that taking calcium seems to reduce symptoms as well. For most of our patients, I just have them start taking a multivitamin and try to boost up that calcium a little bit. But like I said, a lot of people need a combination of treatments. Different SSRIs work in slightly different ways and may be more effective for some people than others. Just because the first SSRI doesn’t work doesn’t mean that you couldn’t try another one. Again, it’s just a matter of finding a physician that’s willing to work with you to find the right combination and dose of these various treatments. Also possible for some people that none of these things work and those cyclic mood symptoms persist. And then there are other more invasive options for folks who don’t have good success with any of these.

Kimberley: Right. I have a couple of questions about that. You’ve just given us an amazing treatment plan, or treatment options for someone who is experiencing PMDD or they’re having more onset of anxiety not to maybe that degree. I just want to clarify, for those who also have a chronic anxiety disorder, I’m assuming, but please again correct me, that they wouldn’t be one of the people who should be coming off of their SSRIs; they should stay on them if you’ve got an additional psychiatric or a mental illness on the side.

Crystal: Correct. I would never advise someone to come off of their SSRI if they’re still having some breakthrough cyclicity in their symptom exacerbation. What I would suggest instead is to try adding on some of these other options. If you’re already on an SSRI and not doing CBT, that’s maybe where I would start, is to first track your mood symptoms relative to your period. This is a step that many people skip. The only way to diagnose PMDD, but also an important indicator for this cyclic exacerbation of symptoms, is to track every day your mood symptoms. You can just do this really easily on a calendar, even in the Notes app on your phone. I just have my patients make a mood rating of 0 to 10. 0 is feeling terrible, awful, worst I’ve ever felt; 10 is the best I’ve ever felt. It can be as simple as that. Or you can even use a smiley face symptom like, okay, feeling happy, feeling terrible. It doesn’t have to be anything special. There are apps and things you can use as well to do this. But what we’re looking for is a regular pattern of mood change relative to the menstrual cycle. Once you’ve established there is a regular pattern, then a CBT therapist can help you, like I said, prepare for those times and use some coping skills or strategies to manage those mood symptoms. 

But I think the treatments are largely the same for people with PMDD versus other anxiety and depressive disorders. But if you have more of a chronic picture that just has some change in symptoms around the menstrual cycle, then you wouldn’t come off your SSRI. That’s just for people with pure PMDD. 

CBT FOR PMDD and PMS ANXIETY

Kimberley: I’m thinking about questions I’m assuming people will ask, and what comes to mind is, as myself as an OCD Specialist and as an anxiety specialist, we use CBT, but there are different types of CBT. We do a lot of exposure and response prevention for OCD and so forth. When we are talking about CBT, I want us to really be clear about what that looks like compared to all these other forms. What would that look like specific to somebody who has these symptoms, particularly around their menstrual cycle? Would it be more focused on the cognitive component or would it be an equal balance between managing cognitive distortions and behavioral activation? If we did behavioral activations, what would that look like?

Crystal: I’m just going to lay my bias out on the table that I tend to lean more on the B side of CBT. I tend to be a behaviorist, and I do a lot of behavioral activation because, in my experience, it tends to work well in this space and for this population of folks. We do some behavioral planning. We track behaviors and mood symptoms. What did you do or not do when you were having that feeling of frustration or irritability and how did that work out for you? We get pretty in the weeds of like, what did you say, and then what happened next, and that sort of thing, and then we figure out like, okay, how do we prevent this kind of exchange from happening in the future when you’re feeling really frustrated or irritable, if it caused problems, because sometimes it doesn’t. Sometimes anger, frustration, or irritability serves as fuel to make a behavior change that needs to be made. It’s a signal that something isn’t working well. I don’t want to pathologize all negative emotions because they’re not always bad. 

Anyways, we look at what happened and where are the points at which we could have intervened and we rewind back in time to say, “Okay, how did you sleep the night before that thing happened that didn’t go so well? Were you eating that day? What was that like? Were you already pretty depleted going into this negative interaction with your boss?” How do we prepare for the next cycle to make sure that you are allotting enough time to sleep and protecting that sleep time, not staying up super late, getting emails done or something, but really taking good care of yourself, eating well, drinking enough water, taking care of yourself the way you would take care of a child? And then from there, we talk about, “Okay, let’s say this frustrating thing happens again and you’re noticing yourself getting anxious or frustrated in that moment. What are some tools or skills we could use to respond?” Here, we might use something like taking a break, like, “All right, I noticed I’m getting really upset. I need to take a break from this interaction so that I don’t say something that I might regret.” We might practice a skill like, “Thank you for that feedback. I’m feeling myself just getting flustered. I’m going to take five minutes and then I’d like to come back and have this conversation with you later, or an hour,” or “Can we come back and have this conversation next week,” depending on what it is and how out of sorts the person is feeling. And then using some skills to calm down. These might be mindfulness skills or any kind of self-care, emotion regulation skill that a person could use. 

We tend to start with skills that folks have already had good success with. I’m not teaching Buddhist meditation on the first day of treatment, but instead, it might be simple things like, “Oh, I feel better when I get some sunshine and take a walk outside,” so that might be a good skill we could just use right off the bat. It’s pretty skill-based. And then we create a behavioral plan around that time of the month that tends to be more problematic so that we can keep people feeling well and well supported. A lot of times, that’s all it takes. It doesn’t require much more than that. 

Kimberley: I love that. I love that you’re bringing in the mindfulness piece and a lot of self-care. This is really more of a question of curiosity, but I remember as a young teen, having a lot of PMS, being told you have to drink a lot of water. Is that like an old wives’ tale? Because now I’m telling my daughter. I’m curious, is that an old wives’ tale or is that actually a treatment or a part of the work?

Crystal: I don’t know. I mean, I think Americans probably go a little overboard on water consumption, but I think it’s a good part of self-care to stay well-hydrated as well as well-fed and well-rested. You do lose some water through menstruation, and so it’s probably good practice in general just to keep yourself well hydrated. That doesn’t mean drinking a certain amount of water every day, but just noticing when you’re thirsty and drinking something when you are.

Kimberley: Okay, I’ll be better about that because, like I said, as I tell my daughter, I’m always like, “This is probably an old wives’ tale.” Maybe we could talk this one through together. Let’s say I’m treating somebody. They’ve got severe OCD, severe panic disorder or severe health anxiety, severe social anxiety. They know and they’ve tracked using an app or, as you said, the notes on their phone or on paper, they’ve tracked it. They know around approximately that such and such day of the month, they’re going to probably have an onset of treatment. How prepared should they be in terms of what would that preparation time look like? Is there a strategy you would give people? I know for us, on the clinical side, I’m amping up homework skills for them to manage the actual disorder, but is there something they could be doing on the PMS side that we should remember to do?

Crystal: I think it’s in my mind really specific to the individual and the symptoms that they’re having that they find tend to get worse as well as the physical symptoms. If they’re having a lot of pain around that time, then we want to also work on some pain management. Because when you’re feeling a lot of pain, that can make your anxiety worse. That would be something I would think about in addition to the standardized ramping up of homework that you would ordinarily be doing. Pain management can again look more like mindfulness, some meditative practice, or it can mean talking with one’s doctor about how to manage pain because there are non-addictive ways of managing pain as well.

Kimberley: Right. You mentioned before talking to your doctor. Are you speaking specifically about just a GP or should they be going more to a reproductive doctor, OB-GYN? What kind of medical professional would you encourage people to reach out to? 

Crystal: I think if you have a doctor that you trust, whether it’s a GP, OB-GYN, or even a psychiatrist, all of those are good options. Any of them can help treat these symptoms. Sometimes if the symptoms are really severe, then going to a specialist in reproductive mental health—that person would be a psychiatrist—can be helpful. There aren’t that many of us out there though. I have a number of really wonderful colleagues that I work alongside in our clinic and we treat patients together. I provide the psychotherapy and then they provide the pharmacotherapy and then I also have an OB-GYN on the team who provides the hormonal treatment. Not everyone can access this highly skilled team, however, and I do recognize that. I think starting with a GP or your OB-GYN is a good place to start. Again, if they’re not as knowledgeable as they need to be and they’re telling you, you just have to suck it up and deal with it, that’s not the right person. 

Kimberley: I appreciate you saying that because I do think—I’ll be transparent—even to get somebody as skilled as yourself on the show for this was a really difficult thing. I was surprised how few people really understand it and are knowledgeable about the treatment options. It was harder than I thought and I’m so grateful for you to be here and talk about it with us.

Crystal: I’m really sorry to hear that. I think there are a growing number of people interested in this, and I have a number of wonderful colleagues. But like you mentioned, there aren’t that many of us out there. The bright spot, I would say, is that we have a training program at UNC Chapel Hill with lots and lots of applicants every year. We’re training clinical psychologists and social workers and psychiatrists to do this work.

Kimberley: Amazing. Thank you. Last question: Any final advice you would give someone who is experiencing symptoms of PMS and PMDD in regards to getting better or seeking treatment and help?

LAST PIECE OF ADVICE FROM CRYSTAL

Crystal: You’re not alone. It’s not all in your head. You deserve access to treatments that work. There are lots of treatments that work. Unfortunately, our medical system is really complex and sometimes you have to really advocate for yourself in this space. But if you are persistent and know what you’re looking for in a provider, you, I hope, will be able to find one that can be a good advocate and supporter of you to recovery because you don’t have to experience these symptoms by yourself or forever.

Kimberley: Thank you so much for saying that. I think a lot of people feel like they’re crazy or they’ve been told they’re being crazy, which doesn’t help.

Crystal: Yeah. I mean, the word “hysteria” came from studying or psychiatrists working with women who they felt were hysterical and their uterus was traveling around their bodies. The roots of all of this are in this really misogynistic place where many of us are working really hard to overcome that unfortunate history, but there’s often still a lot of stigma and misinformation out there.

Kimberley: I remember in my master’s degree, that was the first part of the history of Psychology, that women who were just having PMS were being totally hyper-pathologized. Horrible.

Crystal: Yeah. Really horrible. I hope that the work that we do makes a difference. I’m so glad that you’re tackling this topic on your podcast. I think this will, I hope, reach a lot of people.

Kimberley: Thank you. Can you tell us where people can get ahold of you, where they might learn about you and the work that you’re doing?

Crystal: Yeah. I have a website, it’s CrystalSchiller.com. C-R-Y-S-T-A-L S-C-H-I-L-L-E-R.com. I’m actually starting to write a book on this topic, so I really appreciate you reaching out and to know that people have questions about this because that’s what I see where I’m at too. And then the UNC Center for Women’s Mood Disorders, if you just Google that, you’ll find our website and you can read more about the different research studies that we’re doing and about our treatment program as well.

Kimberley: Thank you so much and congratulations on writing a book. It’s a big challenge and a big accomplishment.

Crystal: Thanks.

Kimberley: Thank you so much for coming on. It’s been an absolute pleasure.Crystal: It was wonderful being with you today. Thank you so much. Take care.

In this week's podcast episode, we talked with Dr. Katherine Unverferth on Menopause, anxiety, and mental health. We covered the below topics:

• How do we define peri-menopause and menopause? 
• What causes menopause? 
• Why do some have more menopausal symptoms than others? 
• Why do some people report rapid rises in anxiety (and even panic disorder) during menopause. 
• Is the increase in anxiety with menopause biological, physiological, or psychological? 
• Why do some people experience mood differences or report the onset of depression during menopause? 
• What treatments are avaialble to help those who are suffering from menopause (or perimenopause) and anxiety and depression?

Welcome back, everybody. I am so happy to have you here. We are doing another deep dive into sexual health and anxiety as a part of our Sexual Health and Anxiety Series. We first did an episode on sexual anxiety or sexual performance anxiety. Then we did an episode on arousal and anxiety. That was by me. Then we did an amazing episode on sexual side effects of antidepressants with Dr. Aziz. And then last week, we did another episode by me basically going through all of the sexual intrusive thoughts that often people will have, particularly those who have OCD. 

This week, we are deep diving into menopause and anxiety. This is an incredibly important episode specifically for those who are going through menopause or want to be trained to understand what it is like to go through menopause and how menopause impacts our mental health in terms of sometimes people will have an increase in anxiety or depression.

This week, we have an amazing guest coming on because this is not my specialty. I try not to speak on things that I don’t feel confident talking about. This week, we have the amazing Dr. Katherine Unverferth. She is an Assistant Clinical Professor at The David Geffen School of Medicine and she also serves as the Director of the Women’s Life Center and Medical Director of the Maternal Mental Health Program. She is an expert in reproductive psychiatry, which is why we got her on the show. She specializes in treating women during periods of hormonal transitions in her private practice in Santa Monica. She lectures and researches and studies areas on postpartum depression, antenatal depression, postpartum psychosis, premenstrual dysphoric disorder—which we will cover next week, I promise; we have an amazing guest talking about that—and perimenopausal mood and anxiety disorders. I am so excited to have Dr. Unverferth on the show to talk about menopause and the collision between menopause and anxiety. You are going to get so much amazing information on this show, so I’m just going to head straight over there. Again, thank you so much to our guest. Let’s get over to the show.

Kimberley: Welcome. I am so honored to have Dr. Katherine Unverferth with us talking today about menopause and anxiety. Thank you for coming on the show.

Dr. Katie: Of course. Thanks for having me.

HOW DO WE DEFINE PERI-MENOPAUSE AND MENOPAUSE? 

Kimberley: Okay. I have a ton of questions for you. A lot of these questions were asked from the community, from our crew of people who are really wanting more information about this. We’ve titled it Menopause and Anxiety, but I want to get really clear, first of all, in terms of the terms and whether we’re using them correctly. Can you first define what is menopause, and then we can go from there?

Dr. Katie: Definitely. I think when you’re talking about menopause, you also have to think about perimenopause. Menopause is defined as the time after the final menstrual period. Meaning, the last menstrual period somebody has. It can only be defined retrospectively, so you typically only know you’re in menopause a year after you’ve had your final menstrual period. But that’s the technical definition—after the final menstrual period, it’s usually defined one year after. Perimenopause is the time leading up to that where people have hormonal changes. Sometimes they have vasomotor symptoms, they can have mood changes, and that period typically lasts about four years but varies. I think that people often know that they’re getting close to menopause because of the perimenopausal symptoms they might be experiencing.

Kimberley: Okay. How might somebody know they’re going into perimenopause? I think that’s how you would say you go into it. Is that right? 

Dr. Katie: Yeah. You start experiencing it there. I don’t know if there’s a specific term. 

Kimberley: Sure. How would one know they’re moving in that direction? 

Dr. Katie: Typically, we look for a few different things. One of the earliest signs is menstrual cycle changes. As someone enters perimenopause, their menstrual cycle starts to lengthen, whereas before, it might have been a normal 28-day cycle. Once it lengthens to greater than seven days, over 35 days, we would start to think of someone might be in perimenopause because it’s lengthened significantly from their baseline before. 

Other symptoms that are really consistent with perimenopause are vasomotor symptoms. Most women who go through perimenopause will have these. These are hot flashes or hot flushes—those are synonyms for the same experience—and night sweats. Hot flashes, as the name describes what it is, they last about two to four minutes. It’s a feeling of warmth that typically begins in the chest or the head and spreads outward, often associated with flushing, with sweating that’s followed by a period of chills and sometimes anxiety. The night sweats are hot flashes but in the middle of the night when someone is sleeping, so it can be very disruptive to sleep. That combination of the menstrual cycle changes plus these vasomotor symptoms is typically how we define perimenopause or how we diagnose perimenopause. Once someone is later in perimenopause, when they’re getting closer to their final menstrual period, often they’ll skip menstrual cycles altogether, so it might be 60 days in between having bleeding. Whereas before, it was a more regular period of time.

I think one of the defining features too is hormonal fluctuations during those times. But interestingly, there’s not much clinical utility to getting the blood test to check hormone levels because they can vary wildly from cycle to cycle. Overall, what we do see is that certain hormones increase, others decrease, and that probably contributes to some of the symptoms that we see around that time as well.

Kimberley: Right, which is so interesting because I think that’s why a lot of people come to me and I try to only answer questions I’m skilled to answer. Those symptoms can very much mimic anxiety. I know we’ll get into that very soon, but that’s really interesting—this idea of hot flashes. I always remember coming home to my mom from school and she was actually in the freezer, except for her feet. It was one of those door freezers. So, I understand the heat that they’re feeling, this hot flash, it’s a full body hot flash stimulant like someone may have if they’re having a panic attack maybe. 

Dr. Katie: Exactly. There are lots of interesting studies really looking at the overlap of menopausal panic attacks and hot flashes too. There’s a lot of this research that’s really trying to suss out what comes first in perimenopause because we know that anxiety predisposes someone to hot flashes and it can predispose someone to panic attacks, which is interesting. It seems like there’s this common denominator there. But I think that that’s a really interesting thing that hopefully we’ll get into this overlap between the two.

WHAT AGE DOES SOMEONE GET PERIMENOPAUSE AND MENOPAUSE?

Kimberley: I’m guessing this is something I’m moving towards as well. What age groups, what ages does this usually start? What’s the demographics for someone going into perimenopause and menopause?

Dr. Katie: The average age of menopause is 51, and then people spend about four years in perimenopause. Late 40s would be a typical time to start perimenopause. Basically, any age after 40, when someone’s having these symptoms, they’re likely in perimenopause. If it happens before the age of 40 where someone’s having menstrual cycle abnormalities and they’re having these vasomotor symptoms, that might be a sign of primary ovarian insufficiency. It used to be called premature ovarian failure, but that would be a sign that they should probably go see a doctor and get checked out. If it’s after 40, it’s very likely that they’re having perimenopausal symptoms.

Kimberley: Okay. What causes this to happen? What are the shifts that happen in people’s bodies that lead someone into this period of their life?

Dr. Katie: I think there are a lot of things that are going on. I think it’s really important to emphasize that menopause is a natural part of aging. That this isn’t some abnormal process. Nothing is wrong. It’s a natural part of aging. It can still be very uncomfortable, I think. But basically, over time, a woman’s eggs decline and the follicles that help these eggs develop also develop less. There’s this decline in the functioning of the ovaries. There are a few reasons this might be. There are some studies that show that blood flow to the ovaries is reduced as a result of aging, so maybe that makes them function a little bit less. The follicles that remain in the ovaries are probably aging, and then the follicles, which are still there, also might not be the healthiest of follicles, which is why they weren’t used earlier. 

There’s this combination of things that leads to these very significant hormonal changes that start around perimenopause. The first of these is an increase in follicle-stimulating hormone. Follicle-stimulating hormone is released by the pituitary and encourages the ovaries to develop follicles. That increases over time because the follicles aren’t developing in the same way. It’s like the pituitary is trying harder and harder to get them to work. At the same time as these, as the follicles and ovaries are aging, what we see is that the ovaries produce less estrogen and progesterone overall. But there’s still these wild fluctuations that are happening. FSH is going up, but it’s fluctuating up; estrogen and progesterone are going down, but they’re fluctuating down. It’s these really big shifts that seem to cause a lot of the symptoms that we associate with this time.

WHY DO SOME HAVE MORE MENOPAUSAL SYMPTOMS THAN OTHERS? 

Kimberley: Is there a reason why some people have more symptoms than others? Is it your genetic component or is there a hormonal component? What’s your experience?

Dr. Katie: I think there are lots of different reasons and we probably need more research in this area. There are definitely genetic components that influence it. For example, we know that women who have family members who went through menopause earlier are likely to go through menopause themselves earlier. There’s some genetic thing that’s influencing the interplay of factors. I think we know that there are certain lifestyles. There are certain behaviors, like certain behaviors in someone’s life that can influence, I think, their symptoms. We know that smoking, obesity, having a more sedentary lifestyle can impact vasomotor symptoms. I think some really interesting research looks at the psychological influences here. We know that women who have higher levels of neuroticism, when they go through perimenopause, have more anxiety and mood changes associated with it. People who have higher levels of somatic anxiety, coming into this perimenopausal transition, can also have a tougher time. I think that makes sense when we think about someone with somatic anxiety. They’re going to be very, very attuned to these small changes in their body. During perimenopause, there are these huge changes that are happening in your body. That can trigger, I think, a lot of anxiety and a focus on the symptoms. 

I think with vasomotor symptoms specifically, like hot flashes and hot flashes specifically, night sweats, not quite as much, we know that there are these psychological characteristics that probably perpetuate and worsen hot flashes. When someone has a hot flash, it’s certainly uncomfortable for most people. But the level of distress can be very different. They’ve looked at the cognitions that occur when people have hot flashes and at some point, people believe like, “Oh, this is very embarrassing, this is very shameful.” That doesn’t help them process it. They might believe, “This is never going to go away. I can’t cope with it.” That’s also not going to help. I think that’s really a target for cognitive behavioral therapy to help people during this time.

Kimberley: It just makes me think too, as somebody who has friends going through this, and you can please correct me, what I’ve noticed is there’s also a grief process that goes along with it too, like it’s another flag in terms of being flown, in terms of I’m aging. I’ve also heard, but maybe you have more to say about people feeling like it makes them less feminine. Is that your experience too, or is that just my experience of what I’ve heard?

Dr. Katie: No, I agree. I think in my clinical experience, people go through it in a lot of different ways. I think that there is this grief. I think it can bring out a lot of existential anxiety. It is a sign that you are getting older. This can bring up a lot of these questions like, who am I? What’s my purpose? Where am I going? But I think it’s really important to remind women that we’re not defined by our reproductive functioning. I think that that’s something that people forget. Were you less of a woman when you were 15 or when you were 10 maybe and you hadn’t gone through puberty? You’re still the same person. But I do think that there’s a lot of cultural stress around this, and I think there are a lot of complexities around the way society sees aging women. I think that those are cultural issues that need to be fixed, but not necessarily a problem within the woman themselves.

WHAT CAUSES MENOPAUSE AND ANXIETY SYMPTOMS? 

Kimberley: That’s really helpful to know and understand. Okay, let’s talk about if I could get a little more understanding of this relationship with anxiety. Maybe you can be clearer with me so that I understand it. Is it more of what we’re saying in terms of like, it’s the chicken and the egg? Is that what you mean in terms of people who have anxiety tend to have more symptoms, but then those symptoms can create more anxiety and it’s like a snowball? Or is that not true for everybody? Can you explain how that works?

Dr. Katie: With regard to the perimenopausal period, what I think researchers are trying to figure out is, do vasomotor symptoms, like hot flashes, lead to anxiety and panic, or do anxiety and panic worsen the vasomotor symptoms? We don’t have a lot of information there. Part of it is because it’s difficult to study. Because when you’re doing symptom checklists, there’s a lot of overlap between a hot flash and a panic attack. It’s just been difficult, I think, to suss out in research. I think what we do know is there was one study that showed that people who have higher levels of anxiety are five times more likely to report hot flashes than women with anxiety in the normal range. Whether or not the anxiety is necessarily causing it, I do think that there’s probably some perpetuation of like, I think that the anxiety is perpetuating the hot flashes, which perpetuates the anxiety. We just don’t know exactly where it starts. 

MENOPAUSE & PANIC ATTACKS 

But I mean, if we just think about it for a second, if we think about what’s common between them, I think that both panic attacks and hot flashes have a quick onset. They have a spontaneous onset, a rapid peak, they can be provoked by anxiety, they can include changes in temperature, like feelings of heat and sweating. They can have these palpitations, they can have this shortness of breath, nausea. And then it’s very common that panic is reported during hot flashes, and hot flashes can be reported during panic. I think there’s this interplay that we’re trying to figure out. I think what’s interesting too is that common antidepressants can treat both panic and hot flashes, which is not something that probably everybody knows. There are probably different reasons that they’re treating each of them, but it is still just this other place where there is this overlap. 

Kimberley: Okay. That’s really interesting. One thing that really strikes me is I actually have a medical condition called postural orthostatic tachycardic syndrome (POTS), and you get really dizzy. I’m an Anxiety Specialist, so I can be good at pulling apart what is what, but it is very hard. You have to really be mindful to know the difference in the moment because let’s say I have this whoosh of dizziness. My mind immediately first says I’m having a panic attack, which makes you panic. I’m assuming someone with that whoosh of maybe a hot flash has that same thing where your amygdala, I’m guessing, is immediately going to be like, “Yeah, we’re having a panic attack. This is where we’re going.” That makes a lot of sense to me.

Now, some people also have reported to me that their anxiety has made them-- and again we have to understand what causes what, and we don’t understand it, but how does that spread into their daily life? What I’ve heard is people say, “I don’t feel like I can leave the house because what if I have a hot flash, which creates then a panic attack,” or “It’s embarrassing to have a hot flash. You sweat and your clothes are all wet and so forth.” Do you have a common example of how that also shows up for people? 

Dr. Katie: Yeah. I think that what you were alluding to is this behavioral avoidance that can happen. We can see that with panic attacks where people sometimes develop agoraphobia, fear of being in certain places. Sometimes they don’t want to leave their home. I think with hot flashes, we do also see this behavioral avoidance when people especially tend to find them very distressing. They catastrophize it when they happen. They worry about social shaming. That avoidance, I think, the way that we understand anxiety is that if you have an anxiety and then you change your behaviors as a result of that anxiety, that tends to perpetuate the anxiety. That’s one of the targets of cognitive behavioral therapy for hot flashes, is really trying to unwind some of this behavioral avoidance. Also, we know that temperature changes can trigger hot flashes. Unfortunately, it looks like strong positive and strong negative emotion can trigger hot flashes, just feeling any end of the spectrum. There are certain other triggers that can trigger hot flashes. I think that it’s just this discomfort and this fear of having a hot flash that I think really generalizes the anxiety during this time. 

HORMONES, ANXIETY, & MENOPAUSE

There’s also this interesting hormonal component too that’s being studied as well. We’ve talked a little bit about progesterone. But in reproductive psychiatry, we really focus on this metabolite of progesterone called allopregnanolone. I think this is interesting because allopregnanolone is a metabolite of progesterone. We know that progesterone is going like this, up and up and down during this time. Allopregnanolone works on this receptor that tends to have very calming effects. Other things that work at this receptor are benzodiazepines like Xanax and Ativan or alcohol. It has this calming effect. But when it’s going like this, it’s calming and then it’s not, and then it’s calming and then it’s not, up and down rollercoaster. There’s some thought that that specifically might contribute to anxiety during this time. It can be more generalized. It’s not always just related to hot flashes, even though we’ve been more specific on that. It can be the same as anxiety at any point in anyone else’s life, like ruminative thoughts, worry, intrusive thoughts, just this general discomfort. I think this is a really exciting area of research where we’re looking at ways to modulate this pathway to help women cope better. There are studies looking at progesterone metabolites to see if they can be helpful with mood changes during this time.

Kimberley: Interesting. Let’s work through it. As a clinician, if someone presents with anxiety, what I would usually do is do an inventory of the behaviors that they do in effort to reduce or remove that anxiety or uncertainty that they feel. And then we practice purposely returning to those behaviors. Exposure and so forth. From what you understand, would you be doing the same with the hot flashes or is there a balance between, there will be sometimes where you will go in purposely or go out and live your life whether you have a hot flash or not? How do we balance that from a clinical standpoint? Even as a clinician, I’m curious to know. As a clinician, what would I encourage my client to do? Would it be like our normal response of, “Come on, let’s just do it, let’s face all of our fears,” or is there a bit of a balance here that we move towards?

Dr. Katie: It’s more of a balance. I think one of the important things is that what you want to do-- I think the focus is on the cognition here a little bit. I’m not familiar and I don’t think that exposure to hot flashes is intentionally triggering hot flashes repeatedly, like sometimes we do in panic disorders is part of this. What I understand from the protocol is that it’s really looking at the unhelpful cognitions that relate to menopause, aging, and vasomotor symptoms. This idea of like, everybody is looking at me when I’m having a hot flash, this is so shameful. Or maybe it goes further, like no one will like me anymore. Who knows exactly where it can go? We know that when people have cognitive distortions, it’s not really based on rational thinking.

I think other part is you work on monitoring and modifying hot flash triggers, so it feels more in your control like temperature changes and doing those things. I think other things that you do is there’s some evidence for diaphragmatic breathing to help with the management of hot flashes. You teach someone those skills. I think your idea is you want to get them back out there and living their life despite the hot flashes, and also just education. This isn’t going to last forever. Yes, this is uncomfortable, but everybody goes through this. This is a normal part of aging. Also encouraging them to seek treatment if they need it. In addition to therapy, we know that there are medications that can help with this. If the hot flashes are impacting their life in a significant way or very distressing to them, go see a reproductive psychiatrist or go see an OB-GYN who can talk to you about the different options to really treat what’s coming up.

Kimberley: Right. That’s helpful. I want to quickly just add on to that with your advice. I think what you’re saying is when we come from an anxiety treatment model, we are looking at exposure, but when it comes to someone who’s going through this real life, like their actual symptoms aren’t imagined, they’re there, it’s okay for them to modify to not be going to hot saunas and so forth that we know that they’re going to be triggered, but just to do the things that get them back to their daily functioning, but it is still okay for them. I think what I’m trying to say is it’s still okay for them to be doing some accommodation of the symptoms of perimenopause, but not accommodation of the anxiety. Is that where we draw the line?

Dr. Katie: I think that’s a really good way of explaining it.

DEPRESSION AND MENOPAUSE

Kimberley: All right. The other piece of this is as important, which is how depression impacted here. Can you share a little bit how mood changes can be impacted by perimenopause? 

Dr. Katie: Definitely. We know that there’s a significant increase in not only the onset of a new depression, but also recurrence of prior depressive episodes during perimenopause. It’s probably related to the changing levels of hormones, but also, I think what we’ve alluded to and what we have to acknowledge is there are big life changes that are happening around this time as well. I think cultural views of aging, I think a lot of times people have changes in their relationships, their partners. Their libido can change. There’s so many moving parts that they think that also contributes to it. 

But specifically with regard to perimenopausal depression, we categorize this in the reproductive subtype of depression. At these different periods of hormonal transition, certain women are prone to have a depressive episode. We know that that’s true during normal cycling. For example, premenstrual dysphoric disorder or PMDD is a reproductive subtype of depression. People sometimes get depressed in those two weeks before their period and then feel fine during the week of their period or the week after. During the luteal phase, they experience depression. We know that that group of women also is at increased risk for perinatal depression, so depression during pregnancy and postpartum. And then that same group is also at risk for perimenopausal depression. What we know is that a subset of women is probably sensitive to normal levels of changing hormones, and that for them, it triggers a depressive episode. 

One of the biggest risk factors for depression during perimenopause is a prior history of depression. Unfortunately, the way depression works is that once you have it, you’re more likely to have it in the future. For people who have had depression in their life or have specifically had depression around these times of hormonal transition, it’s probably just important to keep an eye on how they’re doing, make sure they have appropriate support, whether that’s from a therapist or a psychiatrist, and monitor themselves closely.

Kimberley: Okay. This is really helpful to know. We know that people with anxiety tend to have depression as well. Have you found those who’ve had previous depression or previous anxiety also have coexisting in terms of having those panic attacks and depression at the same time?

Dr. Katie: That’s interesting. I haven’t read any research on that. It wouldn’t surprise me. But I think at least for research purposes, they’re separating it. I think clinically, of course, we can see it being all mixed together. But for research, it’s depression or panic and they keep those separate.

Kimberley: Right. One thing that just came to me in terms of just clarifying too is, I’m assuming a lot of people who have health anxiety are incredibly triggered during perimenopause as well, these symptoms that are unexplained but explained. But I’m wondering, is that also something that you commonly see in terms of they’re having these symptoms and questioning whether it means something serious is happening? Has that been something that you see a lot of?

Dr. Katie: Definitely. I think the first time someone has a hot flash, it can be extremely distressing. It’s a very uncomfortable sensation. I think there are other changes that happen during perimenopause that, of course, I think, raise concern. We know that in addition to night sweats, people can just have general aches and pains. They can have headaches. Cognitive complaints can be very common during this time. Just this feeling of brain fog, not feeling as sharp as one used to be. They can have sleep disturbances, which can of course worsen the anxiety and the cognitive complaints, and the depression. I think there can be a myriad of symptoms. Other distressing symptoms, I’m not sure if they necessarily-- I think if you know what’s going on, it’s not quite as distressing, but there can be these urogenital symptoms, like vaginal dryness, vaginal burning. There can be recurrent UTIs, there can be difficulty with urination. There are this constellation of symptoms that I’m sure could trigger health anxiety in people, especially if they have preexisting health anxiety.

WHAT TREATMENTS ARE AVAIALBLE TO HELP THOSE WHO ARE SUFFERING FROM MENOPAUSE (OR PERIMENOPAUSE) AND ANXIETY AND DEPRESSION? 

Kimberley: Yeah, absolutely. Someone’s listened to this episode so they’re at least informed, which is wonderful. They start to see enough evidence that this may be what is going on for them. What would be the steps following that? Is it something that you just go through and like a fever, you just ride it out kind of thing? Or are there medications or treatments? What would you suggest someone do in the order as they go through it?

Dr. Katie: I think it depends on what’s going on and how they’re experiencing it. If this is distressing, life interfering, if they’re having trouble functioning, they should absolutely seek treatment. I think there are a few different things they can do depending on what’s going on. For depression and anxiety, medications are the first line. Antidepressants would still be the first-line therapy there. There’s some evidence for menopausal hormone therapy, but there’s not really enough. There is evidence for menopausal hormone therapy, but it’s not currently first line for depression or anxiety. If someone had treatment-resistant depression that came up in the perimenopausal transition, I think it’s reasonable to consider menopausal hormone therapy. But currently, menopausal hormone therapy isn’t really recommended for that. 

If someone is having distressing vasomotor symptoms with night sweats and recurrent hot flashes or hot flushes during the day, menopausal hormone therapy is a very good option. That is something to consider. They could go talk to their OB-GYN about it. Certain people will be candidates for it and other people might not. If you think it might be something you’re interested in, I recommend going and speaking to your OB-GYN sooner rather than later. 

Antidepressants themselves can also help with vasomotor symptoms as well. They can specifically help with hot flashes and night sweats. If someone has depression and anxiety and hot flashes and night sweats, antidepressant can be a really good choice because it can help with both of those. There was a really interesting study that compared Lexapro to menopausal hormone therapy for hot flashes, for quality of life, for sleep, and for depression. Essentially, both of them helped sleep quality of life in vasomotor symptoms, but only the Lexapro helped the depression. It really just depends on what’s going on. 

I think another thing that we’ve also talked about is therapy. This can be a big life transition. I think really no woman going through menopause is the same. Some people have toddlers. Some people have grown children who have just left their home. Some people are just starting their career. Some people are about to retire. Relationships can change. I think that it’s really important to take what’s going on in the context of a woman’s life. I think therapy can be really helpful to help them process and understand what they’re going through.

Kimberley: Right. You had mentioned before, and I just wanted to touch on this, vaginal drying and stuff like that, which I’m sure, again, a reason for this series is just how much sexual intimacy and so forth can impact somebody’s satisfaction in life or functioning or in relationships. Is that something that is also treatable with these different treatment models or is there a different treatment for that? 

Dr. Katie: With menopausal hormone therapy, when someone has hot flashes or these other symptoms that we were talking about, not the urogenital ones, they need to take systemic menopausal hormone therapy. They basically need estrogen and progesterone to go throughout their body. When someone is just having these urogenital symptoms, they can often use topical vaginal estrogen. It’s applied vaginally. That can be really helpful for those symptoms as well. I think if that’s something that someone is struggling with that they want treatment for, it’s very reasonable to go talk to their OB-GYN about it because there are therapies that can be--

Kimberley: Right, that’s like a cream or lotion kind of thing. 

Dr. Katie: Exactly. 

Kimberley: Interesting. Oh wow. All right. That is so helpful. We’ve talked about the medical piece, the medication piece. A lot of people also I see on social media mostly talk about these more-- I don’t want to use the word “natural” because I don’t like that word “natural.” I don’t even know what word I would use, but non-medical--

Dr. Katie: Like supplements or--

Kimberley: Yeah. I know it’s different for everyone and everyone listening should please seek a doctor for medical advice, but is that something that you talk about with patients or do you stick more just to the things that have been researched? What are your thoughts?

Dr. Katie: I think that supplements can be helpful for some people. I don’t always find that they’re as effective as medications. If someone is really struggling on a day-to-day basis, I do think that using treatments that have more evidence behind them is better. I think that there are some supplements that have a little bit of evidence, but I do think that they come with their own risks. Because supplements aren’t regulated by the FDA and things like that, I don’t typically recommend them. I think if someone is interested in finding a more naturopathic doctor who might be able to talk to them about those things is reasonable. 

Kimberley: Super helpful. Is there anything that you feel like we haven’t covered or that would be important for us to really drill home and make sure we point out here at the end before we finish up?

Dr. Katie: I think we’ve covered a lot. I think that the most important thing that I really want to stress is this is a normal part of aging. This is not a disease; this is not a disease state. Also, there are treatments that can be so effective. You don’t have to struggle in silence. It is not something shameful. There are clinicians who are trained, who are able to help if these symptoms are coming up. Just not being afraid to go and talk about it and go reach out for help. I think that that can be so helpful and really life-changing for some people when they get the right treatment.

Kimberley: Right. Thank you. Where can we hear about you, get in touch with you, maybe seek out your services?

Dr. Katie: You can find me online. I have a website. It’s just www.drkatiemd.com. It’s D-R-K-A-T-I-E-M-D.com. You can follow me on Instagram on the same. If you’re interested to see more of my talks and lectures, I often post those on my LinkedIn page. You can follow me on LinkedIn. I think if you are personally interested in learning more about menopause, there’s a really great book by an OB-GYN, her name is Dr. Jen Gunter, and it’s called The Menopause Manifesto. For anybody who really wants to educate themselves about menopause and understand more about what’s going on in their body and their treatments, I really recommend that book.

Kimberley: Amazing. That’s so good to have that resource as well. Thank you. I’m really, really honored. I know you’re doing so many amazing things and running so many amazing programs. I’m so grateful for your time and your expertise on this.

Dr. Katie: Of course. I’m so glad that you’re doing a podcast on this. I think this is a topic that we really need more information and education out there.

Kimberley: Yeah. Thank you.

Welcome. This is Week 4 of the Sexual Health and Anxiety Series. I have loved your feedback about this so far. I have loved hearing what is right for you, what is not right for you, getting your perspective on what can be so helpful. A lot of people are saying that they really are grateful that we are covering sexual health and anxiety because it’s a topic that we really don’t talk enough about. I think there’s so much shame in it, and I think that that’s something we hopefully can break through today by bringing it into the sunlight and bringing it out into the open and just talking about it as it is, which is just all good and all neutral, and we don’t need to judge.

Let’s go through the series so far. In Episode 1 of the series, we did sexual anxiety or sexual performance anxiety with Lauren Fogel Mersy. Number two, we did understanding arousal and anxiety. A lot of you loved that episode, talking a lot about understanding arousal and anxiety. Then last week, we talked about the sexual side effects of anxiety and depression medication or antidepressants with Dr. Sepehr Aziz. That was such a great episode. This week, we’re talking about sexual intrusive thoughts. 

The way that I structured this is I wanted to first address the common concerns people have about sexual health and intimacy and so forth. Now I want to talk about some of the medical pieces and the human pieces that can really complicate things. In this case, it’s your thoughts. The thoughts we have can make a huge impact on how we see ourselves, how we judge ourselves, the meaning we make of it, the identity we give it, and it can be incredibly distressing. My hope today is just to go through and normalize all of these experiences and thoughts and presentations and give you some direction on where you can go from there. Because we do know that your thoughts, as we discussed in the second episode, can impact arousal and your thoughts can impact your sexual anxiety. 

SEXUAL OCD OBSESSIONS

Let’s talk a little bit today about specific sexual intrusive thoughts. Now, sexual intrusive thoughts is also known as sexual obsessions. A sexual obsession is like any other obsession, which is, it is a repetitive, UNWANTED—and let’s emphasize the unwanted piece—sexual thought. There are all different kinds of sexual intrusive thoughts that you can have. For many of you listening, you may have sexual intrusive thoughts and OCD that get together and make a really big mess in your mind and confuse you and bring on doubt and uncertainty, and like I said before, make you question your identity and all of those things. 

In addition to these intrusive thoughts, they often can feel very real. Often when people have these sexual intrusive thoughts, again, we all have intrusive thoughts, but if they’re sexual in nature, when they’re accompanied by anxiety, they can sometimes feel incredibly real, so much so that you start to question everything. 

SEXUAL SENSATIONS

Now, in addition to having sexual intrusive thoughts, some of you have sexual sensations, and we talked a little bit about this in previous episodes. But what I’m really speaking about there is sensations that you would often feel upon arousal. The most common is what we call in the OCD field a groinal response. Some people call it the groinal in and of itself, which is, we know again from previous episodes that when we have sexual thoughts or thoughts that are sexual in nature, we often will feel certain sensations of arousal, whether that be lubrication, swelling, tingling, throbbing. You might simply call it arousal or being turned on. And that is where a lot of people, again, get really confused because they’re having these thoughts that they hate, they’re unwanted, they’re repetitive, they’re impacting their life, they’re associated with a lot of anxiety and uncertainty, and doubt. And then, now you’re having this reaction in your body too, and that groinal response can create a heightened need to engage in compulsions. 

As we know—we talk about this in ERP School, our online course for OCD; we go through this extensively—when someone has an obsession, a thought, an intrusive thought, it creates uncertainty and anxiety. And then naturally what we do is we engage in a compulsion to reduce or remove that discomfort to give them a short-term sense of relief. But then what ends up happening is that short-term relief ends up reinforcing the original obsession, which means you have it more, and then you go back through the cycle. You cycle on that cycle over and over again. It gets so big. It ends up impacting your life so, so much.

INTRUSIVE SEXUAL URGES

Now, let’s also address while we’re here that a lot of you may have intrusive sexual urges. These are also obsessions that we have when you have OCD or OCD-related disorders where you feel like your body is pulling you towards an action to harm someone, to do a sexual act, to some fantasy. You’re having this urge that feels like your body is pulling you like a magnet towards that behavior. Even if you don’t want to do that behavior, or even if that behavior disgusts you and it doesn’t line up with your values, you may still experience these sexual OCD urges that really make you feel like you’re on the cusp of losing control, that you may snap and do that behavior.

This is how impactful these sexual intrusive thoughts can be. This is how powerful they can be in that they can create these layers upon layers. You have the thoughts, then you have the feelings, then you have the sensations, you also have the urges. Often there’s a lot of sexual intrusive images as well, like you see in front of you, like a projector, the image happening or the movie scene playing out that really scares you, concerns you, and so forth. And then all of those layers together make you feel absolutely horrible, terrified, so afraid, so unsure of what’s happening in and of yourself. 

TYPES OF SEXUAL OCD OBSESSIONS

Let’s talk about some specific OCD obsessions and ways in which this plays out. Now, in the OCD field, we call them subtypes. Subtypes are different categories we have of obsessions. They don’t collect all of them. There are people who have a lot of obsessions that don’t fall under these categories, but these subtypes usually include groups of people who experience these subtypes. The reason we do that is, number one, it can be very validating to know that other people are in that subgroup. Number two, it can also really help inform treatment when we have a specific subtype that we know what’s happening, and that can be very helpful and reduce the shame of the person experiencing them. 

1. SEXUAL ORIENTATION OBSESSIONS OR SEXUAL ORIENTATION OCD

It used to be called homosexual OCD. That was because predominantly people who were heterosexual were reporting having thoughts or sexual intrusive thoughts about their sexual orientation—am I gay, am I straight—and really struggling with having certainty about this. Again, now that we’re more inclusive and that I think a lot more people are talking about sexuality, that we have a lot less shame, a lot more education, we scrapped the homosexual OCD or homosexual obsessions or subtype category. Now we have a more inclusive category, which is called sexual orientation OCD. That can include any body of any sexual orientation who has doubt and uncertainty about that. 

Now remember when we started, we talked about the fact that sexual intrusive thoughts are usually unwanted, they’re repetitive and they don’t line up with our values. What we are not talking about here is someone who is actually questioning their sexual orientation. I know a lot of people are. They’re really exploring and being curious about different orientations that appeal to them. That’s way different to the people who have sexual orientation OCD or sexual orientation obsessions. People with OCD are absolutely terrified of this unknown answer, and they feel an incredible sense of urgency to solve it. 

If you experience this, you may actually want to listen back. We’ve got a couple of episodes on this in the past. But it’s really important to understand and we have to understand the nuance here that as you’re doing treatment, we are very careful not to just sweep people under the rug and say, “This is your OCD,” because we want to be informed in knowing that, okay, you also do get to question your sexual orientation. But if it is a presentation of sexual orientation OCD, we will treat it like that and we will be very specific in reducing the compulsions that you’re engaging in so that you can get some relief. That is the first one. 

2. SEXUAL INTRUSIVE THOUGHTS ABOUT FAMILY OR SEXUAL INTRUSIVE THOUGHTS ABOUT INCEST

Incest sexual OCD or that type of subtype is another very common one. But often, again, one that is not talked about enough in fear of being judged, in fear of having too much shame, in fear of being reported. When people have these types of obsessions, they often will have a thought like, “What if I’m attracted to my dad?” Or maybe they’re with their sibling and they experience some arousal for reasons they don’t know. Again, we talked about this in the arousal and anxiety episode, so go back and listen to that if you didn’t. They may experience that, and that is where they will often say, “My brain broke. I feel like I had to solve that answer. I had to figure it out. I need to get complete certainty that that is not the case, and I need to know for sure.” 

The important thing to remember here is a lot of my patients, I will see and they may have some of these sexual intrusive thoughts, but their partners will say, “Yeah, I’ve had the same thoughts.” It’s just that for the person without OCD, they don’t experience that same degree of distress. They blow it off. It doesn’t really land in their brain. It’s just like a fleeting thought. Whereas people with OCD, it’s like the record got stuck and it’s just repeating, repeating, repeating. The distress gets higher. The doubt and uncertainty get higher. Therefore, because of all of this bubbling kettle happening, there’s this really strong urgency to relieve it with compulsions. 

3. SEXUAL INTRUSIVE THOUGHTS ABOUT GOD OR ABOUT A RELIGIOUS LEADER

This is one that’s less common, or should I say less commonly reported. We actually don’t have evidence of how common it is. I think a lot of people have so much shame and are so afraid of sinning and what that means that they may even not report it. But again, this is no different to having thoughts of incest, but this one is particularly focused on having sexual thoughts about God and needing to know what that means and trying to cleanse themselves of their perceived sin, of having that intrusive thought. It can make them question their religion. It can make them feel like they have to stop going to church. They may do a ton of compulsive prayer. They may do a ton of reassurance with certain religious leaders to make sure that they’re not sinning or to relieve them of that uncertainty and that distaste and distress. These are all very common symptoms of people who have sexual intrusive thoughts about God.

4. BESTIALITY OBSESSIONS

These are thoughts about pets and animals, and it’s very common. It’s funny, as we speak, I am recording this with a three-pound puppy sitting on my lap. We just got a three-pound puppy. It is a Malti-Poo puppy dog, and he’s the cutest thing you’ve ever seen. But it’s true that when you have a dog, you’re having to take care of its genitals and wipe it up and its feces and its urine and clean and all the things, and it’s common to have sexual intrusive thoughts about your pet or about your dog or your cat. Some people, again, with bestiality obsessions or bestiality OCD, have a tremendous repetitive degree of these thoughts. They’re very distressing because they love their dog. They would never do anything to hurt their dog, but they can’t stop having these thoughts or these feelings or these sensations, or even these urges.

Again, all these presentations are the same, it’s just that the content is different. We treat them the same when we’re discussing it, but we’re very careful with addressing the high level of shame and embarrassment, humiliation, guilt that they have for these thoughts. Guilt is a huge one with these sexual obsessions. People often feel incredibly guilty as if they’ve done something wrong for having these obsessions. These are a few. 

5. PEDOPHILIA OBSESSIONS

Now, for someone who has intrusive sexual thoughts and feelings and sensations and urges about children (POCD), they tend to be, in my experience, the most distressed. They tend to be, when I see them, the ones who come in absolutely completely taken over with guilt and shame. A lot of the time, they will have completely removed themselves from their child. They feel they’re not responsible. They won’t go near the parks. They won’t go to family’s birthday parties. They’re so insistent on trying to never have these thoughts. Again, I understand. I don’t blame them. But as we know, the more you try not to have a thought, what happens? The more you have it. The more you try and suppress a thought, the more you have it. That can get people in a very stuck cycle. 

SEXUAL OCD  COMPULSIONS

Let’s move on now to really address different sexual OCD compulsions. 

Now, for all sexual obsessions, or what I should say is, for all obsessions in general, there are specific categories of compulsions and these are things again that we do to reduce or remove the discomfort and certainty, dread, doubt, and so forth. 

1. Trigger Avoidance

This is where you avoid the thing that may trigger your obsession or thought. Avoiding your dog, avoiding your child, avoiding your family member, avoiding people of the sexual orientation that you’re having uncertainty about. 

2. Actual Sex Avoidance

We talked about that in the first episode. We talked a lot about how people avoid sex because of the anxiety that being intimate and sexual causes. 

3. Mental Rumination

This is a really common one for sexual intrusive thoughts because you just want to solve like why am I having it? What does it mean? You might be ruminating, what could that mean? And going over and over and over that a many, many time. 

4. Mental Checking

What you can also be doing here is checking for arousal. Next time you’re around, let’s say, a dog and you have bestiality obsessions, you might check to see if you’re aroused. But just checking to see if you’re aroused means that you get aroused. Now that you’re aroused, you’re now checking to see what that means and trying to figure that out and you’re very distressed. 

We can see how often the compulsion that the person does actually triggers more and more and more distress. It may provide you a moment or a fleeting moment of relief, but then you actually have more distress. It usually brings on more uncertainty. We know that the more we try and control life, the more out of control we feel. That’s a general rule. That’s very much the case for these types of obsessive thoughts. 

5. Pornography Use

A lot of people who have sexual orientation OCD in particular, but any of these, they may actually use pornography as a way to get reassurance that they are of a certain sexual orientation, that they are not attracted to the orientation that they’re having uncertainty about, or they’re not attracted to animals or God or a family member because they were aroused watching pornography. That becomes a form of self-reassurance. 

There’s two types of reassurance. One is reassurance where we go to somebody else and say, “Are you sure I wouldn’t do that thing? Are you sure that thing isn’t true? Are you sure I don’t have that? I’m not that bad a person?” The other one is really giving reassurance to yourself, and that’s a very common one with pornography use. 

SEXUAL INTRUSIVE THOUGHTS PTSD 

There are some sexual intrusive thought examples, including specific obsessions and subtypes, and also compulsions. But one sexual intrusive thought example I also wanted to address is not OCD-related; it’s actually related to a different diagnosis, which is called PTSD (post-traumatic stress disorder). Often for people who have been sexually assaulted or molested, they too may experience sexual intrusive thoughts in the form of memories or images of what happened to them or what could have happened to them. Maybe it’s often some version of what happened to them, and that is a common presentation for PTSD. If you are experiencing PTSD, usually, there is a traumatic event that is related to the obsession or the thoughts. They usually are in association or accompanied by flashbacks. There are many other symptoms. I’m not a PTSD specialist, but there’s a high level of distress, many nightmares. You may have flashbacks, as I’ve said. Panic is a huge part of PTSD as well. That is common. If you have had a traumatic event, I would go and see a specialist and help them to make sure that they’ve diagnosed you correctly so that you can get the correct care. 

SEXUAL INTRUSIVE THOUGHTS TREATMENT

If you have OCD and you’re having some of these sexual intrusive thoughts, the best treatment for you to go and get immediately is Exposure and Response Prevention. This is a particular type of cognitive behavioral therapy where you can learn to change your reaction, break yourself out of that cycle of obsessions, anxiety, compulsions, and then feed yourself back into the loop around and around. You can break that cycle and return back to doing the things you want and have a different reaction to the thoughts that you have.

PEOPLE ASK HOW TO STOP SEXUAL INTRUSIVE THOUGHTS? 

Often people will come to me and say, “How do I stop these sexual intrusive thoughts?” I will quickly say to them, “You don’t. The more you try and stop them, the more you’re going to have. But what we can do is we can act very skillfully in intervening, not by preventing the thoughts, but by changing how we relate and respond to those thoughts.” For those of you who don’t know, I have a whole course on this called ERP School. ERP is for Exposure and Response Prevention. I’ll show you how you can do this on your own, or you can reach out to me and we can talk about whether if you’re in the states where we’re licensed, one of my associates can help you one-on-one. If you’re not in a state where I belong, reach out to the IOCDF and see if you can find someone who treats OCD using ERP in your area. Because the truth is, you don’t have to suffer having these thoughts. There is a treatment to help you manage these thoughts and help you be much more comfortable in response to those thoughts. Of course, the truth here is you’re never going to like them. Nobody likes these thoughts. The goal isn’t to like them. The goal isn’t to make them go away. The goal isn’t to prove them wrong even; it’s just to change your reaction to one that doesn’t keep that cycle going. That is the key component when it comes to sexual intrusive thoughts treatment or OCD treatment. That’s true for any subtype of OCD because there are many other subtypes as well. 

That’s it, guys. I could go on and on and on and on about this, but I want to be respectful of your time. The main goal again is just to normalize that these thoughts happen. For some people, it happens more than others. The goal, if you can take one thing away from today, it would be, try not to assign meaning to the duration and frequency of which you have these thoughts. Often people will say, “I have them all day. That has to mean something.” I’m here to say, “Let’s not assign meaning to these thoughts at all. Thoughts are thoughts. They come and they go. They don’t have meaning and we want to practice not assigning meaning to them so we don’t strengthen that cycle.” 

I hope that was helpful for you guys. I know it was a ton of information. I hope it was super, super helpful. I am so excited to continue with this. 

Next week, we are talking about menopause and anxiety, which we have an amazing doctor again. I want to talk about things with people who are really skilled in this area. We have a medical doctor coming on talking about menopause and the impact of anxiety. And then we’re going to talk about PMS and anxiety, and that will hopefully conclude our sexual health and anxiety series. 

Thank you so much for being here. I love you guys so much. Thank you from me and from Theo, our beautiful little baby puppy. I will see you next week.

Hello and welcome back everybody. We are on Week 3 of the Sexual Health and Anxiety Series. At first, we talked with the amazing Lauren Fogel Mersy about sexual anxiety or sexual performance anxiety. And then last week, I went into depth about really understanding arousal and anxiety, how certain things will increase arousal, certain things will decrease it, and teaching you how to get to know what is what so that you can have a rich, intimate, fulfilling life. 

We are now on Week 3. I have to admit, this is an episode that I so have wanted to do for quite a while, mainly because I get asked these questions so often and I actually don’t know the answers. It’s actually out of my scope. In clinical terms, we call it “out of my scope of practice,” meaning the topic we’re talking about today is out of my skill set. It’s out of my pay grade. It’s out of my level of training. 

What we’re talking about this week is the sexual side effects of antidepressants or anxiety medications, the common ones that people have when they are anxious or depressed. Now, as I said to you, this is a medical topic, one in which I am not trained to talk about, so I invited Dr. Sepehr Aziz onto the episode, and he does such a beautiful job, a respectful, kind, compassionate approach to addressing sexual side effects of anxiety medication, sexual side effects of depression medication. It’s just beautiful. It’s just so beautiful. I feel like I want to almost hand this episode off to every patient when I first start treating them, because I think so often when we’re either on medication or we’re considering medication, this is a really common concern, one in which people often aren’t game to discuss. So, here we are. I’m actually going to leave it right to the doctor, leave it to the pro to talk all about sexual side effects and what you can do, and how you may discuss this with your medical provider. Let’s do it.

Kimberley: Welcome. I have been wanting to do this interview for so long. I am so excited to have with us Dr. Sepehr Aziz. Thank you so much for being here with us today.

Dr. Aziz: Thanks for having me.

Kimberley: Okay. I have so many questions we’re going to get through as much as we can. Before we get started, just tell us a little about you and your background, and tell us what you want to tell us.

Dr. Aziz: Sure. Again, I’m Dr. Sepehr Aziz. I go by “Shepherd,” so you can go ahead and call me Shep if you’d like. I’m a psychiatrist. I’m board certified in general adult psychiatry as well as child and adolescent psychiatry by the American Board of Psychiatry and Neurology. I completed medical school and did my residency in UMass where they originally developed mindfulness-based CBT and MBSR. And then I completed my Child and Adolescent training at UCSF. I’ve been working since then at USC as a Clinical Assistant Professor of Psychiatry there. I see a lot of OCD patients. I do specialize in anxiety disorders and ADHD as well.

Kimberley: Which is why you’re the perfect person for this job today.

Dr. Aziz: Thank you. 

WHAT ARE THE BEST MEDICATIONS FOR PEOPLE WITH ANXIETY & OCD (IN GENERAL)?

Kimberley: I thank you so much for being here. I want to get straight into the big questions that I get asked so regularly and I don’t feel qualified to answer myself. What are the best medications for people with anxiety and OCD? Is there a general go-to? Can you give me some explanation on that?

Dr. Aziz: As part of my practice, I first and foremost always try to let patients know that the best treatment is always a combination of therapy as well as medications. It’s really important to pursue therapy because medications can treat things and they can make it easier to tolerate your anxiety, but ultimately, in order to have sustained change, you really want to have therapy as well. Now, the first-line medications for anxiety and OCD are the same, and that’s SSRIs or selective serotonin reuptake inhibitors. SNRIs, which are selective norepinephrine reuptake inhibitors, also work generally, but the best research that we have in the literature is on SSRIs, and that’s why they’re usually preferred first. There are other medications that also might work, but these are usually first-line, as we call it. There are no specific SSRIs that might work better. We’ve tried some head-to-head trials sometimes, but there’s no one medication that works better than others. It’s just tailored depending on the patient and the different side effects of the medication.

SSRI’S VS ANTIDEPRESSANTS DEFINITION

Kimberley: Right. Just so people are clear in SSRI, a lot of people, and I notice, use the term antidepressant. Are they synonymous or are they different?

Dr. Aziz: Originally, they were called antidepressants when they first were released because that was the indication. There was an epidemic of depression and we were really badly looking for medications that would work. Started out with tricyclic antidepressants and then we had MAOIs, and then eventually, we developed SSRIs. These all fall under antidepressant treatments. However, later on, we realized that they work very well for anxiety in addition to depression. Actually, in my opinion, they work better for anxiety than they do for depression. I generally shy away from referring to them as antidepressants just to reduce the stigma around them a little bit and also to be more accurate in the way that I talk about them. But yes, they’re synonymous, you could say. 

BEST MEDICATION FOR DEPRESSION

Kimberley: Sure. Thank you for clearing that up because that’s a question I often get. I know I led you in a direction away but you answered. What is the best medication for people with depression then? Is it those SSRIs or would you go--

Dr. Aziz: Again, these are first-line medications, which means it’s the first medication we would try if we’re starting medication, which is SSRIs. Other medications might also work like SNRIs again. For depression specifically, there are medications called serotonin modulators that are also effective such as vortioxetine or nefazodone, or vilazodone. But SSRIs are generally what people reach for first just because they’ve been around for a long time, they’re available generic, they work, and there’s no evidence that the newer medications or modulators work better. They’re usually first line.

Kimberley: Fantastic. Now you brought up the term “generic” and I think that that’s an important topic because the cost of therapy is high. A lot of people may be wondering, is the generic as good as the non-generic options?

Dr. Aziz: It really depends on the medication and it also depends on which country you’re in. In the US, we have pretty strict laws as to how closely a generic has to be to a regular medication, a brand name medication, and there’s a margin of error that they allow. The margin of error for generics is, I believe, a little bit higher than for the brand name. However, most of the time, it’s pretty close. For something like Lexapro, I usually don’t have any pressure on myself to prescribe the brand name over the generic. For something like other medications we use in psychiatry that might have a specific way that the brand name is released, a non-anxiety example is Concerta, which is for ADHD.

This medication uses an osmotic release mechanism and that’s proprietary. They license it out to one generic company, but that license is expiring. All those patients who are on that generic in the next month or two are going to notice a difference in the way that the medication is released. Unless you’re a physician privy to that information, you might not even know that that’s going to happen. That’s where you see a big change. Otherwise, for most of the antidepressants, I haven’t noticed a big difference between generic and brand names.  

Kimberley: Right. Super helpful. Now you mentioned it depends on the person. How might one decide or who does decide what medication they would go on?

Dr. Aziz: It’s really something that needs to be discussed between the person and their psychiatrist. There are a number of variables that go into that, such as what’s worked in a family member in the past, because there are genetic factors in hepatic metabolism and things like that that give us some clue as to what might work. Or sometimes if I have a patient with co-occurring ADHD and I know they’re going to be missing their medications a lot, I’m more likely to prescribe them Prozac because it has a longer half-life, so it’ll last longer. If they miss a dose or two, it’s not as big of a deal. If I have a patient who’s very nervous about getting off of the medication when they get pregnant, I would avoid Prozac because it has a long half-life and it would take longer to come off of the medication. Some medications like Prozac and Zoloft are more likely to cause insomnia or agitation in younger people, so I’ll take that into consideration. Some medications have a higher likelihood of causing weight loss versus weight gain. These are all things that would take into consideration in order to tailor it to the specific patient.

Kimberley: Right. I think that’s been my experience too. They will usually ask, do you have a sibling or a parent that tried a certain medication, and was that helpful? I love that question. I think it informs a lot of decisions. We’re here really. The main goal of today is really to talk about one particular set of side effects, which is the sexual side effects of medication. In fact, I think most commonly with clients of mine, that tends to be the first thing they’re afraid of having to happen. How common are sexual side effects? Is it in fact all hype or is it something that is actually a concern? How would you explain the prevalence of the side effects?

Dr. Aziz: This is a really important topic, I just want to say, because it is something that I feel is neglected when patients are talking to physicians, and that’s just because it can be uncomfortable to talk about these things sometimes, both for physicians and for patients. Oftentimes, it’s avoided almost. But because of that, we don’t know for sure exactly what the incidence rate is. The literature on this and the research on this is not very accurate for a number of reasons. There are limitations. The range is somewhere between 15 to 80% and the best estimate is about 50%. But I don’t even like saying that because it really depends on age, gender, what other co-occurring disorders they have such as depression. Unipolar depression can also cause sexual dysfunction. They don’t always take that into account in these studies. A lot of the studies don’t ask baseline sexual function before asking if there’s dysfunction after starting a medication, so it’s hard to tell. What I can say for sure, and this is what I tell my patients, is that this sexual dysfunction is the number one reason why people stop taking the medication, because of adverse effects. 

WHAT MEDICATIONS ARE MORE PRONE TO SEXUAL SIDE EFFECTS? 

Kimberley: Right. It’s interesting you say that we actually don’t know, and it is true. I’ve had clients say having anxiety has sexual side effects too, having depression has sexual side effects too, and they’re weighing the pros and cons of going on medication comparative to when you’re depressed, you may not have any sexual drive as well. Are some medications more prone to these sexual side effects? Does that help inform your decision on what you prescribe because of certain meds?

Dr. Aziz: Yeah. I mean, the SSRIs specifically are the ones that are most likely to cause sexual side effects. Technically, it’s the tricyclics, but no one really prescribes those in high doses anymore. It’s very rare. They’re the number one. But in terms of the more commonly prescribed antidepressants and anti-anxiety medications among the SSRIs and the SNRIs and the things like bupropion and the serotonin modulators we talked about, the SSRIs are most likely to cause sexual dysfunction.

Kimberley: Right. Forgive me for my lack of knowledge here, I just want to make sure I’m understanding this. What about the medications like Xanax and the more panic-related medications? Is that underneath this category? Can you just explain that to me?

Dr. Aziz: I don’t usually include those in this category. Those medications work for anxiety technically, but in current standard practice, we don’t start them as an initial medication for anxiety disorders because there’s a physical dependency that can occur and then it becomes hard to come off of the medication. They’re used more for panic as an episodic abortive medication when someone is in the middle of a panic attack, or in certain cases of anxiety that’s not responding well to more conventional treatment, we’ll start it. We’ll start it on top of or instead of those medications. They can cause sexual side effects, but it’s not the same and it’s much less likely. 

SEXUAL SIDE EFFECTS OF MEDICATION FOR MEN VS WOMEN 

Kimberley: Okay. Very helpful. Is it the same? I know you said we don’t have a lot of data, and I think that’s true because of the stigma around reporting sexual side effects, or even just talking about sex in general. Do we have any data on whether it impacts men more than women?

Dr. Aziz: The data shows that women report more sexual side effects, but we believe that’s because women are more likely to be treated with SSRIs. When we’re looking at the per capita, we don’t have good numbers in terms of that. In my own practice, I’d say it’s pretty equal. I feel like men might complain about it more, but again, I’m a man and so it might just be a comfort thing of reporting it to me versus not reporting. Although I try to be good about asking before and after I start medication, which is very important to do. But again, it doesn’t happen all the time.

Kimberley: Yeah, it’s interesting, isn’t it? Because from my experience as a clinician, not a psychiatrist, and this is very anecdotal, I’ve heard men because of not the stigma, but the pressure to have a full erection and to be very hard, that there’s a certain masculinity that’s very much vulnerable when they have sexual side effects—I’ve heard that to be very distressing. In my experience. I’ve had women be really disappointed in the sexual side effects, but I didn’t feel that... I mean, that’s not really entirely true because I think there’s shame on both ends. Do you notice that the expectations on gender impacts how much people report or the distress that they have about the sexual side effects? 

Dr. Aziz: Definitely. I think, like you said, men feel more shame when it comes to sexual side effects. For women, it’s more annoyance. We haven’t really talked about what the sexual side effects are, but that also differs between the sexes. Something that’s the same between sexes, it takes longer to achieve orgasm or climax. In some cases, you can’t. For men, it can cause erectile dysfunction or low libido. For women, it can also cause low libido or lack of lubrication, which can also lead to pain on penetration or pain when you’re having sex. These are differences between the sexes that can cause different reporting and different feelings, really.

Kimberley: Right. That’s interesting that it’s showing up in that. It really sounds like it impacts all the areas of sexual playfulness and sexual activity, the arousal, the lubrication. That’s true for men too, by the sounds of it. Is that correct? 

Dr. Aziz: Yeah. 

Kimberley: We’ve already done one episode about the sexual performance anxiety, and I’m sure it probably adds to performance anxiety when that’s not going well as well, correct?

Dr. Aziz: It’s interesting because in my practice, when I identify that someone is having sexual performance anxiety or I feel like somebody, especially people with anxiety disorders, if I feel like they have vulvodynia, which means pain on penetration—if I see they have vulvodynia and I feel that this is because of the anxiety, oftentimes the SSRI might improve that and cause greater satisfaction from sex. It’s a double-edged sword here.

COMMON SEXUAL SIDE EFFECTS OF ANTIDEPRESSANTS

Kimberley: Yeah. Can you tell me a little more about What symptoms are they having? The pain? What was it called again?

Dr. Aziz: Vulvodynia.

Kimberley: Is that for men and women? Just for women, I’m assuming.

Dr. Aziz: Just from vulva, it is referring to the outside of the female genitalia. Especially when you have a lack of lubrication or sometimes the muscles, everyone with anxiety knows sometimes you have muscle tension and there are a lot of complex muscles in the pelvic floor. Sometimes this can cause pain when you’re having sex. There are different ways to address that, but SSRIs sometimes can improve that. 

Kimberley: Wow. It can improve it, and sometimes it can create a side effect as well, and it’s just a matter of trial and error, would you say?

Dr. Aziz: It’s a delicate balance because these side effects are also dose-dependent. It’s not like black or white. I start someone on 5 milligrams, which is a child’s dose of Lexapro. Either they have sexual side effects or don’t. They might not have it on 5, and then they might have it a little bit on 10, and then they get to 20 and they’re like, “Doctor, I can’t have orgasms anymore.” We try to find the balance between improving the anxiety and avoiding side effects.

SEXUAL SIDE EFFECTS TREATMENT

Kimberley: You’re going right into the big question, which is, when someone does have side effects, is it the first line of response to look at the dose? Or how would you handle a case if someone came to you first and said, “I’m having sexual side effects, what can we do?” 

Dr. Aziz: Again, I’m really thorough personally. Before I even seem to start a medication, I’ll ask about libido and erectile dysfunction and ability to climax and things like that, so I have a baseline. That’s important when you are thinking about making a change to someone’s medications. The other thing that’s important is, is the medication working for them? If they haven’t seen a big difference since they started the medication, I might change the medication. If they’ve seen an improvement, now there’s a pressure on me to keep the medication on because it’s working and helping. I might augment it with a second medication that’ll help reverse the sexual side effects or I might think about reducing the dose a little bit while maintaining somewhere in the therapeutic zone of doses or I might recommend, and I always recommend non-pharmacological ways of addressing sexual side effects. You always do that at baseline.

Kimberley: What would that be?

Dr. Aziz: There’s watchful waiting. Sometimes if you just wait and give it some time, these symptoms can get better. I’m a little more active than that. I’ll say it’s not just waiting, but it’s waiting and practicing, whether that’s solo practice or with your partner. Sometimes planning sex helps, especially if you have low libido. There’s something about the anticipation that can make someone more excited. The use of different aids for sex such as toys, vibrators, or pornography, whether that’s pornographic novels or imagery, can sometimes help with the libido issues and also improve satisfaction for both partners. The other thing which doesn’t have great research, but there is a small research study on this, and not a lot of people know about this, but if you exercise about an hour before sex, you’re more likely to achieve climax. This was specifically studied in people with SSRI-related anorgasmia.

Kimberley: Interesting. I’m assuming too, like lubricants, oils, and things like that as well, or?

Dr. Aziz: For lubrication issues, yes. Lubricants, oils, and again, you really have to give people psychoeducation on which ones they have to use, which ones they have to avoid, which ones interact with condoms, and which ones don’t. But you would recommend those as well.

Kimberley: Is it a normal practice to also refer for sex therapy? If the medication is helping their symptoms, depression, anxiety, OCD, would you ever refer to sex therapy to help with that? Is that a standard practice or is that for specific diagnoses, like you said, with the pain around the vulva and so forth?

Dr. Aziz: Absolutely. A lot of the things I just talked about are part of sex therapy and they’re part of the sexual education that you would receive when you go to a sex therapist. I happen to be comfortable talking about these things, and I’ve experienced talking about it. When I write my notes, that would fall under me doing therapy. But a lot of psychiatrists would refer to a sex therapist. Hopefully, there are some in the town nearby where someone is. It’s sometimes hard to find someone that specializes in that.

Kimberley: Is there some pushback with that? I mean, I know when I’ve had patients and they’re having some sexual dysfunction and they do have some pushback that they feel a lot of shame around using vibrators or toys. Do you notice a more willingness to try that because they want to stay on the meds? Or is it still very difficult for them to consider trying these additional things? Are they more likely to just say, “No, the meds are the problem, I want to go off the medication”?

Dr. Aziz: It really depends on the patient. In my population that I see, I work at USC on campus, so I only see university students in my USC practice. My age group is like 18 to 40. Generally, people are pretty receptive. Obviously, it’s very delicate to speak to some people who have undergone sexual trauma in the past. Again, since I’m a man, sometimes speaking to a woman who’s had sexual trauma can be triggering. It’s a very delicate way that you have to speak and sometimes there’s some pushback or resistance. It can really be bad for the patient because they’re having a problem and they’re uncomfortable talking about it. There might be a shortage of female psychiatrists for me to refer to. We see that. There’s also a portion of the population that’s just generally uncomfortable with this, especially people who are more religious might be uncomfortable talking about this and you have to approach that from a certain angle. I happen to also be specialized in cultural psychiatry, so I deal with these things a lot, approaching things from a very specific cultural approach, culturally informative approach. Definitely, you see resistance in many populations.

Kimberley: I think that that’s so true. One thing I want to ask you, which I probably should have asked you before, is what would you say to the person who wants to try meds but is afraid of the potential of side effects? Is there a certain spiel or way in which you educate them to help them understand the risks or the benefits? How do you go about that for those who there’s no sexual side effects, they’re just afraid of the possibility?

Dr. Aziz: As part of my practice, I give as much informed consent to my patients as I can. I let them know what might happen and how that’s going to look afterwards. Once it happens, what would we do about it if it happened? A lot of times, especially patients with anxiety, you catastrophize and you feel this fear of some potential bad thing happening, and you never go past that. You never ask yourself, okay, well now let’s imagine that happens. What happens next? I tell my patients, “Yeah, you might have sexual dysfunction, but if that happens, we can reduce the medications or stop them and they’ll go away.” I also have to tell my patients that if they search the internet, there are many people who have sexual side effects, which didn’t go away, and who are very upset about it. This is something that is talked about on Reddit, on Twitter. When my patients go to Dr. Google and do their research, they often get really scared. “Doctor, what if this happens and it doesn’t go away?” I always try to explain to them, I have hundreds of patients that I’ve treated with these medications. In my practice, that’s never happened. As far as I know from the literature, there are no studies that show that there are permanent dysfunctions sexually because of SSRIs. 

Now, like I said, the research is not complete, but everything that I’ve read has been anecdotal. My feeling is that if you address these things in the beginning and you’re diligent in asking about the side effects of baseline sexual function beforehand and you are comfortable talking with your patients about it, you can avoid this completely. That’s been my experience. When I explain that to my patients, they feel like I have their back, like they’re protected, like I’m not just going to let them fall through the cracks. That has worked for me very well.

Kimberley: Right. It sounds like you give them some hope too, that this can be a positive experience, that this could be a great next step.

Dr. Aziz: Yeah, absolutely.

Kimberley: Thank you for bringing up Dr. Google, because referring to Reddit for anything psychologically related is not a great idea, I will say. Definitely, when it comes to medications, I think another thing that I see a lot that’s interesting on social media is I often will get dozens of questions saying, “I heard such and such works. Have your clients taken this medication? I heard this medication doesn’t work. What’s your experience?” Or if I’ve told them about my own personal experience, they want to know all about it because that will help inform their decision. Would you agree, do not get your information from social media or online at all?

Dr. Aziz: I have patients who come to me and they’re like, “My friend took Lexapro and said it was the worst thing in the world, and it may or not feel any emotions.” I’m explaining to them, I literally have hundreds of patients, hundreds that I prescribe this to, and I go up and down on the dose. I talk to them about their intimate lives all day. But for some reason, and it makes sense, the word of their friend or someone close to them, really, carries a lot of weight. Also, I don’t want to discount Reddit either, because I feel like it’s as a support system and as a support group. I find other people who have gone through what you’ve gone through. It’s very strong. Even pages like-- I don’t want to say the page, but there’s a page that’s against psychiatry, and I peruse this page a lot because I have my own qualms about psychiatry sometimes. I know the pharmaceutical companies have a certain pressure on themselves financially, and I know hospitals have a certain pressure on themselves. I get it. I go on the page and there’s a lot of people who have been hurt in the past, and it’s useful for patients to see other people who share that feeling and to get support. But at the same time, it’s important to find providers that you can trust and to have strong critical thinking skills, and be able to advocate for yourself while still listening to somebody who might have more information than you.

Kimberley: I’m so grateful you mentioned that. I do think that that is true. I think it’s also what I try to remember when I am online. The people who haven’t had a bad experience aren’t posting on Reddit. They’re out having a great time because it helped, the medication helped them, and they just want to move on. I really respect those who have a bad experience. They feel the need to educate. But I don’t think it’s that 50% who gave a great experience are on Reddit either. Would you agree?

Dr. Aziz: Right. Yeah. The people who are having great outcomes are not creating a Reddit page to go talk about it, right?

Kimberley: Yeah. Thank you so much for answering all my questions. Is there a general message that you want to give? Maybe it’s even saying it once over on something you’ve said before. What would be your final message for people who are listening?

WHEN SSRIs IMPACTS YOUR SEX LIFE: ADVICE FROM DR AZIZ

Dr. Aziz: I just want to say that when SSRI’s impact your sex life, it’s really important for psychiatry, and especially in therapy, that you feel comfortable sharing your experiences in that room. It should be a safe space where you feel comfortable talking about your feelings at home and what’s going on in your intimate life and how things are affecting you. Your feelings, positive or negative towards your therapist or your psychiatrist, whether things they said made you uncomfortable, whether you feel they’re avoiding something, that room should be a safe space for you to be as open as possible. When you are as open as possible, that’s when you’re going to get the best care because your provider, especially in mental health, needs to know the whole picture of what’s going on in your life. Oftentimes, we are just as uncomfortable as you. And so, again, a lot of providers might avoid it because they’re afraid of offending you by asking about your orgasms. As a patient, you take the initiative and you bring it up. It’s going to improve your care. Try not to be afraid of bringing these things up. If you do feel uncomfortable for any reason, always let your provider know. 

I always tell my patients, I have a therapist. I pay a lot of money to see my therapist, and sometimes I tell him things I hate about him. He’s a great therapist. He’s psychoanalytic. Every time I bring something up, he brings it back to something about my dad. He’s way older than me. But he’s a great therapist. Every time I’ve brought something like that up, it’s been a breakthrough for me because that feeling means something. That would be my main message to everyone listening.

Kimberley: Thank you. I’m so grateful for your time and your expertise. Really, thank you. Can you tell us where people can get in touch with you, seek out your services, read more about you?

Dr. Aziz: Sure. I work for OCD SoCal. I’m on the executive board, and that’s the main way I like to communicate with people who see me on programs like this. You can always email me at S, like my first name, Aziz, that’s A-Z-I-Z, @OCDSoCal.org. If you’re a USC student, you can call Student Health and request to see me at the PBHS clinic. That’s the Psychiatry and Behavioral Health Services clinic on campus at USC.

Kimberley: They’re lucky to have you.

Dr. Aziz: Thank you.

Kimberley: Yes. I love that you’re there. Thank you so much for all of your expertise. I am so grateful. This has been so helpful.

Welcome back, everybody. We are on Episode 2 of the Sexual Health and Anxiety Series. Today, I will be the main host and main speaker for the episode, talking about arousal and anxiety. This is a topic that goes widely misunderstood, particularly in the OCD and anxiety field where people are having arousal that they can’t make sense of. It’s also very true of people with PTSD. They’re having arousal that makes no sense to them, that confuses them, that increases anxiety, increases shame, increases guilt, and from there, it all becomes like a huge mess to them. It becomes incredibly painful, and it’s just so messy they can’t make sense of it. 

My hope with this episode is to help you understand the science behind arousal and the science behind arousal and anxiety so that you can move forward and manage your anxiety around arousal and manage your shame and guilt and sadness and grief around arousal, and have a better relationship with your body and with yourself and your soul.

Now, these are more difficult conversations. I have talked about them in the past, and so I want you just to go into this really, really gentle, really open with con compassion and kindness, and curiosity. Your curiosity is going to help you immensely as you move through this series, as you move through some of the difficult conversations we’re going to have, maybe a little bit embarrassing, humiliating, and so forth. Even me telling my kids that I’m so excited, I’m doing a series on sexual health, they’re like, “Mom, you can’t talk about that to other people.” I’m like, “Yes, I can. We’re going to talk about it. Hopefully, when you’re old enough, you’ll be able to listen to this and you’ll be so glad that we’re having conversations around this and taking the shame and stigma, and misinformation out of it.”

I’m going to go straight into the episode. This is our episode on understanding arousal and anxiety. We are going to come on next week talking about an entirely different subject about sexual health and intimacy, sex and anxiety, and arousal and anxiety. I am so excited. Stick around. Enjoy every bit of it. Take as many notes as you can, but please, please be kind to yourself. Let’s get to the show.

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ANXIETY AND AROUSAL

Let’s get into the episode. Let me preface the episode by, we’re talking about anxiety and arousal. If I could have one person on the podcast, it would be Emily Nagoski. I have been trying to get her on the podcast for a while. We will get her on eventually. However, she’s off doing amazing things—Netflix specials, podcasts, vet documentaries. She’s doing amazing things. Hopefully one day. But until then, I want to really highlight her as the genius behind a lot of these concepts. 

Emily Nagoski is a doctor, a psychology doctor. She is a sex educator. She’s written two amazing books. Well, actually three or four, but the ones I’m referring to today is Come As You Are. It’s an amazing book, but I’m actually in my hand holding The Come As You Are Workbook. I strongly encourage you after you listen to this podcast episode to go and order that book. It is amazing. It’s got tons of activities. It might feel weird to have the book. You can get it on Kindle if you want to have it be hidden, but it’s so filled with amazing information and I’m going to try and give you the pieces that I really want you to take away. If you want more, by all means, go and get the workbook. The workbook is called The Come As You Are Workbook: A Practical Guide to The Science of Sex. The reason I love it is because it’s so helpful for those who have anxiety. It’s like she’s speaking directly to us. She’s like, “It’s so helpful to have this context.”

Here’s the thing I want you to consider starting off. A lot of people who have anxiety report struggles with arousal. We’re going to talk about two different struggles that are the highlight of today. Either you have no arousal because of your anxiety, or you’re having arousal at particular times that concern you and confuse you, and alarm you. You could be one or both of those camps. Let’s first talk about those who are struggling with arousal in terms of getting aroused. 

The thing I want you to think about is, commonly, this is true for any mental health issue too. It’s true for depression, anxiety disorders, eating disorders, dissociative disorders—all of them really. But the thing I want you to remember, no matter who you are and what your experience is, even if you have a really healthy experience of your own sexual arousal and you’re feeling fine about it, we all have what’s called inhibitors and exciters. Here is an example: An inhibitor is something that inhibits your arousal. An exciter is something that excites your arousal. 

Now, you’re probably already feeling a ton of judgment here like, “I shouldn’t be aroused by this, and I should be aroused by this. What if I’m aroused by this and I shouldn’t be,” and so forth. I want us to take all the judgment out of this and just look at the content of what inhibits our arousal or excites our arousal. Because sometimes, and I’ll talk about this more, it’s for reasons that don’t make a lot of sense, and that’s okay.

SEXUAL INHIBITORS AND SEXUAL EXCITERS

Let’s talk about a sexual inhibitor—something that pumps the brakes on arousal or pleasure. It could be either. There’s exciters, which are the things that are really like the gas pedal. They just really bring on arousal, bring on pleasure, and so forth. 

We have the content. The content may be, first, mental or physical, and this includes your health, your physical health. For me, I know when I am struggling with POTS, arousal is just barely a thing. You’re just so wiped out and you’re so exhausted and your brain is foggy, and it’s just like nothing. That would be, in my case, an inhibitor. I’m not going to talk about myself a lot here, but I was just using that as an example. You might say your anxiety or your obsession is an inhibitor. It pumps the brakes on arousal. It makes it go away. Worry is one. It could also be other physical health like headaches or tummy aches or, as we said before, depression. It could be hormone imbalances, things like that. It’s all as important. Go and speak with your doctor. That’s super important. Make sure medically everything checks out if you’re noticing a dip or change in arousal, that’s concerning you. 

The next one in terms of content that may either excite you or inhibit you is your relationship. If your relationship is going well, you may or may not have an increase in arousal depending on what turns you on. If your partner smells of a certain smell or stench that you don’t like, that may pump the brakes. But if they smell a certain way that you do really like, and really is arousing to you, that may excite your arousal. It could also be the vibe of the relationship. A lot of people said, at the beginning of COVID, there was a lot of fear. That was really, really strong on the brakes. But then all of a sudden, no one had anything to do, and there was all this spare time. All of a sudden, the vibe is like, that’s what’s happening. Now, this could be true for people who are in any partnership, or it could be just you on your own too. There are things that will excite you and inhibit your arousal if you’re not in a relationship as well, and that’s totally fine. This is for all relationships. There’s no specific kind. 

Setting is another thing that may pump the brakes or hit the gas for arousal, meaning certain places, certain rooms, certain events. Did your partner do something that turned you on? Going back to physical, it could also depend on your menstrual cycle. People have different levels of arousal depending on different stages of their menstrual cycle. I think the same is true for men, but I don’t actually have a lot of research on that. But I’m sure there are some hormonal impacts for men as well.

There’s also ludic factors, which are like fantasy, whether you have a really strong imagination that either pumps the brakes or puts the gas pedal in terms of arousal. It could be like where you’re being touched. Sometimes there’s certain areas of your body that will set off either the gas pedal or the brakes. It could be a certain foreplay. Again, really what I’m trying to get at here isn’t breaking it down according to the workbook, but there’s so many factors that may influence your arousal. 

SHAME AND SEXUAL AROUSAL

Another one is environmental and cultural and shame. If arousal and the whole concept of sex was shamed or booked down on, or people have a certain opinion about your sexual orientation, that too can impact your gas pedal and your brakes pedal. I want you to explore this not from a place of pulling it apart really aggressively and critically, but really curiously, and check in for yourself. What arouses me? What presses my brakes? What presses my gas? And just start to get to know that. Again, in the workbook, there’s tons of worksheets for this, but you could also just consider this on your own. Write it down on your own. Be aware over the next several days or weeks, just jot down in a journal what you’re noticing.

Now, before we move on, we’ve talked about a lot of people who are struggling with arousal and they’ve got a lot of inhibitors and brake pushing. There are the other camps who have a lot of gas pedal pushing. I speak here directly to the folks who have sexual obsessions, because often if you have sexual obsessions, the fact that your sexual obsession is sexual in nature may be what sets the gas pedal off, and all of a sudden, you have arousal for reasons that you don’t understand, that don’t make sense to you or maybe go against your values.

I’ve got a quote that I took from the book and from the workbook of Emily Nagoski. Again, none of this is my personal stuff. I’m quoting her and citing her throughout this whole podcast. She says: “Bodies do not say yes or no; they say sex-related or not sex-related.” Let me say it again. “Bodies do not say yes or no; they say sex-related or not sex-related.” This is where I want you to consider, and I’ve experienced this myself. Just because something arouses you doesn’t mean it brings you pleasure—main point. We’ve got to pull them apart.

SEXUAL OBSESSIONS & AROUSAL

Culture has led us to believe that if you feel some groinal response to something, you must love it and want more of it. An example of this is, for people with sexual obsessions, maybe they have OCD or some other anxiety disorder and they have an intrusive thought about a baby or an animal. Bestiality is another very common obsession with OCD, or could be just about a person. It could be just about a person that you see in the grocery store. When you have a thought that is sex-related, sometimes, because the context of it is that it’s sex-related, your body may get aroused. Our job, particularly if you have OCD, is not to try and figure out what that means, is not to try and resolve like, does that mean I like it? Does that mean I’m a terrible person? What does that mean? I want you to understand the science here to help you understand your arousal, to help you understand how you can now shift your perspective towards your body and your mind and the pleasure that you experience in the area of sexuality.

THE GROINAL RESPONSE

Let’s talk about the groial resopsne. Again, the body doesn’t say yes or no; they say either sex-related or not sex-related. Here’s the funny thing, and I’ve done this experiment with my patients before, if you look at a lamp post or it could be anything. You could look at the pencil you’re holding, and you think about, and then you bring to mind a sexual experience, you may notice arousal (or the groinal response). Again, it doesn’t mean that you’re now aroused by pencils or pens; it’s that it was labeled as sex-related. Often your brain will naturally press the accelerator. That’s often how I educate people, particularly those who are having arousal that concern it. It’s the same for a lot of people who have sexual trauma. They maybe are really concerned about the fact that they do have arousal around a memory or something, and then that concerns them, what does that mean about me? 

The thing to remember too is it’s not your body saying yes or no; it’s your body saying sex-related or not sex-related. It’s important to just help remind yourself of that so that you’re not responding to the content so much and getting caught up in compulsive behaviors. 

A lot of my patients in the past have reported, particularly during times when they’re stressed, their anxiety is really high, life is difficult, any of this content we went through, they may actually have a hard time being aroused at all. Some people have reported not getting an erection and then it completely going for reasons they don’t understand. I think here, we want to practice, again, non-judgment. Instead, move to curiosity. There’s probably some content that impacted that, which is, again, very, very normal. 

BETTER SEX THROUGH MINDFULNESS

I’m talking with patients. I’ve done episodes on this in the past and we’ve in fact had sex therapists on the podcast in the past. They’ve said, if you’ve lost arousal, it doesn’t mean you give up. It doesn’t mean you say, “Oh, well, that’s that.” What you do is you move your attention to the content that pumps the gas. When I mean content, it’s like touch, smell, the relationship, the vibe, being in touch with your body, bringing your attention to the dance that you’re doing, whether it’s with a partner or by yourself or whatever means that works for you. You can bring that back. Another amazing book is called Better Sex Through Mindfulness. It talks a lot about bringing your attention to one or two sensations. Touch and smell being two really, really great ones. 

Again, if your goal is to be aroused, you might find it’s very hard to be aroused because the context of that is pressure. I don’t know about you, but I don’t really find pressure arousing. Some may, and again, this is where I want this to be completely judgment free. There is literally no right and wrong. But pressure is usually not that arousing. Pressure is not that pleasurable in many cases, particularly when it’s forceful and it feels like you have to perform a certain way. Again, some people are at their best in performance mode, but I want to just remind you, the more pressure you put on yourself on this idea of ending it well, it’s probably going to make some anxiety. Same with test anxiety. The more pressure you put on yourself to get an A, the more you’re likely to spin out with anxiety. It’s really no different. 

Here is where I want you to catch and ask yourself, is the pressure I put on myself or is the agenda I put on myself actually pumping the brakes for me when it comes to arousal? Is me trying not to have a thought, actually in the context of that, does that actually pump the brakes? Because I know you’re trying not to have the thought so that you can be intimate in that moment and engaged in pleasure. But the act of trying not to have the thought can actually pump the brakes. I hope that makes sense. I want you to get really close to understanding what’s going on for you. Everyone is different. Some things will pump the brakes, some things will pump the accelerator. A lot of the times, thought suppression pumps the brakes. A lot of the times, beating yourself up pumps the brakes. A lot of the time, they’re more like goal, like I have to do it this way. That often pumps the brakes. Keep an eye out for that. Engage in the exciters and get really mindful and present. 

A couple of things here. We’ve talked about erections. That’s for people who struggle with that. It’s also true for women and men with lubrication. Some people get really upset about the fact that there may or may not be a ton of lubrication. Again, we’ve been misled to believe that if you’re not lubricated, you mustn’t be aroused or that you mustn’t want this thing, or that there must be something wrong with you, and that is entirely not true. A lot of women, when we study them, may be really engaged and their gas pedal is going for it, but there may be no lubrication. It doesn’t mean something is wrong in those cases. Often a sex therapist or a sex educator will encourage you to use lubrication, a lubricant. I’ve talked to clients and they’re so ashamed of that. But I think it’s important to recognize that that’s just because somebody taught us that, and sadly, it’s a lot to do with patriarchy and that it was pushed on women in particular, that that meant they’re like a good woman if they’re really lubricated. That’s not true. That’s just fake, false, no science, has no basis in reality. 

Now we’ve talked about lubrication, we’ve talked about erection. Same for orgasm. Some people get really frustrated and disheartened that they can’t reach orgasm. If for any reason you’re struggling with this, please, I urge you, go and see a sex therapist. They are like the most highly trained therapists. They are so sensitive and compassionate. They can talk with you about this and you can target the specific things you want to work on. But orgasm is another one. If you put pressure on yourself to get there, that pumps the brakes often. 

What I want you to do, and this is your homework, is don’t focus on arousal; focus on pleasure. Again, it’s really about being in connection with your partner or yourself. As soon as you put a list of to-dos with it is often when things go wrong. Just focus on being present as much as you can and in the moment being aware of, ooh. Move towards the exciters, the gas pedal things. Move away from the inhibitors. Be careful there. Again, for those of you who have anxiety, that doesn’t mean thought suppress, that doesn’t mean judge your thoughts because that in and of itself is an inhibitor often.

I want to leave you with that. I’m going to, in the future, do a whole nother episode about talking more about this idea of arousal non-concordance, which is that quote I used: “The bodies don’t say yes or no; they say sex-related or not sex-related.” I’ll do more of that in the future, but for right now, I want it to be around you exploring your relationship with arousal, understanding it, but then putting your attention on pleasure. Being aware of both, being mindful of both. 

I’m not a sex therapist. Again, I’m getting all of this directly from the workbook, but most of the clients I’ve talked to about this, and we’ve used some worksheets and so forth, they’ve said, “When I put all the expectations away and I just focus on this touch and this body part and this smell and this kiss or this fantasy, or being really in touch with your own body, when I just make it as simple as that and I bring it down to just engaging in what feels good, use it as a north star. You just keep following, that feels good. Okay, that feels good. That doesn’t feel so great. I’ll move towards what feels good”—moving in that direction non-judgmentally and curiously, they’ve had the time of their lives. I really just want to give you that gift. Focus on pleasure. Focus non-judgmentally and curiously, being aware of what’s current and present in your senses.

That’s all I got for you for today. I think it’s enough. Do we agree? I think it’s enough. I could talk about this all day. To be honest, and I’ve said this so many times, if I had enough time, I would go back and I would become a sex therapist. It is a huge training. Sex therapists have the most intensive, extensive training and requirements. I would love to do it. But one day, I’ll probably do it when I’m like 70. That will be awesome. I’ll be down for that for sure. 

I just love this content. Again, I want to be really clear, I’m not a sex therapist and so I still have tons to learn. I still have. Even with what we’ve covered today, there’s probably nuanced things that I could probably explain better, which is why I’m going to stress to you, go and check out the book.

I was thinking about this. Remember I just recently did the episode on the three-day silent retreat and I was sitting in meditation. I remember this so clearly. I’m just going to tell you this quick story. For some reason, my mind was a little scattered this day and something came over with me where I was like, “Wouldn’t it be wonderful if I didn’t just treat anxiety disorders but I treated the person and the many problems that are associated with the anxiety disorder? Isn’t that a beautiful goal? Isn’t that so? Because it’s not just the anxiety; it’s the little tiny areas in our lives that it impacts.” As soon as I finished the meditation, I went on to my organization board that I use online and it was like, “Arousal. Let’s talk about pee and poop,” which is one episode we recently did. “Let’s talk about all the things because anxiety affects it all.” We can make little changes in all these areas, and slowly, you get your life back. So, I hope this gives you a little bit of your sexual expression back, if I could put it into words. Maybe not expression, but just your relationship with your body and pleasure. 

I love you. Thank you for staying with me for this. This was brave work you’re doing. You probably had cringey moments. Hopefully not. Again, none of this is weird, wrong, bad. This is all human stuff. So, finish up. Again, go check out the book. Her name is Emily Nagoski. I’ll leave a link in the show notes. One day we’ll get her on. But in the meantime, I’ll hopefully just give you the science that she’s so beautifully given us.

You guys, I am literally giggling with excitement over what we are about to do together. 

Last year, we did a series, the first series on Your Anxiety Toolkit where we talked about mental compulsions. It was a six-part series. We had some of the best therapists and best doctors in the world talking about mental compulsions. It was such a hit. So many people got so much benefit out of it. I loved it so much, and I thought that was fun, let’s get back to regular programming. But for the entire of last year after that series, it kept bugging me that I needed to do a series on sexual health and anxiety. It seems like we’re not talking about it enough. It seems like everyone has questions, even people on social media. The algorithm actually works against those who are trying to educate people around sex and sexual side effects and arousal and how anxiety impacts it. And so here I am. No one can stop us. Let’s do it. 

This is going to be a six-part sexual health and anxiety series, and today we have a return guest, the amazing Lauren Fogel Mersy. She is the best. She is a sex therapist. She talks all about amazing stuff around sexual desire, sexual arousal, sexual anxiety. She’s going to share with you, she has a book coming out, but she is going to kick this series off talking about sexual anxiety, or we actually also compare and contrast sexual performance anxiety because that tends to better explain what some of the people’s symptoms are. 

Once we go through this episode, we’re then going to meet me next week where I’m going to go back over. I’ve done an episode on it before, but we’re going to go back over understanding arousal and anxiety. And then we’re going to have some amazing doctors talking about medications and sexual side effects. We have an episode on sexual intrusive thoughts. We have an episode on premenstrual anxiety. We also have an episode on menopause and anxiety. My hope is that we can drop down into the topics that aren’t being covered enough so that you feel like you’ve got one series, a place to go that will help you with the many ways in which anxiety can impact us when it comes to our sexual health, our sexual arousal, our sexual intimacy. I am so, so, so excited. Let’s get straight to it. 

This is Episode 1 of the Sexual Health and Anxiety Series with Dr. Lauren Fogel Mersy. Lauren is a licensed psychologist. She’s a certified sex therapist, she’s an author, and she is going to share with us and we’re going to talk in-depth about sexual anxiety. I hope you enjoy the show. I hope you enjoy all of the episodes in this series. I cannot wait to listen to these amazing speakers—Lauren, being the first one. Thank you, Lauren.

What Is Sexual Anxiety Or Sexual Performance Anxiety? Are They The Same Thing?

Kimberley: Welcome. I am so happy to have you back, Dr. Lauren Fogel Mersy. Welcome.

Dr. Lauren: Thank you so much for having me back. I’m glad to be here.

Kimberley: I really wanted to deep dive with you. We’ve already done an episode together. I’m such a joy to have you on. For those of you who want to go back, it’s Episode 140 and we really talked there about how anxiety impacts sex. I think that that is really the big conversation. Today, I wanted to deep dive a little deeper into talking specifically about sexual anxiety, or as I did a little bit of research, what some people call sexual performance anxiety. My first question for you is, what is sexual anxiety or what is sexual performance anxiety? Are they the same thing or are they a little different?

Dr. Lauren: I think people will use those words interchangeably. It’s funny, as you say that, I think that performance anxiety, that word ‘performance’ in particular, I hear that more among men than I do among women. I think that that might be attributed to so many people’s definition of sex is penetration. In order for penetration to be possible, if there’s a partner who has a penis involved that that requires an erection. I often hear that word ‘performance’ attributed to essentially erection anxiety or something to do with, will the erection stay? Will it last? Basically, will penetration be possible and work out? I think I often hear it attributed to that. And then sexual anxiety is a maybe broader term for a whole host of things, I would say, beyond just erection anxiety, which can involve anxiety about being penetrated. It could be anxiety about certain sexual acts like oral sex giving, receiving. It could be about whether your body will respond in the way that you want and hope it to. I think that word, sexual anxiety, that phrasing can encompass a lot of different things.

WHAT ARE SOME SEXUAL ANXIETY SYMPTOMS?

Kimberley: Yeah. I always think of it as, for me, when I talk with my patients about the anticipatory anxiety of sex as well. Like you said, what’s going to happen? Will I orgasm? Will I not? Will they like my body? Will they not? I think that it can be so broad. I love how you define that, how they can be different. That performance piece I think is really important. You spoke to it just a little, but I’d like to go a little deeper. What are some symptoms of sexual anxiety that a man or a woman may experience? 

Dr. Lauren: I think this can be many different things. For some people, it’s the inability to get aroused, which sifting through the many things that can contribute to that, knowing maybe that I’m getting into my head and that’s what’s maybe tripping me up and making it difficult to get aroused. It could be a racing heartbeat as you’re starting to get close to your partner, knowing that sex may be on the table. I’ve had some people describe it can get as severe as getting nauseated, feeling like you might be sick because you’re so worked up over the experience. Some of that maybe comes from trauma or negative experiences from the past, or some of it could be around a first experience with a partner really hoping and wanting it to go well. Sometimes we can get really nervous and those nerves can come out in our bodies, and then they can also manifest in all of the thoughts that we have in the moment, really getting distracted and not being able to focus and just be present. It can look like a lot of different things.

SEXUAL AVOIDANCE

Kimberley: That’s so interesting to hear in terms of how it impacts and shows up. What about people who avoid sex entirely because of that? I’m guessing for me, I’m often hearing about people who are avoiding. I’m guessing for you, people are coming for the same reason. You’re a sex therapist. How does that show up in your practice?

Dr. Lauren: One of the things that can cause avoidance-- there’s actually an avoidance cycle that people can experience either on their own or within a partnership, and that avoidance is a way of managing anxiety or managing the distress that can come with challenging sexual experiences and trying to either protect ourselves or protect our relationships from having those outcomes as a possibility. There used to be a diagnosis called sexual aversion. It was called a sexual aversion disorder. We don’t have that in our language anymore. We don’t use that disorder because I think it’s a really protective, sensible thing that we might do at times when we get overwhelmed or when we’re outside of what we call a window of tolerance. It can show up as complete avoidance of sexual activity. It could show up as recoiling from physical touch as a way to not indicate a desire for that to progress any further. It could be avoidance of dating because you don’t want the inevitable conversation about sexuality or the eventuality that maybe will come up. Depending on whether you’re partnered or single and how that manifests in the relationship, it can come out in different ways through the avoidance of maybe different parts of the sexual experience, everything from dampening desire to avoiding touch altogether. 

Kimberley: That’s really interesting. They used to have it be a diagnosis and then now, did they give it a different name or did they just wipe it off of the DSM completely? What would you do diagnostically now? 

Dr. Lauren: It’s a great question. I think it was wiped out completely. I haven’t looked at a DSM in a long time. I think it was swiped out completely. Just personally as a sex therapist and the clinician I am today, I don’t use many of the sexual health diagnoses from the DSM because I think that they are pathologizing to the variation in the human sexual experience. I’m not so fond of them myself. What I usually do is I would frame that as an anxiety-related concern or just more of a sexual therapy or sex counseling concern. Because I think as we have a growing understanding of our nervous system and the ways in which our system steps in to protect us when something feels overwhelming or frightening or uncertain, I think it starts to make a lot of sense as to why we might avoid something or respond in the ways that we do. Once we have some understanding of maybe there’s some good sense behind this move that you’re making, whether that’s to avoid or protect or to hesitate or to get in your head, then we can have some power over adjusting how we’re experiencing the event once we understand that there’s usually a good reason why something’s there.

Kimberley: That is so beautiful. I love that you frame it that way. It’s actually a good lesson for me because I am always in the mindset of like, we’ve got to get rid of avoidance. That’s the anxiety work that I do. I think that you bring up a beautiful point that I hadn’t even considered, which is, we always look at avoidance as something we have to fix as soon as possible. I think what you’re saying is you don’t conceptualize it that way at all and we can talk more about what you could do to help if someone is having avoidance and they want to fix that. But what I think you’re saying is we’re not here to pathologize that as a problem here.

Dr. Lauren: Yeah. I see it, I’m trained less in the specifics. I think that makes a lot of sense when you’re working with specific anxiety disorders and OCD and the like. I’ve, as of late, been training in more and more emotionally focused therapy. I’m coming at it from an attachment perspective, and I’m coming at it from somewhat of a systemic perspective and saying, what is the avoidance doing? What is it trying to tell us? There’s usually some good reason somewhere along the way that we got where we are. Can I validate that that makes sense? That when something is scary or uncertain or you were never given good information or you really want something to go well and you’re not sure about it, and it means a lot to you, there’s all kinds of good reasons why that might hit as overwhelming.

When we’re talking about performance anxiety or sexual anxiety, really the number one strategy I’m looking for is, how can we work with what we call your window of tolerance? If your current comfort zone encompasses a certain amount of things, whatever that might be, certain sexual acts with maybe a certain person, maybe by yourself, I want to help you break down where you want to get to and break that into the smallest, manageable, tolerable steps so that what we’re doing is we’ve got one foot in your current window of what you can tolerate and maybe just a toe at a time out, and breaking that up into manageable pieces so that we don’t keep overwhelming your system. That is essentially what my job is with a lot of folks, is helping them take those steps and often what our nervous system needs to register, that it’s okay, that it’s safe, that we can move towards our goals. Cognitively, we think it’s too slow or it’s too small. It’s not. We have to really break that down. 

If there’s something about the sexual experience that you’re avoiding, that is overwhelming, that you’re afraid of, what I do is validate that, makes sense that that maybe is just too much and too big all at once. And then let’s figure out a way to work ourselves up to that goal over time. Usually, slower is faster. 

WHY DO PEOPLE HAVE SEXUAL ANXIETY? 

Kimberley: I love that. I really do. Why do people have sexual anxiety? Is that even an important question? Do you explore that with your patients? I think a lot of people, when I see them in my office or online, we know there’s a concern that they want to fix, but they’re really quite distressed by the feeling that something is wrong with them and they want to figure out what’s wrong with them. Do you have some feedback on why people have sexual anxiety? 

Dr. Lauren: I do. I think it can stem from a number of experiences or lack thereof in our lives. There are some trends and themes that come up again and again that I’ve seen over the years in sex therapy. Even though we’re taping here in the US, we’re in a culture that has a lot of sexuality embedded within the media, there is still a lot of taboo and a lot of misinformation about sex or a lack of information that people are given. I mean, we still have to fight for comprehensive sex education. Some people have gotten explicitly negative messages about sex growing up. Some people have been given very little to know information about sex growing up. Both of those environments can create anxiety about sex. We also live in a world where we’re talking openly about sex with friends, parents teaching their children more than just abstinence, and going into a little bit more depth about what healthy sexuality looks like between adults. A lot of that is still not happening. What you get is a very little frame of reference for what’s ‘normal’ and what’s considered concerning versus what is par for the course with a lifetime of being a sexual person. So, a lot of people are just left in the dark, and that can create anxiety for a good portion of those folks, whether it’s having misinformation or just no information about what to expect. And then the best thing that most of us have to draw on is the Hollywood version of a very brief sex scene.

Kimberley: Yes. I was just thinking about that.

Dr. Lauren: And it’s just so wildly different than your actual reality.

Kimberley: Yeah. That’s exactly what I was thinking about, is the expectation is getting higher and higher, especially as we’re more accessible to pornography online, for the young folks as well, just what they expect themselves to do.

Dr. Lauren: That’s right. We have young people being exposed to that on the internet. We’ve got adults viewing that. With proper porn literacy and ethical porn consumption, that can be a really healthy way to enjoy erotic content and to engage in sexuality. The troubling thing is when we’re not media literate, when we don’t have some of the critical thinking to really remember and retain the idea that this entertainment, this is for arousal purposes, that it’s really not giving an accurate or even close depiction of what really goes on between partners. I think it’s easier for us to maintain that level of awareness when we’re consuming general movies and television. But there’s something about that sexuality when you see it depicted in the media that so many people are still grappling with trying to mimic what they see. I think that’s because there’s such an absence of a frame of reference other than those media depictions.

SEXUAL ANXIETY IN MALES VS SEXUAL ANXIETY IN FEMALES 

Kimberley: Right. So good. Is there a difference between sexual anxiety in males and sexual anxiety in females?

Dr. Lauren: I think it can show up differently, certainly depending on what role you play in the sexual dynamic, what positions you’re looking to or what sexual acts you’re looking to explore. There’s a different level or a different flavor of anxiety, managing erection anxiety, managing anxiety around premature ejaculation. They’re all similar, but there’s some unique pieces to each one. All of the types of anxiety that I’ve seen related to sex have some common threads, which is getting up into our heads and dampening the experience of pleasure not being as present in the moment, not being as embodied in the moment, because we get too focused on what will or won’t happen just moments from now. 

While that makes so much sense, you’re trying to foretell whether it’s going to be a positive experience, there is a-- I hate to say like a self-fulfilling prophecy, but there’s a reaction in our bodies to some of those anxious thoughts. If I get into my head and I start thinking to myself, “This may not go well. This might hurt. I might lose my arousal. I might not be able to orgasm. My partner may not think I’m good in bed,” whatever those anxious thoughts are, the thoughts themselves can become a trigger for a physical reaction. That physical reaction is that it can turn on our sympathetic nervous system, and that is the part of our body that says, “Hey, something in the environment might be dangerous here, and it’s time to mobilize and get ready to run.”

What happens in those moments once our sympathetic system is online, a lot of that blood flow goes out of our genital region, out of our chest and into our extremities, to your arms, to your legs. Your body is acting as if there was a bear right there in front of you and your heart rate goes up and all of these things. Now, some of those can also be signs of arousal. That’s where it can get really tricky because panting or increased heart rate or sweating can also be arousal. It’s really confusing for some people because there can be a parallel process in your physiology. Is this arousal or is this anxiety? 

CAN ANXIETY IMPACT AROUSAL? CAN ANXIETY IMPACT SEX DRIVE? 

Kimberley: It’s funny that you mentioned that because as I was researching and doing a little bit of Googling about these topics, one of the questions which I don’t get asked very often is, can anxiety cause arousal? Because I know last time, we talked about how anxiety can reduce arousal. Is that something that people will often report to you that having anxiety causes them to have sexual arousal, not fight and flight arousal?

Dr. Lauren: Yeah. I mean, what I see more than anything is that it links to desire, and here’s how that tends to work for some people because then the desire links to the arousal and it becomes a chain. For many people out in the world, they engage in sexual activity to impart self-soothe and manage stress. It becomes a strategy or an activity that you might lean on when you’re feeling increased stress or distress. That could be several different emotions that include anxiety. If over my lifetime or throughout the years as I’ve grown, maybe I turn to masturbation, maybe I turn to partnered sex when I’m feeling anxious, stressed, or distressed, over time, that’s going to create a wiring of some of that emotion, and then my go-to strategy for decreasing that emotion or working through that emotion. That pairing over time can definitely work out so that as soon as I start feeling anxious, I might quickly come to feelings of arousal or a desire to be sexual.

Kimberley: Very interesting. Thank you. That was not a question I had, but it was interesting that it came up when I was researching. Very, very cool. This is like a wild card question. Again, when I was researching here, one of the things that I got went down a little rabbit hole, a Google rabbit hole, how you go down those...

Dr. Lauren: That’s never happened to me.

WHAT IS POST-SEX ANXIETY? 

Kimberley: ...is, what about post-sex anxiety? A lot of what we are talking about today, what I would assume is anticipatory anxiety or during-sex anxiety. What about post-sex anxiety? What is post-sex anxiety?

Dr. Lauren: I’ve come across more-- I don’t know if it’s research or articles that have been written about something called postcoital dysphoria, which is like after-sex blues. Some people get tearful, some get sad, some feel like they want to pull away from their partner and they need a little bit of space. That’s certainly a thing that people report. I think either coexisting with that or sometimes in its place can be maybe feelings of anxiety that ramp up. I think that can be for a variety of things. Some of it could be, again, getting into your head and then doing a replay like, was that good? Are they satisfied? We get into this thinking that it’s like a good or bad experience and which one was it.

Also, there’s many people who look to sex, especially when we have more anxiety, and particularly if we have a more predominantly anxious attachment where we look to sex as a way to validate the relationship, to feel comforted, to feel secure, to feel steady. There’s a process that happens where it’s like seeking out sex for comfort and steadiness, having sex in the moment, feeling more grounded. And then some of that anxiety may just return right on the other end once sex is over, and then you’re back to maybe feeling some insecurity or unsteadiness again. When that happens, that’s usually a sign that it’s not just about sex. It’s not just a sexual thing. It’s actually more of an attachment and an insecurity element that needs and warrants may be a greater conversation. 

The other thing is your hormones and chemicals change throughout the experience. You get this increase of bonding maybe with a partner, oxytocin, and feel-good chemicals, and then they can sometimes drop off after an orgasm, after the experience. For some people, they might just experience that as depressed mood anxiety, or just a feeling of being unsettled.

Kimberley: That’s so interesting. It makes total sense about the attachment piece and the relational piece, and that rumination, that more self-criticism that people may do once they’ve reviewed their performance per se. That’s really helpful to hear. Actually, several people have mentioned to me when I do lives on Instagram the postcoital dysphoria. Maybe you could help me with the way to word it, but is that because of a hormone shift, or is that, again, because of a psychological shift that happens after orgasm?

Dr. Lauren: My understanding is that we’re still learning about it, that we’ve noticed that it’s a phenomenon. We’re aware of it, we have a name for it, but I don’t know that we have enough research to fully understand it just yet. Right now, if I’m not misquoting the research, I believe our understanding is more anecdotal at this point. I would say, many different things could be possible, anything from chemical changes to attachment insecurities, and there’s probably things that are beyond that I’m also missing in that equation. I think it’s something we’re still studying.

HOW TO OVERCOME SEX ANXIETY, AND HOW CAN WE COPE WITH SEX ANXIETY?  

Kimberley: Very interesting. Let’s talk now about solutions. When should someone reach out to either a medical professional, a mental health professional? What would you advise them to do if they’re experiencing sexual anxiety or performance anxiety when it comes to sex?

Dr. Lauren: That makes a lot of sense. That’s a great question. What I like to tell people is I want you to think of your sexual experiences like a bell curve. For those who were not very science or math-minded like myself, just a quick refresher, a bell curve basically says that the majority of your experiences in sex are going to be good, or that’s what we’re hoping for and aiming for. And then there’s going to be a few on one tail, there’s going to be some of those, not the majority, that are amazing, that are excellent, that really stand out. Yes, mind-blowing, fabulous. And then there’s the other side of that curve, that pole. The other end is going to be, something didn’t work out, disappointing, frustrating. There is no 100% sexual function across a lifetime with zero hiccups. That’s not going to be a realistic goal or expectation for us. 

I always like to start off by reminding people that you’re going to have some variation and experience. What we’d like is for at least a good chunk of them to be what Barry McCarthy calls good enough sex. It doesn’t have to be mind-blowing every time, but we want it to be satisfying, of good quality. If you find that once or twice you can’t get aroused, you don’t orgasm, you’re not as into it, one of the liabilities for us anxious folks, and I consider myself one of them having generalized anxiety disorder my whole life—one of the things that we can do sometimes is get catastrophic with one or two events where it doesn’t go well and start to jump to the conclusion that this is a really bad thing that’s happening and it’s going to happen again, and it’s life-altering sort of thing. One thing is just keeping this in mind that sometimes that’s going to happen, and that doesn’t necessarily mean that the next time you go to be sexual that it’ll happen again. But if you start to notice a pattern, a trend over several encounters, then you might consider reaching out to someone like a general therapist, a sex therapist to help you figure out what’s going on. 

Sometimes there’s a medical component to some of these concerns, like a pattern of difficulty with arousal. That’s not a bad idea to get that checked out by a medical provider because sometimes there could be blood flow concerns or hormone concerns. Again, I think we’re looking for patterns. If there’s a pattern, if it’s something that’s happening more than a handful of times, and certainly if it’s distressing to you, that might be a reason to reach out and see a professional.

Kimberley: I think you’re right. I love the bell curve idea and actually, that sounds very true because often I’ll have clients who have never mentioned sex to me. We’re working on their anxiety disorder, and then they have one time where they were unable to become aroused or have an erection or have an orgasm. And then like you said, that catastrophic thought of like, “What happens if this happens again? What if it keeps happening?” And then as you said, they start to ruminate and then they start to avoid and they seek reassurance and all those things. And then we’re in that kind of, as you said, self-fulfilling, now we’re in that pattern. That rings very, very true. What about, is there any piece of this? I know I’m disclosing and maybe from my listeners, you’re probably thinking it’s TMI, but I remember after having children that everything was different and it did require me to go and speak to a doctor and check that out. So, my concerns were valid in that point. Would it be go to the therapist first, go to the doctor first? What would you recommend?

Dr. Lauren: Yeah. I mean, you’re not alone in that. The concerns are always valid, whether they’re medical, whether they’re psychological, wherever it’s stemming from. If after once or twice you get freaked out and you want to just go get checked out, I don’t want to discourage anybody from doing that either. We’re more than happy to see you, even if it’s happened once or twice, just to help walk you through that so you’re not alone. But the patterns are what we’re looking for overall. 

I think it depends. Here’s some of the signs that I look for. If sex is painful, particularly for people with vaginas, if it’s painful and it’s consistently painful, that’s something that I would recommend seeing a sexual medicine specialist for. There are some websites you can go to to look up a sexual medicine specialist, someone in particular who has received specialized training to treat painful sex and pelvic pain. That would be an indicator. If your body is doing a lot of bracing and tensing with sex so your pelvic floor muscles are getting really tight, your thighs are clenching up, those might be some moments where maybe you want to see a medical provider because from there, they may or may not recommend, depending on whether it’s a fit for you, something called pelvic floor therapy. That’s something that people can do at various stages of life for various reasons but is doing some work specifically with the body. 

Other things would be for folks with penises. If you’re waking up consistently over time where you’re having difficulty getting erections for sexual activity and you’re not waking up with erections anymore, that morning wood—if that’s consistent over time, that could be an indicator to go get something checked out, maybe get some blood work, talk to your primary care just to make sure that there’s nothing in addition to maybe if we think anxiety is a part of it, make sure there’s nothing else that could be going on as well.

HOW TO COPE WITH SEX ANXIETY

Kimberley: Right. I love this. This is so good. Thank you again. Let’s quickly just round it out with, how may we overcome this sex anxiety, or how could we cope with sex anxiety?

Dr. Lauren: It’s the million-dollar question, and I’ve got a pretty, I’ll say, simple but not easy answer. It’s a very basic answer.

Kimberley: The good answers are always simple but hard to apply.

Dr. Lauren: Simple, it’s a simple theory or idea. It’s very hard in practice. One of, I’d say, the main things I do as a sex therapist is help people really diversify what sex is. The more rigid of a definition we have for sex and the more rigidly we adhere to a very particular set of things that have to happen in a particular order, in a very specific way, the more trouble we’re going to have throughout our lifetime making that specific thing happen. The work is really in broadening and expanding our definition of sex and having maybe a handful of different pathways to be sexual or to be intimate with a partner so that, hey, if today I have a little bit more anxiety and I’m not so sure that I get aroused that we can do path A or B. If penetration is not possible today because of whatever reason that we can take path C. When we have more energy or less energy, more time, less time, that the more flexibility we have and expansiveness we have to being intimate and sexual, the more sexual you’ll be.

Kimberley: Just because I want to make sure I can get what you’re saying, when you say this inflexible idea of what this narrow you’re talking about, I’m assuming, I’m putting words in your mouth and maybe what you’re thinking because I’m sure everybody’s different, but would I be right in assuming that the general population think that sex is just intercourse and what you’re saying is that it’s broader in terms of oral sex and other? Is that the A, B, and C you’re talking about? 

Dr. Lauren: Yeah. There’s this standard sexual script that most people follow. It’s the one that we see in Hollywood, in erotic videos. It centers mostly heterosexual vaginal penetration, so penis and vagina sex. It centers sex as culminating in orgasm mainly for the man, and then nice if it happens for the woman as well in these heterosexual scenarios. It follows a very linear progression from start to finish. It looks something like—tell me if this doesn’t sound familiar—a little bit of kissing and some light touching and then some heavier touching, groping, caressing, and then maybe oral sex and then penetration as the main event, orgasm as the finish line. That would be an example of when I say path A or B or C. I’m thinking like that in particular what I just described. 

Let’s call that path A for not that it’s the gold standard, but it’s the one we draw on. Let’s say that’s one option for having a sexual encounter. But I also want people to think about there’s going to be times where that is not on the table for a variety of reasons, because if you think about it, that requires a certain energy, time. There might be certain conditions that you feel need to be present in order for that to be possible. For some people, it automatically goes to the wayside the moment something happens like, “Well, I don’t feel like I have enough time,” or “I’m tired,” or “I’m menstruating,” or whatever it is. Something comes up as a barrier and then that goes out the door. That can include things like anxiety and feeling like we have to adhere to this progression in this particular way. Let’s call that path A. Path B might be, we select a couple of things from that that we like. Let’s say we do a little kissing and we do oral sex and we say goodnight. Let’s say path C is we take a shower together and we kiss and we soap each other’s backs and we hug. That’s path C. Path D is massaging each other, full body. You’ve got all these different pathways to being erotic or sensual or intimate or sexual. The more that you have different pathways to being intimate, the more intimate you’ll be.

Kimberley: That is so relieving is the word I feel. I feel a sense of relief in terms of like, you’re right. I think that that is a huge answer, as you said. Actually, I think it’s a good answer. I don’t think that’s a hard answer. I like that. For me, it feels like this wonderful relief of pressure or change of story and narrative. I love that. I know in the last episode you did, you talked a lot about mindfulness and stuff like that, which I will have in this series. People can go and listen to it as well. I’m sure that’s a piece of the pie. I want to be respectful of your time. Where can people hear more about you and the work that you’re doing? I know that you have an exciting book coming out, so tell us a little bit about all that.

Dr. Lauren: Thank you. I do. I co-authored a book called Desire. It’s an inclusive guide to managing libido differences in relationships. I co-authored that with my colleague Dr. Jennifer Vencill. That comes out August 22nd, 2023 of this year. We’ll be talking in that book mainly about desire. There are some chapters or some sections in the book that do intersect with things like anxiety. There’s some particular instructions and exercises that help walk people through some things that they can do with a partner or on their own to work through anxiety. We’ve got an anxiety hierarchy in there where whatever your goal might be, how to break that up into smaller pieces. We’re really excited about that. I think that might be helpful for some people in your audience. And then in general, I am most active on Instagram. My handle is my full name. It’s @drlaurenfogelmersy. I’m also on Facebook and TikTok. My website is drlaurenfogel.com.

Kimberley: Thank you. Once again, so much pleasure having you on the show. Thank you for your beautiful expertise. You bring a gentle, respectful warmth to these more difficult conversations, so thank you.

Dr. Lauren: Oh, I appreciate it. Thanks for having me back.

Welcome back, everybody. I had a whole other topic planned to talk with you about today and I’ve had to basically bench it because I feel so compelled to talk to you about this topic, which is the topic of having fun. Now, you might be having a strong reaction to this and maybe there’s a bunch of people who didn’t listen because the idea of having fun feels so silly when you are anxious and depressed. It feels like a stupid idea, a ridiculous idea. But the last few weeks have taught me such valuable lessons about mental health. I talk about mental health all the time. That’s what I live and breathe pretty much. Sometimes when you have an experience—I keep saying it changes your DNA—I feel to a degree my DNA has been changed these last few weeks and let me share with you why. 

For those of you who follow me on social media, you will know that in the last couple of weeks, I made a very last-minute trip to the United Kingdom. What happened was pre-COVID, I had booked tickets to visit London for a work event, and COVID happened. I had a certain amount of time to use these tickets, and I actually had thought that those tickets had expired on December 30th of last year. And then one Friday morning, I woke up and checked my email and it said, “You have 18 days until you depart.” I’m thinking, 18 days to depart, where? I haven’t booked any tickets. Only to find out that my tickets were put on what’s called an “open hold,” which meant they had just put a date to a trip knowing that I would log in and reschedule it when I was ready. It turned out to be three years later. And then I logged on and saw I have 19 days to use my ticket. 

I went upstairs, I talked to my husband, and I said, “I have this ticket to the United Kingdom I’ve never been to. I would really love to go.” He said, “You should go. I think it would be really good for you. I’ll stay home with the kids. You go.” That was the plan. I was going to go, I was going to keep working, I was going to see my clients, but when I wasn’t working, I would go out and have British food and maybe go walk around London and maybe visit a castle or two. That was the plan. I was so excited. 

I happened to mention it to my sister-in-law who I love, and I said, “Ha-ha, you should come.” She said, “Oh! No, there’s no way I could come and I didn’t think anything of it.” And then the next morning I woke up, she had messaged me and said, “I’ve changed my mind. I’m coming.”

Now, there is a point to this story, which is, my first thought was, “Oh my gosh, that’s so exciting.” My second thought was, “Oh my gosh, that is scary,” because my sister-in-law is the most wonderful human being and she loves to have fun. What was shocking to me is I started to notice I was going to pump the brakes on fun. No, no, no, no, no, no. Oh my gosh. Now quickly, of course, I said, “Come, I’m so excited.” We went, but that response was so interesting to me. What it was, was my anxiety did not like the idea that we were going to go and let loose. My anxiety did not like that inhibitory piece, that amygdala deep in my brain was like, “Whoa, whoa, whoa, whoa, pump the brakes. This is going way too fast for me.” 

The reason I’m doing today’s episode is I bet you that’s what your brain does too. It wants to pump the brakes on fun and pleasure because it creates uncertainty and it creates vulnerability and it creates where things aren’t in control anymore. Letting go and having fun is hard when you have anxiety. Letting go and having fun is hard when you have depression. 

“Yes” Week

We went and we called the week “YES week.” Actually, I called it “YES week” because I knew this was an exposure I needed to do. We made an agreement that if one person wanted to do something, both of us had to say yes. If someone wanted to try a food, and my sister-in-law loves to try all the different foods, we both had to say yes. It was such a deep exposure experience for me. A deep, oh my gosh, pleasurable. I don’t want you to think it was all hard because the truth is, it was all pleasurable and I was so surprised at how my brain kept making problems out of having fun. 

I’ll give you another example. We’re sitting at this Indian restaurant. We kept saying to the maitre d’ or the people at the front desk, “Tell us the best Indian restaurant. Tell us the best high tea. Tell us the best place to go and have drinks. Tell us the best place to get scotch eggs. Tell us the best place to have Scottish pie. Tell us the best.” We kept saying that. We were sitting at this Indian restaurant and my sister-in-law was like, “We’ll have one of those and one of those and one of those and one of those.” She’s a foodie. I could even feel my body going like, “No, no, no, no, that’s too much fun.” It’s so interesting to me how my brain was pumping the breaks on fun and how when you have fun, again, after doing this for one week, I felt like my DNA was changed. I realized how-- I don’t want to use the word controlling because I don’t consider myself a controlling person, but how much my brain wants to monitor the amount of fun that happens and how much my brain’s anxiety wants to raise alerts about the simplest things.

We went to a million abbeys and I realized that I have this deep love for visiting churches and abbeys. Oh my gosh, I feel like my whole heart just shines bright. I’m not particularly a religious person at all, but just visiting these abbeys in these gorgeous places. And then she’ll come up and she’ll pull on my sleeve and she’ll say, “Let’s go do this extra tour.” My mind wants to be like, “No, no, no, no. We’ve done enough fun for one day.” She’s like, “Let’s go.” I’d be like, “Yes,” because we have to say yes. 

There’s this place called Duck & Waffle, which is a ‘70s nightclub restaurant. It was fabulous. She’s like, “We should try that.” My brain kept going, “No, no. We just had some food before.” It was all these things and it was just keep saying yes to fun. Keep saying yes, keep saying yes. Yes week, that’s what it was. I realized after a week of doing this how little power my anxiety had. I’m thinking about it. I’m just dropping down into it. You can see I’m slowing down.

Now, number one, I want to acknowledge, you can’t live like that forever. That was a vacation. I would never do that on a day-to-day basis because it’s not realistic, it’s not reasonable. We have to live a reasonable life. But I made a deal with myself as I was going back over Greenland. I was flying over Greenland looking at this huge snowy country and I was thinking, wow, I wish I lived in a country this beautiful. And then I was like, “Wait, I do.” You could start to practice being in the beauty of your country more. And then I started thinking, what would happen if I went home and I deeply enjoyed the food? Like I slowed down to actually take in the pleasure of the food. I mean, I think I do an okay job at this, but on vacation, like I said, we were practicing going, “Ooh, I love the flavor of this. Ooh, that’s so soft and that’s so sweet and that’s so tender,” and all the things. 

What if I actually really allowed pleasure and fun to tickle my senses here in my daily life? What if instead of making dinner like a serious mom, which I often do because I don’t want to embarrass my children—what if instead I let myself dance more? What if I goofed off more? What if I enjoyed laughing more? What if I practiced and made a habit of implementing fun into my life on the daily? This is what I was thinking about, what’s the ratio of work to fun in your life? I mean, I’m guessing you have either school or work or family or a mental health issue that you’re managing or a medical health issue that you’re managing. That’s work. What’s the ratio of work to fun? It made me really think like I have a wonderful life and I’m so grateful for my wonderful life, but the ratio of work to fun is not ideal. It’s not where I want it to be.

Once I had spent a week of just saying yes, yes, yes, and not letting fear ever say no, it was so cool because I had this accountability buddy right next to me. I realized like once I’d done that for a week, I wanted to keep it going. I didn’t want to go back to pumping the brakes anymore. It’s been such a beautiful gift that I had. 

The Fun Habit

Now, I’m going to encourage you to create a yes week or a yes day, or a yes hour. I just finished a book called The Fun Habit: How the Pursuit of Joy and Wonder Can Change Your Life. It’s by Mike Rucker. A friend of mine encouraged me to read it after I had told her like I literally just had this date with fun. I had this exposure of fun. I had a yes week where we said yes to. If we wanted to sleep in, we slept in. If we wanted to read, we read. It was really beautiful. Again, I understand the privilege of having that experience, but I worked my butt off too. I needed that. I really, really needed that. My mental health really needed it and so forth. But the book is talking about how we have talked about and trained ourselves to be afraid of fun. We’ve demonized fun as if it’s irresponsible or unnecessary or ridiculous or lazy. 

I want to leave you today with the idea to plant a seed where you go and have more fun. I was thinking about it. For those of you who have anxiety disorders or depressive disorder, this is the biggest FU to anxiety. It’s the biggest FU to depression. It’s the biggest “Don’t tell me what to do” when it comes to recovering from anxiety and depression. Is it going to fix it completely? No. I don’t want to oversell it here. But is it a major game changer? Does it change the way we see the world? Does it increase the dopamine that gets released into your body? Does it make the hard work worth it? Yes. 

I was thinking like, I was so excited to go back to work because I had a week of fun. If I had have done my original plan, which is where I worked while I was in London, and I just visited a little on the side, I wouldn’t have been that excited to come back to work. But I was so excited to come back to work and I was so excited to sit down and talk to you on this podcast. I don’t think that would’ve been the case if I had have pumped the brakes like I was planning to for that week.

Have More Fun!

There you have it. I’m going to ask you, please give you permission. Go and have more fun. Increase the percentage a few percent or 100% or 50% or 10%, whatever you can do. But do your best to implement pieces of fun into your daily life. It will literally change your DNA. Not literally, that’s scientifically not true. Don’t take that as literal. But for me, I felt like my DNA had been changed. I kept saying it. I’m like, “I feel like my DNA has something shifted in me.” It’s because I realized even though I have so much joy in my life, I do still pump the brakes on fun and I want there to be more and I’m dedicating more time to fun and savoring pleasure. 

So that’s all I want to say. Go and have some fun, please. I’d love to hear about the fun that you’re having. When fear shows up, try to confuse it by saying, “You know what, fear? You can be here and I’m going to go choose fun anyway.” Fun can be whatever it is for you. There’s no right way of having fun and it doesn’t have to be expensive here either. Like I said, a lot of the things that my sister-in-law and I did cost no money. It’s just that we were saying yes to silly things. Some of it was even like cartwheeling in the underground train station or giggling at stupid things that are so silly and so immature, but having fun with it. Just have some fun.

I love you. I hope you’re having a wonderful day. It is a beautiful day to have fun is all I’m going to say to you today. I will see you next week. We have a very cool series coming up, which you are going to love, so stick around. I’ll see you next week.

Today, we’re going to talk about the 15 depression symptoms you may not know about. My hope is that it will help you, number one, understand your symptoms, and number two, get help faster. Let’s do this. Let’s get started. 

I hope you are well. I hope you are kind and gentle to yourself today. I hope you are taking moments to notice that the trees are changing, the leaves are changing, and spring is here. If you’re in the Northern Hemisphere, maybe the weather is changing. Also, if you’re in the southern hemisphere, my lovely friends in Australia, I just want to remind you to stop and take note of the weather. It can be one of the most mindful activities we engage in, and it can help us be grounded in the present instead of thinking forward, thinking backward, and ruminating on the past and the future. 

I hope you can take a minute. We can take a breath right here... and you can actually take in this present moment before we get started. 

Today, we’re talking about 15 depression symptoms you may not know about. As I said in the intro, my hope is that these symptoms help you understand what’s going on for you if you’re depressed or help you get help faster. 

Mnemonic For Depression Symptoms

Now, some of you may really have a good understanding of depression symptoms. Some of you may know the common ways that it shows up, so I will first address those just to make sure you’ve got a basic understanding of common depression symptoms. I’m going to actually give you a mnemonic for depression symptoms. I find it’s very helpful to have this on hand when I’m assessing my clients and my patients. It’s a really good check-in even for myself like, what’s going on? Could this be depression? Let’s go through this mnemonic for depression. 

D is for depressed mood. I think we all know about that one. That’s a very common Hollywood way of understanding people who are sad, feeling very down, and so forth. We mostly all know the D for depression. 

E is for energy loss and fatigue. In fact, I did a poll on Instagram. For those of you who don’t follow me, go ahead and follow me @youranxietytoolkit. I did a poll and I asked, what are the most painful parts of depression, and the most common response was complete fatigue, complete exhaustion, just overwhelming tiredness and energy loss. I think that that’s a really common one. It can be confusing because you’re like, “What’s going on?” It makes you feel like maybe there’s a medical condition going on, but often it is depression.

The P is for pleasure loss. Now, this is an important one that we look for in clinical work as we’re looking for. Is the person with depression completely at a loss and they’re not enjoying the things they used to? Are they struggling to get joy out of even the most joyful things that they used to find joyful? That’s a very common one. 

The R is for retardation or excitation. What we’re talking about there is moving very slowly, like a sloth pace or even just sitting there and staring and unable to move your body completely, inability to get motivated to move. Excitation is the other one, which is like you feel very jittery and you feel very on edge and so forth. 

The E is for eating changes such as appetite increase or decrease, or weight increase or decrease. Again, common symptoms for depression. 

The S is for sleep changes. It is very common for people with depression to either want to sleep or need to sleep all day, again, because of that energy loss. Or they lay awake for hours at night staring at the roof, unable to sleep, experiencing sleep anxiety, which can often then impact their sleep rhythm. They’re sleeping all day, staying awake all night, or vice versa, but in a very lethargic way. 

The next S is for suicidal thoughts or what we call suicidal ideation. These are thoughts of death, thoughts of dying, and sometimes plans to die. If that is you, please do go and see a mental health professional immediately or go to your ER or call the emergency in whatever country you are. For America, it’s 911. Suicidal thoughts are very, very common with depression. We have two types of suicidal thoughts in depression, and that’s usually passive suicidal thoughts and then active suicidal thoughts. Passive is thoughts of death, but you just want to crawl under a rock and just go to sleep and never wake up. Active suicidal thoughts is where you’re actually wishing to die. It’s important to differentiate, and clinically, we do make some changes depending on which is which. 

The I for depression is “I am a failure.” This has a lot to do with shame or loss of confidence and self-esteem issues. “I am a failure” is a big one that often doesn’t get disclosed until the person is in therapy. We even did an episode a couple of weeks ago. Depression Is A Liar was the title. Depression tells you all these lies. It tells you you’re a failure and you start to believe it. It tells you there’s something wrong with you and you start to believe it. That is a very common part of having depression. 

The O is “only me to blame,” and this is what we call guilt. With depression, often people will feel guilty for everything, feel guilt & regret all day, every day. “I’m not a good mom,” “I’m not a good friend,” “I’m not a good talk daughter,” “I’m not a good employee,” “I’m not a good boss,” whatever it may be. And then they blame themselves, punish themselves, and a lot. 

The N is for no concentration. Again, when I did the poll on Instagram, so many people posted that they just cannot think, they can’t plan, they can’t concentrate, they can’t learn if they’re in school, they can’t stay focused on a conversation. These are all very common symptoms of depression that may be impacting you either a little bit or, in many cases, an immense amount.

They’re the most common. That’s a mnemonic for depression symptoms. They’re the most common that we assess for. But now I want to go into the 15 depression symptoms you may not know about. 

The way that I’m structuring this podcast episode is I’ve broken it down into different categories of people. But what I want you to recognize before we go down is these are not specific to only these categories of people because it depends on the person. We have to be very person-centered when it comes to looking at depression and diagnosing depression and treating depression because there’s no one way to have depression. I don’t want to miscategorize any of this. I’m just talking very generally, so I want to give a disclaimer as I go through these different categories or groups of people. Please note that it’s probably true for everybody. It’s just more common in these groups. 

Before we get started, I want to remind you. I know I did an announcement. I want to remind you, the Overcoming Depression Course is going live on March 11th. This is very exciting. This is a live online course that I am teaching live on Zoom. I will be teaching you over the course of three different weekends on Saturday mornings from 9:00 to 10:30 on March 11th, March 18th, and March 25th, 2023. If you want to sign up and come and learn from me, I’ll be going through five major areas in which you can make changes related to depression. I will be giving you all of this psychoeducation upfront. There will be a workbook that you can use on your own to really put the skills and tools and strategies into place. If you’re interested in joining us, may I say again live, head on over to CBTSchool.com/Depression. It’ll take you to the page. You can sign up there and then I will send you via email all of the information you need to be there for our live conversations. You can ask questions in the chat box. My hope is to double down with motivating you, inspiring you, educating you, and getting you feeling a little more confident on what to do if you’re struggling with these symptoms. My hope is to help you see that depression is a liar and you can break free! 

Here we go. 

Depression Symptoms In Men

Again, I’m speaking generally here, and I really want to be careful here because it’s definitely not just men who experienced this, but I did a lot of research for this episode and these were the statistics that I found to be most common in these areas. 

Anger, irritability, or aggressiveness

That’s not in the mnemonic for depression that we went over. A lot of times people miss this core symptom, which is anger, irritability, or aggressiveness. Now, is it only men? Absolutely not. I want to be really clear here, that is absolutely not the case, but I think because of the stigma for men around showing sadness or showing depression, they have shown that men tend to express it in a different way, because sometimes men don’t feel comfortable crying in public with their friends or loved ones. Not always true. Again, I’m going to keep saying not always, but I think that’s a cultural expectation put on men and therefore it does come out when in the form of anger, irritability, or aggressiveness. Irritability is a huge one when it comes to depression that I have seen clinically. 

Problems with sexual desire and performance

This is, again, not just for men, but common in the research for men is common problems with sexual desire and performance. A lot of men and women, but again, I don’t want to be excluding anyone here, have found that they either have a massive lack of sexual desire or struggle to reach arousal, struggle to reach orgasm. We are going to be addressing this in-depth here in the next couple of months and I’m going to put a lot of energy into making sure we address how much it impacts people and sex. Stick around for that. I’m super excited. But there is another common depression symptom you may not know about. Sometimes we think it’s anxiety that causes that, but it’s not just anxiety; it can be depression too. 

Engaging in high-risk activities

Again, not just for men, but it has been shown to be more prevalent in men. High-risk activities, spending a lot of money, driving fast in cars, gambling, drug use, and so forth. Again, not just in men, but this is another common depression symptom you may not know about and maybe diagnosed and put in a different category when really the person is deeply depressed and trying to feel pleasure. Remember we talked about the mnemonic P is for pleasure loss. Often we engage in these high-risk activities because we’re just desperate to feel that sense of pleasure and exhilaration again. 

A need for alcohol or drugs

Again, not just men and I will discuss this in other categories as well, but it is common that an increased use of alcohol and drugs could be a sign that you are getting an increased level of depression. Then what happens is when you’re using a lot of alcohol and drugs, you usually have a hangover or some kind of side effect to that which makes you feel more depressed, which then makes you feel more like you need to have more alcohol and drugs. Again, it’s a cycle that can really cause a lot of chaos in people’s life and could be simply the first symptom or way to cope with depression. 

Depression Symptoms In Women

Women are twice as likely to develop depression than men. That’s a statistic I didn’t know. Up to 1 in 4 women are likely to have major depressive disorder or major depression at some point in their life. 1 in 4, that is so high. We have to make sure we’re catching people and helping people with this massive issue. 

Premenstrual Dysphoric Disorder

Prementstrual Dysphoric Disorder involves a massive influx of depressive symptoms right before your period or at specific stages of your menstrual cycle. Very common. In fact, again, we’re going to be addressing this very soon on the podcast as well. These are some areas I feel like I have completely missed as your podcast host, so I want to really make sure we’re targeting and addressing these issues as we move forward. 

Perinatal Depression

Perinatal depression occurs around pregnancy before or after pregnancy starts. 

Perimenopausal Depression

Perimenopausal depression is around the menopausal period for people going into menopause. 

These are common symptoms of depression that get missed all the time or get misdiagnosed or underdiagnosed when the person is really suffering. 

A lot of people who follow me have said they’ve gone to their doctor to share how they get this massive influx of depression before their period or in their cycle, and the doctor has blown them off and said, “Eat more celery juice,” or “Exercise more.” While, yes, exercising can be helpful for depression, we are missing a major depression symptom, and I want you to be informed about those.

Depression Symptoms In Kids

Oh, the kiddos. It’s so hard on the kiddos. In fact, one of the reasons I have been so hyped on talking about depression was, in August of last year, my daughter went in for her yearly checkup with her pediatrician and the pediatrician insisted on doing all of these mental checklists with her. I was saying to her, “Is this really necessary? She’s doing fine. To what degree are you scaring her?” She said, “Oh, you have no idea the degree of depression in children since COVID.” “I had no idea and I’m a mental health professional. How did I not know this?” She said, “Yeah, it’s everywhere in kids, and kids are really good at hiding it.” I literally sank in my chair like, “How did I miss this? How did I not know this?”

We talked about it a lot and I think it’s really important that we understand that depression symptoms in kids often look like what we call in some societies like naughty kids. Again, let’s go through them. 

Big emotional outbursts 

When we see kids on the playground having big outbursts, big anger responses, again, we talked about that before, sometimes they get labeled as the naughty kids. Well, guess what? We’ve got to make sure we check to make sure they’re not depressed. Because that is a symptom of depression. 

Difficulty initiating and maintaining social relationships

Again, after COVID, a lot of parents I’ve heard have said, “Oh, I think they just lost their ability to make friends during COVID,” which I totally get. We had to train my son after COVID to follow basic social cues because he hadn’t seen people in so long. But again, we have to keep an eye on whether this is a symptom of depression in children. 

Extreme sensitivity to rejection or failure

This one is so important not just for kids, but for teens, adults, everyone. With depression, we all have sensitivity to rejection of failure. No one wants that. But often a symptom of depression is extreme sensitivity and absolute devastation about getting rejected for, let’s say, a school play or to be picked in soccer or they had a big issue with a test or so forth. They have a strong, strong reaction to that. 

Frequent absences from school and/or a sudden decline in grades

If kids got a massive decline in grades or they started refusing to go to school, my instinct is to always say, “Oh, there’s some anxiety going on. They’re anxious. They don’t want to go to school, they must be ‘avoiding school’ because of anxiety as a compulsion.” Well, guess what? It could be depression, and let’s make sure we assess these kiddos correctly. This is true for adults as well. If we’re depressed, we don’t want to go out, we don’t want to go to the show on Friday night, we don’t want to hang out with friends. That makes sense as well. 

Depression With Somatic Symptoms

This is probably the most important one. Very common symptoms of depression include headaches, stomach ache, muscle pain, sore back. These are very common physical symptoms of depression and ones that we have to make sure that we aren’t ignoring to make sure that they get the care. A lot of people go into the medical system complaining of physical symptoms only to find out that nothing is wrong and they can’t understand it, and it could be depression. Not always—please always go and get a medical checkup—but it could be. 

Depression Symptoms In Teens

All of the symptoms I’ve shared above could be present in teens as well. Like I said, these are not categories that are only just for these categorical lots of people. 

General overwhelming sense of apathy

Commonly with teens is this general overwhelming sense of apathy like, “I don’t care. I don’t care about you, I don’t care about me, I don’t care about school.” Often parents can interpret this as like, “Oh my god, my kid is horrible.” But again, we have to make sure we’re assessing for depression first.

Excessive guilt

I did have that as the mnemonic under O (only me to blame), but this shows up a lot in kids and teens—excessive saying I’m sorry, excessive apologizing, feeling hyper-responsible for everything that happens, feeling hyper-responsible for the social issues and drama that’s happening at school, ruminating a lot about that. Again, this is common for anybody, very common for anybody with depression as well, but with teens, it really does start to spike. 

Preoccupation with death or on death

Again, this could be true for other categories or any human being, but we do see it show up a lot in teens—a preoccupation on death regarding movies, music, shows, or books they’re reading. Just really a heavy focus on things related to death or very dark, dark topics, aggressive topics. This can play out in many ways. Again, it could also be very normal behavior and that could be something that brings them great pleasure. But again, I’m only bringing it up because these are common unknown depression symptoms that you don’t possibly know could be a symptom of depression. I think it’s better to be educated than to ignore it and not know. 

That’s the 15 depression symptoms you may not know about. One thing to consider, and I did touch on this during the episode, is commonly we have to look at depression symptoms versus anxiety symptoms. The truth is, many of these are also symptoms of anxiety. Let’s go through some of them. Anger, irritability, aggressiveness—true for anxiety. Sexual desire—true for anxiety, engaging in high-risk activities—true for anxiety. A need for alcohol and drugs—true for anxiety.

We do notice some perinatal symptoms and perimenopausal symptoms impact anxiety as well, but we’re specifically weren’t speaking to those today. But if we move into the kids category: outbursts, difficulty maintaining relationships, sensitivity to failure, frequent absences, somatic symptoms, guilt, apathy, preoccupation—these are also very common in anxiety. 

What I want you to leave with today is this: Take everything you learnt today. I hope that this didn’t create more anxiety for you. Just take it as knowledge. Take it as something you now know so that you can be an informed consumer, an informed patient, an informed client with your therapist so that you can know. I will say, if I’m speaking completely vulnerably, reading all the research I did made me very anxious because I have a close to teen child and I was thinking, oh my gosh, what happens if this starts to go down this track and looking at the statistics of suicide and so forth. It is anxiety provoking. But what I did in that moment—and if this helps you, I hope it does—is I said to myself, “Kimberley, you’re better to be informed and practice not ruminating and doing mental compulsions about this and catastrophizing than you are to not know at all.” Here I have an opportunity to practice all of the response prevention skills, the mindfulness skills, the self-compassion skills that I have in my tool belt and that you hopefully have in your tool belt if you’ve been a long-term listener here on Your Anxiety Toolkit. We’re going to use those tools to help us manage this, but we’re going to practice being an informed consumer here.

I hope this has been helpful. They are the 15 depression symptoms you may not know about and now you know. 

Thank you, guys. I’m so happy to be here with you today. Stick around because some pretty exciting things are coming up. A lot of you know we had the mental compulsion series last year. This year, we are having a full sexual health related to mental health series that is just around the corner. It is going to be so incredible. I have some amazing doctors, psychiatrists, sex therapists, educators coming on to talk specifically with you around specific issues, around sexual health related to anxiety and depression. I’m so, so excited, so proud, and so honored to get to do this work with you. 

All right, I’m going to hit the road. Have a wonderful day. It is a beautiful day to do hard things, and I’ll see you next week.

In this episode, we are talking about the emotional toll of OCD. 

Kim: Welcome back, everybody. This week is going to include three of some of my most favorite people on this entire planet. We have the amazing Chris Trondsen, Alegra Kastens, and Jessica Serber—all dear friends of mine—on the podcast. This is the first time I’ve done an episode with more than one guest. 

Now, this was actually a presentation that the four of us did at multiple IOCDF conferences. It was a highly requested topic. We were talking a lot about trauma and OCD, shame and OCD, the stigma of OCD, guilt and OCD, and the depression and grief that goes with OCD. After we presented it, it actually got accepted to multiple different conferences, so we all agreed, after doing it multiple times and having such an amazing turnout, that we should re-record the entire conversation and have it on the podcast.

I’m so grateful for the three of them. They all actually join me on Super Bowl Sunday—I might add—to record this episode. I am going to really encourage you to drop down into your vulnerable self and listen to what they have to say, and note the validation and acknowledgment that they give throughout the episode. It is a deep breath. That’s what this episode is. 

Before we get into this show, let me just remind you again that we are recording live the Overcoming Depression course this weekend. On March 11th, March 18th, and March 25th, at 9:00 AM Pacific Standard Time, I will be recording the Overcoming Depression course. I am doing it live this time. If you’re interested in coming on live as I record it, you can ask your questions, you can work along with me. There’ll be workbooks. I’ll be giving you a lot of strategies and a lot of tools to help you overcome depression. 

If you’re interested, go to CBTSchool.com/depression. We will be meeting again, three dates in March, starting tomorrow, the 11th of March, at 9:00 AM Pacific Time. You will need to sign up ahead of time. But if for any reason you miss one of them, you can watch the replay. The replays will be uploaded. You’ll have unlimited on-demand access to any of them. You’ll get to hear me answering people’s questions. This is the first time I’ve ever recorded a course live. I really felt it was so important to do it live because I knew people would have questions and I wanted to address them step by step in a manageable, bite-sized way. Again, CBTSchool.com/depression, and I will see you there. Let’s get over to this incredible episode. 

Again, thank you, Chris Trondsen. Thank you, Alegra Kastens. Thank you, Jessica Serber. It is an honor to call you my friend and my colleague. Enjoy everybody. 

Kim: Welcome. This has been long, long. I’ve been waiting so long to do this and I’m so thrilled. This is my first time having multiple guests at once. I have three amazing guests. I’m going to let them introduce themselves. Jessica, would you like to go first?

Jessica: I’m Jessica Serber. I’m a licensed marriage and family therapist, and I have a practice specializing in the treatment of OCD and related anxiety and obsessive-compulsive spectrum disorders in Los Angeles. I’m super passionate about working with OCD because my sister has OCD and I saw her get her life back through treatment. So, I have so much hope for everyone in this treatment process.

Kim: Fantastic. So happy to have you. Chris?

Chris: Hi everyone. My name is Chris Trondsen. I am also a licensed marriage family therapist here in Orange County, California at a private group practice. Besides being a therapist, I also have OCD myself and body dysmorphic disorder, both of which I specialize in treatment. Because of that, I’m passionate about advocacy. I am one of the lead advocates for the International OCD Foundation, as well as on their board and the board of OCD Southern California, as well as some leadership on some of their special interest groups. Kind of full circle for me, have OCD and now treat it.

Kim: Amazing. Alegra?

Alegra: My name is Alegra Kastens and I am a licensed therapist in the states of California and New York. I’m the founder of the Center for OCD, Anxiety and Eating Disorders. Like Chris, I have lived experience with OCD, anxiety, eating disorders, and basically everything, so I’m very passionate. We got a lot going on up here. I’m really passionate about treating OCD, educating, advocating for the disorder, and that is what propelled me to pursue a career as a therapist and then also to build my online platform, @obsessivelyeverafter on Instagram.

GRIEF AND OCD

Kim: Amazing. We have done this presentation before, actually, multiple times over the years. I feel like an area that I want to drop into as deeply as we can today to really look at the emotional toll of having and experiencing and recovering from OCD. We’re going to have a real conversation style here. But first, we’ll follow the format that we’ve used in the past. Let’s first talk about grief and OCD because I think that that seems to be a lot of the reason we all came together to present on this. Alegra, would you talk specifically about some of the losses that result from having OCD? I know this actually was inspired by an Instagram post that you had put out on Instagram, so do you want to share a little bit about what those emotional losses are? 

Alegra: For sure. I think that number one, what a lot of people with OCD experience is what feels like a loss of identity. When OCD really attacks your values, attacks your core as a human being, whether it’s pedophile obsession, sexual orientation obsessions, harm obsessions, you really start to grieve the person that you once thought you were. Of course, nothing has actually changed about you, but because of OCD, it really feels like it has. In addition to identity, there’s lost relationships, there’s lost time, lost experiences. For me, I dropped out of my bachelor’s degree and I didn’t get the four years of undergrad that a lot of people experienced. I mean, living with OCD is one of the most debilitating, difficult things to do. And that means, if you’re fighting this battle and trying to survive, you probably are missing out on life and developmental milestones.

Kim: Right. Was that the case for you too, Chris?

Chris: Yeah. I actually host a free support group for families and one of the persons with OCD was speaking yesterday talking about how having OCD was single-handedly the most negatively impactful experience in his life. He is dealt with a lot of loss. I feel the same way. It’s just not something you could shake off and recover from in the sense of just pretending nothing happened. I know for me, the grief was hard. I mean, I had mapped out what I thought my life was going to look like. I think my first stage of grief, because I think it became two stages, my first, like Alegra said, was about the loss. I always wanted to go to college and be around people in my senior year, like make friends and things like that. It’s just my life became smaller and smaller. I became housebound. I missed out on normal activities, and six years of my life were pretty much spent alone. 

I think what Alegra also alluded to, which was the second layer of grief, was less about the things that I lost, but who I became. I didn’t recognize myself in those years with OCD. I think it’s hard to explain to somebody else what it’s like to literally not live as yourself. I let things happen to me or I did things that I would never do in the mind state that I am in now. I was always such a brave and go-for-it kind of person and confident and I just became a shell of myself. I grieve a lot of the years lost, a lot of the things I always wanted to do, and places I wanted to go. And then I grieve the person I became because it was nothing I ever thought I could become.

Kim: Jessica, will you speak also to just the events that people miss out on? I don’t know if you want to speak about what you see with your clients or even with your sibling, like just the milestones that they missed and the events they missed.

Jessica: Yeah, absolutely. My sister was really struggling the most with her OCD during middle school and high school. Those are such formative years, to begin with. I would say, she was on the fortunate end of the spectrum of being diagnosed relatively early on in her life. I mean, she definitely had symptoms from a very, very young age, but still, getting that diagnosis in middle school is so much before a lot of people get that. I mean, I work with people who aren’t diagnosed until their twenties, thirties, and sometimes even later. Different things that most adolescents would go through she didn’t. 

Speaking to the identity piece that Alegra brought up, a big part of her identity was being a sports fan. She was a diehard Clippers fan, and that’s how everyone knew her. It was like her claim to fame. She didn’t even want to go to Clippers games. My dad was trying to get tickets to try to get her excited about something to get out of the house. She missed certain events in high school because it was too anxiety-provoking to go and it was more comforting to know she could stay in the safety of the home. Their experiences all throughout the lifespan, I think that can be impacted. Even if you’re not missing out on them entirely, a lot of people talk about remembering those experiences as tainted by the memories of OCD, even if they got to go experience them.

Kim: Right. For me, as a clinician, I often hear two things. One is the client will say something to the likes of, “I’ve lost my way. I was going in this direction and I’ve completely lost the path I was supposed to go on.” I think that is a full grief process. I think we’ve associated grief with the death of people, but it’s not. It’s deeper than that and it’s about like you’re talking about, identity and events and occasions. 

The other thing that I hear is—actually, we can go totally off script here in terms of we’ve talked about this in the past separately—people think that once they’re recovered, they will live a really happy life and that they’ll feel happy now. Like, “Oh, the relief is here, I’ve recovered.”  But I think there is a whole stage of grief that follows during recovery and then after recovery. Do you have any thoughts on that, anybody? 

Alegra: Well, yeah. I think it reminds me a lot of even my own experience, but my client’s experiences of when you recover, there tends to be grief about life before OCD. If I’m being perfectly honest, my life will just never be what it was before OCD, and it’s different and wonderful in so many ways that maybe it wouldn’t be if I didn’t have OCD. But I’m laughing because when you were like, “I’m going to mark my calendar in July because you’re probably going to have a relapse,” then I have to deal with it every six months. My brain just goes off for like two weeks. I don’t know why it happens. It’s just my OCD brain, and there’s grief associated with that. I can go for six months and I have some intrusive thoughts, but it doesn’t really do anything to me to write back in it for two weeks. That’s something I have to deal with and I have to get to that acceptance place in the grieving process. I’m not going to have the brain that I did before OCD when I didn’t have a single unwanted sexual thought. That just isn’t happening. I think we think that we’re going to get to this place after recovery, and it’s like game over, I forget everything that happened in the past, but we have to remember that OCD can be traumatizing for people. Trauma is stored in the body. The brain is impacted and I think that we can carry that with us afterwards.

Kim: Right.

Chris: Yeah. I mean, everything that Alegra was saying—I’ll never forget. I always joke, but I thought when treatment was done, rainbows were going to shoot out and butterflies. I was going to jump on my very own unicorn and ride off to the sunset. But it was like a bomb had gone off and I had survived the blast, but everything around me was completely pulverized. I just remember thinking, what do I do now? I remember going on social media to look up some of my friends from high school because my OCD got really, really bad after high school. I just remember everybody was starting to date or marry or travel and move on and I’m like, “Great, I live in my grandma’s basement. I don’t have anything on my calendar. I’m not dating, I don’t have any friends. What do I do?” I was just completely like, “Okay, I don’t even know where to begin.” I felt so lost. Anything I did just didn’t feel right. Like Alegra said, there was so much aftermath that I had to deal with. I had to deal with the fact that I was lost and confused and I was angry and I had all these emotions. I had these memories of just driving around. 

As part of my OCD, I had multiple subtypes—sexual intrusive thoughts, harm thoughts. I remember contamination, stores around me would get dirty, so I’d be driving hours to buy products from non-dirty stores at 4:00 or 5:00 in the morning, crying outside of a store because they were closed or didn’t have the product I need, getting home and then my checking would kick in. You left something at the store, driving back. You just put yourself through all these different things that are just not what you would ever experience. 

I see it with my clients. One client sticks in mind who was in his eighties and after treatment, getting better. He wasn’t happy and he is like, “I’m so happy, Chris. You helped me put OCD in remission. But I now realize that I never got married because I was scared of change. I never left the house that I hated in the city I didn’t really like because I was afraid of what would happen if I moved.” He’s like, “I basically lived my OCD according to OCD’S rules and I’m just really depressed about that.” I know we’re going to talk about the positive sides and how to heal in the second half, but this is just really what OCD can ravish on our lives.

Kim: Right. 

Jessica: If I can add one thing too really quickly, something I really think is a common experience too is that once healing happens, even if people do get certain parts of their lives back and feel like they can function again in the ways that they want to, there’s always this sense of foreboding joy, that it feels good and I’m happy, but I’m just waiting for the other shoe to drop all the time. Or what if I go back to how I was and I lose all my progress? Even when there are those periods of joy and happiness and fulfillment, they might also be accompanied with some anxiety and some what-ifs. Of course, we can work on that and should work on that in treatment too because we want to maximize those periods of joy as much as we can. But that’s something that I commonly see, that the anxiety sticks around just in different ways.

OCD, SHAME, & GUILT

Kim: Yeah, for sure. I see that very commonly too. Let’s talk now about OCD, shame, and guilt. I’ll actually go straight to you, Jessica, because I remember you speaking about this beautifully. Can you explain the difference between shame and guilt specifically related to how it may show up with OCD? 

Jessica: Yeah. I mean, they’re definitely related feelings but they are different. I think the simplest way to define the difference is guilt says, “I did something bad,” whereas shame says, “I am bad.” Shame is really an identity-based emotion and we see a lot of shame with any theme of OCD. It can show up in lots of different ways, but definitely with some of the themes that are typically classified as Pure O—the sexual intrusive thoughts or unwanted harm thoughts, scrupulosity, blasphemous thoughts. There can be a lot of shame around a person really identifying with their thoughts and what it means about them. Attaching that, meaning about what it means about them. And then of course, there can also be guilt, which I think feels terrible as well, but it’s like a shame light where it’s like, “I did something wrong by having this thought,” or just guilt for maybe something that they’ve thought or a compulsion that they’ve done because of their OCD. 

Kim: Yeah. I’ve actually also experienced a lot of clients saying they feel guilty because of the impact their OCD has had on their loved ones too. They’re suffering to the biggest degree, but they’re also carrying the guilt of like, “I’ve caused suffering to my family,” or “I’m a financial burden to my parents with the therapy and the psychiatrist.” I think that there’s that secondary guilt that shows up for a lot of people as well, which we can clump in as an outcome or a consequence or an experience of having OCD.

Chris: Yeah. I mean, right before you said this, Kim, I was thinking for me personally, that was literally what I was going to say. I have a younger sister. She’s a couple of years younger than me and I just put her through hell. She was one of the first people that just felt the OCD’s wrath because I was so stressed out. She and I shared a lot of the same spaces in the home, so we’d have a lot of fights. Also, when I was younger, because she looks nothing like me—she actually looks more like you, Kim, blonde hair, blue eyes—people didn’t know we were related. People would always say things like, “Oh, is that your girlfriend?” So then I’d have a lot of ancestral intrusive thoughts that caused a lot of harm to me, so I’d get mad at her. Because I was young, I didn’t know better. And then just the hell I put my mom through. 

I always think about just like, wow, once again, that’s not who Chris is. I would jump in front of eight bullets for both my mom and my sister. I remember one time I needed something because I felt dirty, and my mom hit our spending money so that if there was an emergency. My sister knew where it was and she wouldn’t give it to me. I remember taking a lighter and lighting it and being like, “I’ll burn your hair if you don’t give me the money,” because I was so desperate to buy it because that’s how intense the OCD was. I remember she and I talking about that and it just feels like a different human. Once again, it’s more than just guilt. It’s shame of who I had become because of it and not even recognizing the boy I was now compared to the man I am now, way than man now.

OCD AND ANGER

Kim: One thing we haven’t talked a lot about, but Chris, you just spoke to it, and I’ve actually been thinking about this a lot. Let’s talk about OCD and anger because I think that is another emotional toll of OCD. A lot of clients I’ve had—even just recently, I’ve been thinking about this a lot—sometimes instead of doing compulsions, they have an anger outburst or maybe as well as compulsions. Does anyone want to speak to those waves of frustration and anger that go around these thoughts that we have or intrusive whatever obsessions in any way, but in addition, the compulsions you feel you have to do when you have OCD?

Alegra: I feel like sometimes there can be maybe a deeper, more painful emotion that’s underneath that anger, which can be shame or it can be guilt, but it feels like anger is maybe easier to express. But also, there just is inherent anger that comes up with having to live with this. I remember one time in my own personal therapy, my therapist was trying to relate and she pulled out this picture that she had like an, I don’t know, eight-year-old client with OCD and was like, “She taps herself a lot.” I screamed at her at that moment. I was like, “Put that fucking picture away, and don’t ever show that to me again. I do not want to be compared to an eight-year-old who taps himself, like I will tap myself all day fucking long, so long as I don’t have these sexually unwanted thoughts about children.” I was so angry at that moment because it just felt like what I was dealing with was so much more taboo and shameful. I was angry a lot of the time. I don’t think we can answer the question of, why? Why did I have to experience this? Why did someone else not have to experience this? And that anger is valid. 

The other thing that I want to add is that anger does not necessarily mean that we are now going to act on our obsessions because I think clients get very afraid of that. I remember one time I was so fucking pissed at my coworker. He was obnoxious when I worked in PR, and I was so mad at him, I had to walk outside and regulate. And then instantly, of course, my brain went, “You want his kid to die?” or whatever it was. I felt like, oh my God, I must really want this to happen because I’m mad at him. In terms of anger, we can both feel angry and not align with unwanted thoughts that arise.

CAN OCD CAUSE ANGER ISSUES? 

Kim: Right. OCD can attack the emotions that you experience, like turn it back on you. It’s funny, I was doing a little bit of research for this and I typed in ‘OCD in anger.’ I was looking to see what was out there. What was so fascinating to me is, you know when you type something in on Google, it shows all of the other things that are commonly typed in. At the very top was ‘Can OCD cause anger issues?’ I was like, that is so interesting, that obviously, loved ones or people with OCD are searching for this because it’s so normal, I think, to have a large degree of just absolute rage over what you’ve been through, how much you’ve suffered, just the torment and what’s been lost, as we’ve already talked about. I just thought that was really fascinating to see, that that’s obviously something that people are struggling with. 

Chris: When you think about it, when we’re struggling with OCD, the parts of our brain that are trying to protect us are on fire or on high alert. If you always think about that, I always think of a feral dog. If you’re trying to get him help, then he starts to bite. That’s how I honestly felt. My anger was mostly before I was diagnosed, and once again, like I said, breaking things at home, screaming, yelling at my family, intimidating them, and stuff. I know that once again, that wasn’t who I am at the course. When I finally got a diagnosis, I know for me, the anger dissipated. I was still angry, but the outbursts and the rage, and I think the saddest thing I hear from a lot of my clients is they tell me, I think people think I’m this selfish and spoiled and bratty and angry person. I’m not. I just cannot get a break. 

I always remind parents that as your loved one or spouses, et cetera—as your loved one gets better, that anger will subside. It won’t vanish, it won’t disappear, it may change into different emotions, like Alegra was saying, to guilt and to shame and loss of identity. But that rage a lot of times is because we just don’t know what to do and we feel attacked constantly with OCD. 

Kim: Yeah.

Jessica: I also want to validate the piece that anger is a really natural and normal stage of grief. I like that you’re differentiating, Chris, between the rage that a lot of people experience in it versus maybe just a different type of anger that can show up after when you recognize how—I think, Alegra, you brought up—we can’t answer the question of, why did this happen to me? Or “I missed out on all these times or years of my life that I can’t get back.” Anger is not a problem. It’s not an issue when it shows up like that. It’s actually a very healthy natural part of grief. We want to obviously process it in ways that really honor that feeling and tend to that feeling in a helpful way. I just wanted to point out that part as well.

DO YOU CONSIDER HAVING OCD A TRAUMATIC EVENT?   

Kim: Yeah, very, very helpful. This is for everybody and you can chime in, but I wanted to just get a poll even. Alegra spoke on this a little bit already. Do you consider having OCD a traumatic event?

Alegra: A hundred thousand percent. I’m obviously not going to trauma dump on all of you all, but boy, would I love to. I have had quite a few of what’s classified as big T traumas, which I even hate the differentiation of big T, sexual assault, abuse, whatever. I have had quite a bit of big T traumas and I have to say that OCD has been the most traumatizing thing I have been through and I think we’ll ever go through. It bothers me how much I think gatekeeping can happen in our community. Like, no, it’s only trauma if you’ve been assaulted, it’s only trauma if X, Y, and Z. I have a lot of big T trauma and I’m here to say that OCD hands down, like I would go through all of that big T trauma 15 times over to not have OCD, 100%. I think Chris can just add cherries to the cake, whatever that phrase is.

Chris: Yeah. This is actually how the title, the Emotional Toll of OCD, came about. We had really talked about this. I was really inspired mainly by Alegra talking about the trauma of OCD and I was like, finally, someone put the right word because I always felt that other words didn’t really speak to my personal experience and the experience I see with clients. We had submitted it for a talk and it got denied. I remember they liked it so much that they literally had a meeting with you and I, Kim, and we’re like, “We actually really love this. We just got to figure out a way to change it.” Like Alegra was saying, a lot of the people that were part of a trauma special interest group just said, “Look, we can’t be using the word ‘trauma’ like this.” But we had a good talk about it. It’s like, I do believe it’s trauma.

I always feel weird talking about him because sometimes he listens to my stuff, but still, I’ll say it anyways. But my dad will hopefully be the first to admit it. But there were a lot of physical altercations between he and I that were inappropriate—physical abuse, emotional abuse, yelling, screaming. Like Alegra said, I would relive that tenfold than go through the depths of my OCD again where I attempted suicide, where I isolated, where I didn’t even recognize myself. 

If ‘trauma’ isn’t the correct word, we only watered it down to emotional toll just to make DSM-5 folks happy. But if ‘trauma’ isn’t the word, I don’t know what is, because like I said, trauma was okay to describe the pain I went through childhood, but in my personal experience, it failed in comparison to the trauma that I went through with OCD. 

Alegra: I also want to add something. Maybe I’m wrong, but if I’m thinking about the DSM definition, I think it’s defining post-traumatic stress disorder. I don’t think it’s describing trauma specifically. Maybe I’m wrong, but it’s criteria for PTSD. I will be the first to say and none of you have to agree. I think that you can have PTSD from living with OCD. DSM-wise diagnostically, you can’t. But I think when people are like, “Well, that’s not the definition of trauma in the DSM,” no, they’re defining PTSD. It’s like, yeah, some people have anxiety and don’t have an anxiety disorder. You can experience trauma and not have full-blown PTSD. That’s my understanding of it.

Kim: Yeah. It’s funny because I don’t have OCD, so I am an observer to it. What I think is really interesting is I can be an observer to someone who’s been through, like you’ve talked about, a physical assault or a sexual assault and so forth, and they may report I’m having memories of the event and wake up with the physiology of my heart beating and thoughts racing. But then I’ll have clients with OCD who will have these vivid memories of having to wash their hands and the absolute chaos of, “I can’t touch this. Oh my God, please don’t splash the water on me,” Memories of that and nightmares of that and those physiological experiences. They’re remembering the events that they felt so controlled and so stuck in. That’s where for me, I was, with Chris, really advocating for. These moments imprint our brain right in such a deep way.

Alegra: Yeah. I’m reading this book, not to tell everyone to buy this book, but it’s by Dr. Bruce Perry and he does a bunch of research on trauma and the brain. Basically, the way that he describes it is like when we experience something and it gets associated. Let’s say, for instance, there are stores that I could go to and I could still feel that very visceral feeling that I did when I was suffering. Part of that is how trauma is stored in the brain. Even if you logically know I’m not in that experience now, I’m not in the war zone or I’m not in the depths of my OCD suffering, just the store, let’s say, being processed through the lower part of your brain can bring up all of those associations. So, it does do something to the brain.

Kim: Right. 

Chris: Absolutely. I was part of a documentary and it was the first time I went back to the home that I had attempted suicide, and the police got called the hospital and all that. It was a bad choice. They didn’t push me into it. It was my idea because I haven’t gone back there, had no clue how I’d react and I broke down. I mean, broke down in a dry heaving way that I never knew I could and we had to stop filming and we left. Where I was at my worst of OCD was there and also at my grandma’s house because that’s where I moved right after the suicide attempt. I’d have people around me, and still going down to the basement area that I lived in. It is very hard. I rarely do it. So, I have a reaction. To me, it was like, if that isn’t once again trauma, I don’t know what is.

Alegra: It is. 

Chris: Exactly. I’ll never forget there was a woman that was part of a support group I ran. She was in her seventies and she had gone through cancer twice. I remember her telling the group that she’s like, “I’ll go through cancer a third time before I’ll ever go back to my worst of OCD.” Obviously, we’re not downplaying these other experiences—PTSD, trauma, cancer, horrible things, abuse, et cetera. What we’re saying is that OCD takes a lasting imprint and it’s something that I have not been able to shake. I’ve done so much advocacy, so much therapy, so much as a therapist and I don’t still struggle, but the havoc it has on my life, that’s something I think is going to be imprinted for life.

Alegra: Forever.

Jessica: Also, part of the definition of trauma is having a life-threatening experience. What you’re speaking to, Chris, you had a suicide attempt during that time. Suicidality is common with OCD. Suicidal ideation, it’s changing your life. I think Alegra, you said, “I’ll never have the life or the brain that I had before OCD.” These things that maybe it’s not, well, some of them are actually about real confrontation with death, but these real life-changing, life-altering experiences that potentially also drive some people to have thoughts or feelings about wanting to not be alive anymore. I just think that element is there.

Alegra: That’s so brilliant, Jessica, because that is so true. If we’re thinking about it being life-threatening and life-altering, it was life-threatening for me. I got to the point where I was like, “If something doesn’t change, I will kill myself. I will.” That is life-threatening to a person. I would be driving on the freeway like, “Do I just turn the car? Do I just turn it now? Because I was so just fucking done with what was happening in my brain.”

Kim: It feels crisis.

Alegra: Yeah.

Kim: It’s like you’re experiencing a crisis in that moment, and I think that that’s absolutely valid.

Alegra: It’s an extended crisis. For me, it was a crisis of three to four years. I never had a break. Not when I was sleeping. I mean, never.

Chris: I was just going to add that I hear in session almost daily, people are like, “If I just don’t wake up tomorrow, I’m fine. I’d never do anything, but if I just don’t wake up tomorrow, I’m fine.” We know this is the norm. The DSM talks about 50% of individuals with OCD have suicidal ideation, 25% will attempt. This is what people are going through as they enter treatment or before treatment. They just feel like, “If I just don’t wake up or if something were to happen to me, I’d actually be at peace with it.” It’s a really alarming number.

THE EMOTIONAL TOLL OF OCD TREATMENT

Kim: Right. Let’s move. I love everything that you guys are saying and I feel like we’ve really acknowledged the emotional toll really, the many ways that it universally impacts a person emotionally and in all areas of their lives. I’m wondering if you guys could each, one at a time or bounce it off each other, share what you believe are some core ways in which we can manage these emotional tolls, bruises left, or scars left from having OCD? Jessica, do you want to go first? 

Jessica: Sure. I guess the first thing that comes to mind is—I’ll speak from the therapist perspective—if you’re a therapist specializing in treating OCD, make sure you leave room to talk about these feelings that we’re bringing up. Of course, doing ERP and doing all of the things to treat OCD is paramount and we want to do that first and foremost if possible. But if you’re not also leaving room for your client to process this grief, process through and challenge their shame, just hold space for the anger and maybe talk about it. Let your client have that anger experience in a safe space. We’re missing a huge, huge part of that person’s healing if we’re leaving that out. Maybe I’ll piggyback on what you two say, but that’s just the baseline that I wanted to put out there.

Chris: I could go next. I would say the first thing is what Jess said. We have to treat the whole person. I think it’s great when a client’s Y-BOCS score has gone down and symptomology is not a daily impact. However, all the things that we talked about, we aren’t unicorns. This is what many of our clients are going through and there has to be space for the therapist to validate, to address, and to help heal. I would say the biggest thing that I believe moves you past where we’ve been talking about is re-identity formation. We just don’t recognize until you get better how nearly every single decision we make is based off of our OCD fears, that some way or another, what we listen to, how we speak, what direction we drive, what we buy. I mean, everything we do is, will the OCD be okay with this? Will this harm me, et cetera? 

One of the things I do with all my clients before I complete treatment is I start to help them figure out who they are. I say, “Let’s knock everything we know. What are the parts of yourself that you organically feel are you and you love? Let’s flourish those. Let’s water those. Let’s help those grow. What are some other things that you would be doing if OCD hadn’t completely ransacked your life? Do you spend time with family? Are you somebody that wants to give back to communities? What things do you like to do when you’re alone?” I help clients and it was something I did after my own treatment, like re-fall in love and be impressed with yourself and start to rebuild.

I tell clients, one of the things that helped me flip it and I try to do it with them is instead of looking at it like, “This is hard, this is tough,” look at it as an opportunity. We get to take that pause, reconnect with ourselves and start to go in a direction that is absolutely going to move as far away from the OCD selves as possible, but also to go to the direction of who we are. Obviously, for me, becoming a therapist and advocate is what’s helped me heal, and not everybody will go that route. But when they’re five months, six months, a year after the hard part of their treatment and they’re doing the things they always picture they could do and reconnecting with the people that they love, I start to see their light grow again and the OCD starts to fade. That’s really the goal. 

Alegra: I think something that I’ll add—again, I don’t want to be the controversial one, but maybe I will be—is there might be, yes. Can I get canceled after this in the community? There might be some kind of trauma work that somebody might need to do after OCD treatment, after symptoms are managed, and this is where we need to find nuance. Obviously, treatments like EMDR are not evidence-based for OCD, but if somebody has been really traumatized by OCD, maybe there is some kind of somatic experience, some kind of EMDR, or some kind of whatever it might be to really help work on that emotional impact that might still be affecting the person. It’s important of course to find a therapist who understands OCD, who isn’t reassuring you and you’re falling back into your symptoms. But I have had clients successfully go through trauma therapy for the emotional impact OCD had and said it was tremendously helpful. That might be something to consider as well. If you do all the behavioral work and you still feel like, “I am really in the trenches emotionally,” we might need to add something else in.

Chris: I actually don’t think that’s controversial, Alegra. I think that what you’re speaking--

Alegra: I don’t either, but a lot of clinicians do.

Jessica: No, I agree. I think a lot of people will, and it’s been a part of my recovery. I don’t talk about a lot for that very reason. But after I was done with treatment, I didn’t feel like I needed an OCD therapist anymore. I was doing extremely well, but all the emotions we’d been talking about, I was still experiencing. I found a clinician nearby because I was going on a four-hour round trip for treatment. I just couldn’t go back to my therapist because of that. She actually worked with a lot of people that lost their lifestyle because of gambling. I went to her and I said, “What really spoke to me is how you help people rebuild their lives. I don’t need to talk about OCD. If I need to, I’ll go back to my old therapist. I need to figure out how to rebuild my life.” That’s really what she did. She helped me work through a lot of the trauma with my dad and even got my dad to come to a session and work through that. We worked through living in the closet for my sexual orientation for so long and how hard coming out was because I came out while I was in the midst of OCD. It was a pretty horrible coming out experience. She helped me really work through that, work through the time lost and feeling behind my peers and I felt like a whole person leaving. I decided, as a clinician, I have to do that for my clients. I can’t let my clients leave like I felt I left. It was no foul to my therapist. We just didn’t talk about these other things. 

Now what I’ll say as a clinician is, if I’m working with a client and I feel like I could be the one to help them, I’ll keep them with me. I also know my limitations. Like Alegra was saying, if they had the OCD went down so other traumas came to surface and they’ve dealt with molestation or something like that, I know my limitations, but what I will make sure to do is refer to a clinician that I think can help them because once again, I think treating the whole client is so important. 

Kim: Yeah. There’s two things I’ll bring up in addition because I agree with everything you’re saying. I don’t think it’s controversial. In fact, I often will say to my staff who see a lot of my clients, we want to either be doing, like Jessica said, some of the processing as we go or really offer after ERPs. “Do you need more support in this process of going back to the person you want?” That’s a second level of treatment that I think can be super beautiful. As you’re going too with exposures and so forth, you’re asking yourself those questions like, what do I value? Take away OCD, what would I do? A lot of times, people are like, “I have no idea. I have really no idea,” like Chris then. I think that you can do it during treatment. You can also do it after, whichever feels best for you and your clinician. 

The other thing that I find shows up for my patients the most is they’ll bring up the shame and the guilt, or they’ll bring up the anger, they’ll bring up the grief. And then there’s this heavy layer of some judgment for having it. There’s this heavy layer as if they don’t deserve to have these emotions. Probably, the thing I say the most is, “It makes complete sense that you feel that way.” I think that we have to remember that. That every emotion that is so strong and almost dysregulating, it makes complete sense that you feel that way given what you’re going through. 

I would just additionally say, be super compassionate and non-judgmental for these emotional waves that you’re going to have to ride. I mean, think about the grief. This is the other thing. We don’t go in and then process the grief and then often you’re running. It’s a wave. It’s a process. It’s a journey. It’s going to keep coming and going. I think it’s this readjustment on our thinking, like this is the life goal, the long-term practice now. It’s not a one-and-done. Do you guys have thoughts?

Jessica: I think as clinicians, validating that these are absolutely normal experiences and you deserve to be feeling this way is important because I think that sometimes, I don’t think there’s ill intent, but clinicians might gaslight their clients in a certain way by saying, “This isn’t traumatic. This is not trauma. You can feel sad, but it is absolutely not a trauma,” and not validating that for a person can be really painful. I think as clinicians, we need to be open to the emotional impact that OCD has on a person and validate that so we’re not sitting there saying, “Sorry, you can’t use that word. This is not your experience. You can be sad, you can be whatever, but it’s not trauma,” because I have seen that happen.

Kim: Or a clinician saying, “It’s not grief because no one died.”

Jessica: Yeah. It was just hard. That was it. Get over it. 

Kim: Or look at how far you’ve come. Even that, it’s a positive thing to say. It’s a positive thing to say, but I think what we’re all saying is, very much, it makes complete sense. What were you going to say, Jessica? Sorry.

Jessica: No. I just wanted to point out this one nuance that I see come up and that I think is important to catch, which is that sometimes there can be grief or shame or all these emotions that we’re talking about, but sometimes those emotions can also become the compulsion themselves at times. Shala Nicely has a really, really good article about this, about how depression itself can become a compulsion, or I’ve seen clients engage in what I refer to as stewing in guilt or excessive guilt or self-punishment. What we want to differentiate is, punishing yourself by stewing in guilt is actually providing some form of covert reassurance about the obsessions. Sometimes we need to process the true emotional experiences that are happening as a result of OCD, but we also want to make sure that we’re on the lookout for self-punishment compulsions and things like that that can mask, or I don’t know. That can come out in response to those feelings, but ultimately are feeding the OCD still. I just wanted to point out that nuance, that if someone feels like, “I’m doing all this processing of my feelings with my therapist, but I’m not getting any better or I’m actually feeling worse,” we want to look at, is there a sneaky compulsion happening there? 

Chris: I was just going to quickly add two things. One, I think what you were saying, Kim, with your clients, I see all the time. “I shouldn’t feel this way. It’s not okay for me to feel this way. There’s people out there that are going through bigger traumas.” For some reason, I feel society gives a hierarchy of like, “Oh, if you’re going through this you can grieve for this much, but we’re going to grief police you if you’re going through this. That’s much down here.” So, my clients will feel guilty. My brother lost an arm when he was younger. How dare I feel bad about the time lost with OCD? I always tell my clients, there’s no such thing as grief police and your experience is yours. We don’t need to compare or contrast it to others because society already does that.

And then second, I’m going to throw in a little plug for Kim. I feel as a clinician, it’s my responsibility to keep absorbing things that I think will help my client. Your book that really talks about the self-compassion component, I read that from cover to cover. One thing that I’ve used when we’re dealing with this with my clients is saying like, “We got to change our internal voice. Your internal voice has been one that’s been frightened, small, scared, angry for so long. We got to change that internal voice to one that roots for you that has you get up each day and tackle the day.” If a client is sitting there saying that they shouldn’t feel okay, I always ask them, “What kind of voice would you use to your younger brother or sister that you feel protective about? Would you knock down their experience? No, you would hold that space for them. What if we did that for you? It may feel odd, but this is something that I feel you need at this time.” Typically, when they start using a more self-compassionate tone, they start to feel like they’re healing. So, that’s something that we got to make sure they’re doing as well.

OCD AND DEPRESSION

Kim: Yeah. Thank you for saying that. One thing we haven’t touched on, and I will just quickly bring it up too, is I think secondary depression is a normal part of having OCD as well and is a part of the emotional toll. Sometimes either that depression can impact your ability to recover, or once you’ve gone through treatment, you’re still not hopeful about the future. You’re still feeling hopeless and helpless about the way the world is and the way that your brain functions in certain stresses. I would say if that is the case, also don’t be afraid to bring up to your clinician. Like, I actually am concerned. I might have some depression if they haven’t picked up on it. Because as clinicians, we know there’s an emotional toll, we forget to assess for depression. That’s something else just to consider.

Chris: Yeah. I’m a stats nerd and I think it’s 68% of the DSM, people with OCD have a depressive disorder, and 76% have an anxiety disorder. I always wonder, how can you have OCD and not be depressed? I was extremely depressed when my OCD was going on, and I think it’s because of how it ravishes your life and takes you away from the things you care about the most. And then the things that would make you happy to get you out of the depression, obviously, you can’t do. I will say the nice thing is, typically, what I see, whether it’s through medication or not medication, but the treatment itself—what I see is that as people get better from OCD, if their depression did come from having OCD, a lot of it lifts, especially as they start to re-engage in life.

Kim: All right. I’m looking at the time and I am loving everything you say. I’d love if you could each go around, tell us where we can hear more about you. If there’s any final word that you want to say, I’m more than happy for you to take the mic. Jessica?

Jessica: I’ll start. I think I said in the introduction, but I have a private practice in Los Angeles. It’s called Mindful CBT California. My website is MindfulCBTCalifornia.com. You can find some blogs and a contact page for me there. I hope to see a lot of you at the IOCDF conference this year. I love attending those, so I’ll be there. That’s it for me.

Kim: Chris?

Alegra: Like I said, if you’re in the Southern California area, make sure to check out OCD SoCal. I am on the board of that or the International OCD Foundation, I’m on the board. I’m always connected at events through that. You can find me on my social media, which is just my name, @ChrisTrondsen. I currently work at the Gateway Institute in Orange County, California, so you can definitely find me there. My email is just my name, ChrisTrondsen@GatewayOCD.com. I would say the final thought that I want to leave, first and foremost, is just what I hope you got from this podcast is that all those other mixed bags of emotions that you’re experiencing are normal. We just want to normalize that for you, and make sure as you’re going through your recovery journey that you and your clinician address them, because I feel much more like a whole person because I was able to address those. You’re not alone. Hopefully, you got from that you’re not alone.

Kim: Alegra?

Alegra: You can find me @obsessivelyeverafter on Instagram. I also have a website, AlegraKastens.com, where you can find my contact info. You can find my Ask Alegra workshop series that I do once a month. I also just started a podcast called Sad Girls Who Read, so you can find me there with my co-host Erin Kommor, who also has OCD. My final words would probably be, I know we talked about a lot of really dark stuff today and how painful OCD can be, but it absolutely can get so much better. I would say that I am 95% better than I was when I first started suffering. It’s brilliant and it’s beautiful, and I never thought that would be the case. Yes, you’ll hear from me in July, Kim, but other than that, I feel like I do have a very-- Kim’s like, “Oh, will I?”

Kim: I’ve scheduled you in.

Alegra: She’s like, “I have seven months to prep for this.” But other than that, I would say that my life is like, I never would’ve dreamed that I could be here, so it is really possible.

Kim: Yeah.

Chris: Amen. Of that.

Kim: Yeah. Thank you all so much. This has been so meaningful for me to have you guys on. I’m really grateful for your time and your advocacy. Thank you.

Chris: Thanks, Kim. Thanks for having us. 

Alegra: Thanks, Kim.

I can barely hold in my excitement!

We have a three-day live event where I will teach a new course called Overcoming Depression. 

I have had all of this passion show up in my body after seeing loved ones and clients struggle and after you guys repeatedly asking for a course on depression.  

Our new online course called Overcoming Depression is finally here. 

I will record it live on March 11th, 18th and 25th from 9:00 a.m. to 10:30 a.m. 

If you are interested, please join me, and I will teach you LIVE, and you can ask all your questions.

NOTE: This course will not be considered therapy. Just like all of our courses, it will be educational. 

Overcoming Depression will be me teaching you the skills I teach my clients when it comes to Psychoeducation and strategies and tools to overcome depression.   

Head over to CBTSCHOOLcom/depression to sign up!  

I am so excited to have you guys join me live. 

• Ask your questions in the question box. 
• We will tackle not only your negative thinking but also
  • your behaviors
  • your motivation
  • Self-compassion
  • Long-term recovery techniques 

 I'm so excited and hope to see you there.
SIGN UP at CBTschool.com/depression

OCD TREATMENT OPTIONS 

Today, we have Elizabeth McIngvale and we are talking all about different OCD treatment options. 

Elizabeth (Liz) McIngvale is the Director of the McLean OCDI Houston. She has an active clinical and research and leadership role there. McLean OCDI is a treatment center for people with OCD and she talks extensively about different OCD treatment options in this episode. She’s the perfect one to talk to in this episode about knowing when you need a higher level of care, particularly related to OCD. 

In this episode, we walk through the different levels of care from self-help all the way through to inpatient facilities. Elizabeth spoke so beautifully about how to know when you’re ready for the next step of care, what to look out for, what you should be interested in, and questions you should ask. This is such an important episode. I’m actually blown away that I haven’t addressed it yet, but I’m so grateful we got to talk about it today.

Elizabeth McIngvale is also a lecturer at Harvard Medical School. She treats obsessive-compulsive disorders, anxiety disorders. She’s got a special interest in mental health stigma and access to mental health care. It was actually such an educational episode and I felt like it actually made me a better supervisor to my staff and a better educator as well. You’re going to love this episode if you’re really wanting to understand and take the stigma out of increasing your care if that’s something that you need. 

That being said, I’m going to let you listen to Elizabeth’s amazing words, and I hope you enjoy this episode just as much as I did. Have a great day, everybody.

Kimberley Quinlan:  Well, welcome, Liz McIngvale. I'm so excited to have you on for two reasons. Number one, I really want to talk about giving people information about OCD treatment options, but I also understand that you can also bring in a personal experience here. Anytime, someone can share their personal experience, just lights me up. So thank you for being here.

Elizabeth McIngvale: Thank you for having me. I'm so excited to be here and yeah, I hope that both my personal but also professional kind of background in this arena might help guide. Some individuals who are kind of wondering what treatment do they need right now and and what does treatment for them look like

Kimberley Quinlan: Wonderful. Do you want to share a little bit about your history with OCD and your story as much as you want to share?

Elizabeth McIngvale: For sure. Yeah, I'll try to not take up too much time but you know, basically, I grew up here in Houston, Texas, where I'm from, and was diagnosed with OCD right around 12. I started showing lots of different symptoms prior on and off, but nothing that was disruptive nothing. That really would have warranted a diagnosis. I would do things like track the weather, or every time I read a book, I would start at page one because I didn't like the feeling if I picked up in between and things like that…

Elizabeth McIngvale: but nothing was really out of the norm normal in the sense that I was still doing okay. And academically you know, Relationship-wise and I was functioning well until I wasn't, you know, until my intrusive thoughts, got louder and the disruption became more and more severe. Here in Houston, we have the largest medical center in the world and we are known for our healthcare and so you would think access to good care would be really accessible, but unfortunately, it just wasn't and granted, this was a long time ago, almost 20 years ago but we really started searching for treatment here in Houston and, you know, I was lucky enough that pretty early on I got  a diagnosis and for most of us in the OCD world, we know that that's rare for it to happen that soon. So that was great. That was a huge blessing for me, however we couldn't find good treatment. Every provider would say things like we've never seen a case like this. We don't know how to treat this and there's not help available. You guys should assume that Liz live in a mental health hospital, the rest of her life. And so my parents were just really struggling with What do I do and How do I help my child. And so they kept researching and kept trying to figure it out and actually they got lucky enough that they stumbled across the newspaper article and in that newspaper article talked about an inpatient treatment center at the time which was called the Meninger Clinic and how they had an OCD program. There was a little bitty excerpt and immediately my dad, called my mom, they ended up calling Meninger and learning more and I ended up going to the Meninger clinic when I was 15. I went three days after my 15th birthday, I'll never forget and I talk about this a lot because my treatment stay at Meninger was the first step to my life being changed. It was the first step to me getting appropriate treatment. It didn't cure me, you know, I want to be honest about that. I think sometimes we think, okay, we go do that. We either like get cured or We don't. And, for those of us who live with OCD, we understand that management of our illnesses different than a cure, right? It was a lot of work, but it was also the beginning of a journey where I had to learn to do my own treatment and I had to learn to become my own therapist. And as much as the treatment was super successful for me, I was there for three months and my life changed. I went from being suicidal being hopeless, and not being able to function at all six to eight hour showers and completely, homebound completely riddled by rituals, to being a kid who could fully function. I was able to go back to school. Take five minute showers, do things I never thought I could do again. At the same time, I didn't realize that I had to still take ownership of my illness, I think I thought Oh like the ownership is, I did treatment and that's what it meant. Not that I needed to keep engaging in treatment. And I talk about that because I did relapse later, I ended up going… I ended up doing some outpatient in between and then back to impatient again. And for me, I had to kind of learn what level of care works for me? What does that look like? And how do I manage my illness? And to this day, I still go to outpatient therapy. It's still a big part of my life. Am I actively doing OCD work every week? No I'm doing other stuff right? Family system and boundary setting and things that are important in my life that are tough. But it's been a journey even for myself personally, to know what level of care do I need and at what point. And I think what's really interesting is that when I was 15 I would have told you I'm not going to treatment. My parents had to take me involuntarily and it was a pretty awful day the day they took me to treatment. And, you know, I say this because a lot of times when people hear my story they think Oh, well, y'all did everything right and like, it was just this, like, beautiful path to recovery. That's like, no. It was really messy and it is messy and that's okay. There is no perfect way for us to get treatment in a way that can change our life. And so I really want us to think more about the outcome and what treatment might mean to us versus being super close-minded about the process,…

00:05:00

Kimberley Quinlan:  Right.

Elizabeth McIngvale: because I think a lot of times we have so much anxiety around I want to go to intensive treatment. I don't want to leave my life. I don't want to put things on hold I don't want to go to this hospital like setting if that's where I'm going and really, it's not about that. It's about what might it give us in the long run,  right?

Kimberley Quinlan: Right.

Elizabeth McIngvale: And just that chance at freedom that maybe outpatient care can no longer do.

Kimberley Quinlan: Right? So for the folks who are new here and if just new to us let's sort of just because I feel like I really want to cover this as as much as we can. When you went to Meninger what was the correct OCD treatment in which you received like was it,…

Elizabeth McIngvale: Yeah. Totally.

Kimberley Quinlan: can you kind of give us a little bit of a view of what that looks like?

Elizabeth McIngvale: Yeah. So before Meninger I had gone to outpatient providers and…

Elizabeth McIngvale: I remember playing the  board game life with a therapist once and I crossed the bridge and I remember her saying Liz, how does that feel? And I was like Well I don't know. Like How does it feel to you? Like what? I remember going to my mom and I was young, right? I was adolescent. I said Mom like this isn't working like we're playing the  board game life, I'm not getting better, like this is not therapy and my mom was just like, well, I don't know, she didn't know, she didn't know what she should be doing or not. And so I got to Meninger and I remember there were three things that really put things in perspective for me upon arriving. The first was I met someone else like myself. I met a young girl named Amy who struggled with an eating disorder and OCD and I remember I was crying. I was vomiting. I was so sick. That was so anxious about being there and all she said to me is it's okay. I cried too. And it was the first time in my life. I met someone else like me. And for those of you who know, you know, the the value I believe advocacy has in the OCD world is because we need to feel part of a community, even when we're struggling, And so I got that but it was the first time in my life. I remember, I sat down with my therapists in this conference room and you know, I didn't believe in therapy, candidly. I had gotten really bad therapy for a long time and I just continued to get worse. So I didn't think therapy could help me. I didn't think I could get better and I really was starting to accept that I would just live a life with bad OCD forever and then I would just live in this basically, in the state of misery. And I remember I sat down and for the first time My provider starts asking me all these questions, and he doesn't seem scared. He's like, Oh yeah, no problem. Okay, tell me about this. Tell me about that. And there was this like, not egotistical like this, very humble confidence that. Oh, yeah. Like I know how to treat you, and I was just like, what? And I remember, He said, Yeah, we're gonna do Exposure & Response Prevention (ERP)  I've done this before. You're not the worst case. I've seen, you know, I know how to treat this. I've done all in, It was the first time I realized, Oh my gosh, someone actually knows how to help me.

Elizabeth McIngvale:  And so my entire treatment was based on exposure and response prevention and you know I think ERPs come a long way as somebody who now works in this field and runs a program doing, you know, runs at the same program. We don't do ERP the same way we did when I did it. Right. When I did ERP, it was an older school model. It was a very habituation model. I remember holding contaminated sweaters and just sitting there for an hour or two, right? We don't do that anymore, but there's something about the basis, right? The core of the treatment hasn't changed and it's it's what changed my life and it's it's really important that I will say, I can't imagine what it had been like if I would have gone to an impatient or a residential setting that wasn't OCD specific and that wasn't doing evidence-based care. I would have believed in treatment even last and I would have been even more helpless.

Kimberley Quinlan: Yeah, there is so much beauty to being with someone who's like, Oh yeah, I've had a worst case than you like. I've had so many clients say like that is the best thing anyone has ever said to me.

Elizabeth McIngvale: Yeah. Yeah. Like okay not like Oh like I mean literally providers would say to me in Houston like we've never seen a case of severe. We don't know how to help you and it's like, Well what? So like What do I do?

Kimberley Quinlan: Right.

Elizabeth McIngvale: You know, Can you try and they're like, we don't know, we don't know how to try.

Kimberley Quinlan: Right, right? I'm so grateful that you had that experience. This amazing. So, Let's sort of fast forward to now. You of course are an OCD specialist, we know this an amazing one. I first want to look at the term outpatient For some people, they don't know what that means. So what does OCD outpatient treatment look like?

Elizabeth McIngvale: Yeah.

OCD TREATMENT ONLINE

Kimberley Quinlan: And would you also speak to now since covid? We also have like an online version of that so you want to elaborate on OCD treatment online? 

Elizabeth McIngvale: Yeah, there's so many. So actually, let's have you start first by describing self-help because I think it's. So I think it's really important When we think about levels of care to think about the continuum, right? I look at it as like,…

Kimberley Quinlan: Right. Yep.

OCD SELF HELP

Elizabeth McIngvale: there's self-help options, there's outpatient options and then there's intensive option.

Elizabeth McIngvale:  Yeah.

00:10:00

Kimberley Quinlan: Beautiful, yeah. Like thats the epitome of me, like even with this podcast, right? How can we provide free or not one one one treat metn for people or in the case of CBT School, how can we  help you to do it on your own?  RIght, so there are sort of self lead courses  or we have the self-compassion workbook for OCD, which is ultimately me as a clinician saying, If I was with a client, this is the steps I would take. So, that's the first step and we offer that all the time. And and I think I don't really actually think we've got that much research on it yet. I think we're in the early stages of that, but that is being really helpful for people who sort of want to become educated, want to understand what's going on and they feel motivated and able to do that on their own. So that's that's the self-help model, then what would we use?

Elizabeth McIngvale: Well in one of the things, I want to back up for a second to just and I know you've done so many podcasts on this but for those who've skipped over this one, right, what's really most important is that you're engaging in evidence-based treatment and what we mean by that is that we want to make sure you're getting access to treatment that's been researched and that we know works for OCD. And so there's self-help that is not evidence-based for OCD and they're self-help that is evidence-based for OCD. And one of the beauties of self-help is that you don't have to look at it as a soul intervention, right? Do it while you can, you can do these workbooks, you can do these self-help, you know, in different modalities while you're going to an outpatient therapist. And then one of the things that's really beautiful is that if you live in an area where there isn't OCD providers or OCD specialists your clinicians can actually also use it as a guiding tool in treatment, right? And so again it's allows there to be this rubric of good treatment, all right? This kind of like guide book to,…

Kimberley Quinlan: Yeah.

Elizabeth McIngvale: you know, or handbook to say. And so Always think of that as kind of our least, invasive level of care and…

Kimberley Quinlan:  Right.

Elizabeth McIngvale: it's a level of care. That's my goal that everyone ends up at right that you're able to get to a place…

Kimberley Quinlan:  Yeah.

Elizabeth McIngvale: where like, yes, you're still actively engaged in a treatment community whether that's through self-help workbooks or podcasts or different ways that you connect because that's really helpful, but that you may not need one-to-one anymore, right? I go to one-to-one therapy because it's important for my soul. I don't need it and…

Kimberley Quinlan:  Right.

Elizabeth McIngvale: that's very different, right? I'm at a place where I can engage the tools inependently, using some resources with and when I need them. And so then the next level is outpatient therapy and traditional outpatient therapy would be oftentimes once a week 45 to 50 minutes session with an OCD specialist in person, one to one in the past three years, that's totally shifted right actually, I would say more commonly it's virtual than it is in person and you know, there's pros and cons. I think most of us Most of us still think in person is better,  right? That just if it's feasible, But from a scheduling perspective and feasibilities perspective online is so much easier, right? So most of us, myself included, I do my therapy online because it's, I don't have to schedule the time to drive and get to my clinician and drive back. And so, that's really important. The second piece that's really important to think about is, I would rather you 100 times over be doing virtual sessions with someone who specializes in OCD and knows how to treat OCD then do in person with someone who doesn't.

Elizabeth McIngvale: Right, so really, when we think about therapy and interventions, we want to make sure and this is important because a lot of times people will say, Oh well I've tried out patient therapy, It doesn't work for me but they haven't necessarily tried it with an OCD specialist and they haven't been appropriate evidence-based treatment and really we want you to do that first before you start thinking about next level of care or you know some people will want to do like a medication trial and it's like Well you don't get in the research study in a trial if we haven't tried evidence based stuff first, right? So that's really important. With that being said, outpatient can be a continuum, Some outpatient providers can offer two to three sessions a week for 45 minutes, you know? So they can do kind of what we would call like intensive outpatient and that they may make in their own program, but traditionally most clinicians who carry an outpatient case. Load would see someone once a week for 45 minutes session.

Kimberley Quinlan: Yeah and I think that's for our center as well once maybe twice if there's more of a crisis but that's the level of care that we that's the kind of clients that we have and that's the level of care that we do provide. So I think and I will say going back to your online is quite a few of the people who take ERP school have therapists, right? It's like 55% of the people who take ERP School are therapist. So therapists are, you know, even though that might be their specialty, Let's say they're the only person in their neighborhood. That is what they're doing, right? They're just doing the best, they can learning whatever skills they can. So that's very positive in my mind.

Elizabeth McIngvale: That's right. Yeah, and want people to have a good sound background in ERP but have to mean that they only treat OCD,…

Kimberley Quinlan:  Right.

Elizabeth McIngvale: you know, and I think it's important that you can get really great progress right on an outpatient basis with someone who's knowledgeable and ERP. If you are at a place where outpatient level of care is warranted and important to think about,

00:15:00

Kimberley Quinlan:  Right, and that brings me to my next question, how would someone know if they needed a higher level of care for OCD? What would be some symptoms or signs that would be showing up for them?

Elizabeth McIngvale: And so the first thing I want you to think about is, Are you seeing somebody who does evidence-based care and are you not getting better, right? That's really the first like thing we need to look at is, Are you going to therapy and have you given in a good therapeutic dose, right? So we're talking, you know, at least a couple months. You don't expect that in two sessions, right? We're like better. Because often it may get worse than better. But at least, you know, maybe a couple weeks to a month or two. Are you on your own saying, I'm not seeing the results that I want, right? That this is, this is not getting me where I want to be. The second question is what level of functioning has your OCD impacted?

Elizabeth McIngvale: Traditionally most of our patients in residential care are not working full-time. So their OCD is really impacting their functioning on a level that's disruptive so whether that's either their family life or their job or their school or their career, right? Something is pretty significantly disrupted from their OCD. That once a week may not be enough, right? It again the level of disruption is a little bit too high and then the third thing to really think about is what your provider telling you A good OCD clinician should not be trying to make some sort of a program for you that they don't typically do to keep you on their caseload.

Kimberley Quinlan: Right.

OCD INTENSIVE TREATMENT

Elizabeth McIngvale: They should willing to say to you, You know I think I think you need more right now. And this is what more might look like. And the reality is that you're going to get to go back to them, right? As long as they're doing good ERP and evidence based care, right? You're gonna be encouragedto go back to that outpatient provider but it's about stepping up the level of intensity, right? If we have a medical diagnosis and we're going to our doctor but it starts to warrant the level of hospitalization or certain you know more intensive treatment, we don't want our outpatient doctor to keep seeing us in their private practice, right? We want them to send us to the hospital so that it can get managed and we can get more intensive treatment until we can return back to an outpatient level of management. We cannot treat the brain differently.

Elizabeth McIngvale: You know, and I hear people all the time. Well Liz, you know, I don't really want to go to treatment for four six weeks and my answer is like, well, what's 4 6? 12 18. However, many weeks you're at a treatment center if it gives you the rest of your life.

Kimberley Quinlan: Right.

Elizabeth McIngvale: Right? When we are talking about meeting this level of care, the disruption is not minimal the disruption is significant, right? We know that for patients with OCD, OCD impacts all aspects of your quality of life, right? All facets of it. I'm looking at our data yesterday and all like our 2022 outcomes data. We see significant statistically, significant decrease in OCD scores in phq-9.

Kimberley Quinlan: Right.

Elizabeth McIngvale: But then also in disability scores, right? Because we want you to be able to get back to functioning and get back to the life, you love, or you deserve, or you're excited about that OCD is taking away from you and so, I always want, I always want you to think about that and often with that means is that you typically can't do the homework, you're being assigned,…

Kimberley Quinlan:  Yeah.

Elizabeth McIngvale: you know, being assigned homework, and you're trying to do it, you're trying to engage in it, but you're struggling and you find that you're you're not able to do that homework independently. And so often times patients in our level of care, need extra support. They need support in the evenings. They need support outside of their behavioral therapy sessions to be able to do this ERP They need extra coaching, they need extra support. They need extra motivation.

Kimberley Quinlan: Right. And and recently, we had Micah Howe on the podcast. I was sharing with you before and he was really saying… He said, I went to inpatient thinking that it would be like a new kind of therapy and he's like, it was actually good to see, it's the same therapy, but more, right? Like just so much more.

Elizabeth McIngvale:  That's right. Yeah, if you're with a good therapist, right? It's same, if you're with someone who's doing evidence-based care, it's the same therapy but more and maybe maybe it's implemented a little bit differently, right? I do believe that we use some different language. We try to get things to stick in different ways, right? That sort of thing, but the model of treatment shouldn't change.

OCD INPATIENT TREATMENT 

Kimberley Quinlan: Okay, so this is all beautiful and I think it all of those points that you made are so important. The homework piece the therapist feeling like that's what they're recommendation is. What would be the next step up from outpatient? OCD treatment, in your opinion?

Elizabeth McIngvale: Yeah. So you know I can't speak for all the programs but what I can tell you is that here at the OCD Institute in Houston, Right? Houston Ocdi. We really focus on a super detailed admission process. And so what I mean by that is Kim,…

00:20:00

Elizabeth McIngvale: if you call tomorrow and said Hey I have sever OCD, I need to come to your program. We don't say great, here's our next opening,  that's not how it works at all. So for us we require a provider referral form a family referral form. You have to complete intake forms and then we do a one hour zoom session with you And during that zoom session we want to gather information. We want to understand your current symptoms. We want to make sure two things A: You're a good fit for our program and B: that we think this level of cares appropriate for you, you know, just because sometimes people have really bad OCD but they're actually not right yet for this level here. I run my program with this super strong whatever we want to call it…but deep rooted ethical means because it's happened to me in different ways and I'll never do it is I want to make sure that if someone is coming here and using certain resources that aren't you know, They run out. I want to make sure they're having the best chance of

Elizabeth McIngvale:  Managing their symptoms being able to return and live return to their life or live their life. And so, what I mean by that is that I don't take a patient if they want to come here, but we don't think they're good fit and ethically, I'm never gonna do that, right? I want you to get the right treatment and go to the right providers and the same thing happens when you come here. I think a lot of times people think, Oh, if I go to intensive treatment, I just, you know, they're gonna take my money and hopefully I get better. Absolutely not. You should run from a program that you feel like that programs should be reassessing every week. We have team meeting every day, we have rounds and we're talking about, Is this the right fit? Are we helping move the needle? Is the patient getting better? And so just because you start, somewhere, doesn't always mean you're gonna end somewhere. Sometimes we learn a lot about a patient. And example might be You come here with strong with with really high level OCD. But as you start doing intensive, work we realize. Wow you you're really struggling with emotion regulation and we actually think you need to go get some DBT work first before you're going to be able to effectively engage in ERP. And so we may encourage a patient to discharge,…

Elizabeth McIngvale: go do DBT and come back to us so that there's a chance at us being successful. I never want to patient to stay in my level of care and not be successful because it wasn't the right time or they needed to do something else first because then guess what they think treatment doesn't work for them and they think they can't get better when that's not the case. I talked about this with John Abramowitz the other day on a webinar with Chris Johnson and then we were talking about ERP and I said Guys for all intents and purposes there's years if not decades a decade in my life where I could have said to you ERP doesn't work for me. But it's not that ERP didn't work for me.

Kimberley Quinlan: Mmm.

Elizabeth McIngvale: It's that I wasn't accepting ERP and I wasn't engaging in ERP. I was doing it with one foot in one foot out. And the good news with intensive treatment is, we're going to try to help you get both feet in, right? We're gonna try to increase your motivation, increase your willingness, and we can support you 24 hours a day in that process, which is what outpatient therapy cannot do. An outpatient therapist does not have the capacity to offer that level of support…

Elizabeth McIngvale: where we can and we do. At the same time, If we're trying and you're not able to do that right now, we're not going to keep trying the same thing. We're not gonna keep saying Well let's just keep doing ERP because guess what ERP isn't gonna work for you right now, but it's not that ERP doesn't work. It's because we need to get you ready to do ERP even at an intensive level. And so we should be thinking about that as well. And so my point is that it's not a one size fits all model. And if you're looking for intensive or residential programs, be cautious of that, be cautious of programs that, you know, require you to stay a certain amount of time and take all your money up front and they're not going to, you know, customize a plan, you know, that sort of thing.

Kimberley Quinlan: Mmm. I love that. I love that. So, just for the sake of people understanding and I actually will even admit, like, I really want to know this too because I've only ever been an outpatient provider. I've never been an inpatient or a residential provider. So could you share Maybe the differences between OCD intensive, outpatient therapy, right? With OCD inpatient treatment or residential treatment. What, what would the day look like? And how would that be different for the person with OCD?

Elizabeth McIngvale: Yeah, it's a great question and let's actually walk through. There's a couple levels of care, so there's IOP, which is intensive outpatient, which is often three to five hours a day. Three to five days a week. There's PHP, which is partial hospitalization, which is often five days a week about eight hours a day. And then there's residential level of care, which is 24 hours, a day, 7 days a week. And then there's inpatient level of care, which is also 24 hours a day, seven days a week, but impatient is a little bit different than like what we have here at the Houston OCDI where we're residential. Inpatient can take patients with a higher level of acuity. So impatient is often a locked unit. That's a hospital setting. So they may be able to take patients that are active safety risk, you know, harm of hurting themselves that sort of thing, where residential program like ours, we don't, we don't accept those patients because we can't maintain that level of acuity for them. We are not a facility that can help keep patients safe. And what I mean by that is that while our program operates 24 hours a day. We are a non-locked unit. We have a full kitchen, we've got washer dryers, we get for all intents and purposes, like You're living in a beautiful residential home and you have access to knives, you can leave whenever you want. You can go off site, you can go to the Astros game if you're here in Houston. And we want you to do that. Actually, we want you to start to reintegrate into life, while you're in treatment with us.

00:25:00

Elizabeth McIngvale: And so, the reality is that, we need patients to be at a certain level of acuity right? So they have to be safe, and they have to not be a risk or harm to themselves for us to feel comfortable that they can engage in our level of care safely. And so, the difference between let's say IOP is that often times, we're talking about three to five hours a day, three days a week and so you're doing intensive sessions together, right? Imagine you're going to your therapist and for three hours a day, you're doing some, you know, individual or even group stuff, but you're working together, you're doing exposures and you're getting three hours of support versus 45 minutes.

Elizabeth McIngvale: Residential however, is 24 hours a day. And so, for our residential patients, there's programming from 8:45 to 4 pm Monday through Friday, 8:45 to 3 pm on weekends. But there's residential counselors here 24 hours a day, which means that when we do outings with our patients, Wednesday and Saturday night our RCs are going with you. They're encouraging you. They're helping you. They're supporting you. Because for all all of our patients actually with OCD, there's exposures built into outings you know, to going off, site to going and doing enjoyable things. And so you have that support 24 hours. If you need support in the shower, you have that support. If you need support cooking a meal, you have that support doing your laundry, you have that support in a residential setting. So really, if you need extra support around activities of daily living, we want you to be thinking about a residential level of care, compared to more of an outpatient level of care. Even if it's intensive outpatient or PHP, you're gonna go home in the evenings and you're gonna be expected to be able to engage in those activities on your own.

Kimberley Quinlan: Right. Right. So just because I'm thinking of the listeners and I'm wondering if they're wondering, Does that mean that when they come into your Houston residential program that, let's say, if they're someone who showers for, let's say, two or three hours, that you're immediately, your therapist on staff are going to be cutting them dance for like down right away. Or What does that look like? Is it gradual? Like How would that like, That's just an example…

Elizabeth McIngvale: Oh yeah.

Kimberley Quinlan: But what would that look like in the residential format?

Elizabeth McIngvale:  It's a great question, right? So I can tell you up front, if someone is coming with contamination OCD and they have, Let's just say a two to three hour shower. My goal is definitely gonna be that we're cutting that down, right? And the goal is that you're not going to be engaging in that long of a shower, by the time you leave and that's not your goal, right? Or you wouldn't be coming, but everything is done slowly and systematically and it's done effectively. So, what I mean by that is that we're not gonna push you to do exposures, if you can't engage in response prevention yet. We know, that's not useful. And so, what you would expect really weeks one and two are getting to know our model. You're starting to, you know, engage in readings and videos. And, you know, you have some small exposures. We're starting to do and you're building trust and repor, but you're starting where you want to start. Some of our patients might show up with the two-hour shower, but that's actually not their most distressing compulsion, something else is and that's what they want to work on first and that's where we're gonna meet them, right? We're not gonna start with a place you don't want to start and so we slowly work up to things and we get there together and we do like monitors in the shower and in our staff room so that we can have coached showers. So we might say things. Like If you set a goal of you know I want to be done with shampooing my hair within a five minute period or this, right? We're telling you the time we're communicating with you throughout we're asking you if you need a different level of support, we're talking to you about the amount of supplies you take into the shower prior. So we're doing a lot of planning, a lot of prepping. But I have a lot of rules. For exposures as an OCD clinician and certainly as the program director here. Number one is exposure should never be a surprise? We never throw exposures on someone, right? We talk about it with you. We're all on board. It's not an unplanned exposure by just, you know, say Hey today you're doing this or I just purposely contaminate you. The second is exposures should be agreed upon mutually right? You should be wanting to do it. You should be agreeing to do it. It shouldn't be something that I think makes sense. It should be what you think makes sense. And of course the last is that it should always be something I'm willing to do, right? I'm never ask someone to do an exposure that I'm not willing to do and so that doesn't shift in the residential process, right? Yes. In a residential program, I might be able to push patients a little bit more because I, I know they're gonna have support. I know that we can help them or you're with four hours of activity or people blocks a day compared to you know, 20 minutes within my 45 minute outpatient session. So sure we may be able to push a little bit more or a vote higher levels of distress when we're doing er,

00:30:00

Elizabeth McIngvale:  Than what would be comfortable with on an outpatient level but across the board motivation. Willingness that's on the patient, not on us, and it shouldn't be

Kimberley Quinlan: And I'm just curious because I don't, this is so wonderful and thank you for sharing all that. Because I think that's true for outpatient and…

Elizabeth McIngvale:  forced, or

Kimberley Quinlan: for residential, but I think is so beautiful in that setting and I'm mainly just curious because I haven't been able to visit your center is,…

Elizabeth McIngvale:  Yes.

Kimberley Quinlan: are they as everyone bunked in rooms together? Like, What does that look like? I know that in and of itself may be scary for people going in, right? Like, Do I have to sleep with somebody because I have compulsions around sleep and I'm afraid I won't sleep like, so, what does that look like?

Elizabeth McIngvale: I know it's a great question and it's it's interesting because when I so I actually went to the Meninger clinic when I went impatient at 15 and it was a locked unit, it was a much, lover, level higher, level of acuity. And so it was this like, sterile hospital, like setting, you know, and I remember feeling super upset and anxious and away from my home and One of the things that I don't love about those sort of settings for OCD treatment perspective, is that like, we had a housekeeper there, for example, like there was an access to a washer dryer to a kitchen. So like meals were prepared for you and what laundry was done. And while that's fine or good, actually, for some of us with OCD. It's not good for OCD, right? Because we want patients to actually practice those skills. And so, However, before I jump into what our programs like I do want to say, I still got better.

Elizabeth McIngvale: And I will tell you that, if the cost is being in an uncomfortable, sterile hospital setting, but it was me getting my life back. I do it all over again and so I really want us to think about that.

Kimberley Quinlan: That's really interesting.

Elizabeth McIngvale: You know that I think sometimes we we get so hung up on like, am I gonna be comfortable? What does it look like? What if I have a roommate and at the end of the day, you're getting your life back? So those sort of things are not what's more important, that should not override if it's an OCD specialty program, if you're going to be with other patients with anxiety or OCD, that's more important to me. I want When you're, if you're looking for a higher level of care, you need to be asking questions, like Are all the patients Patients with anxiety OCD are related disorders, is the treatment program specific to that, right? You don't want to be at a program with, you know, people with 20 diagnoses and there's just generalist modalities for groups or generalists, you know, groups and whatnot. You want there to be effective evidence-based care, being taught to you for anxiety and OCD.

Elizabeth McIngvale:  And so our program is actually so different. So our program is, in a beautiful Mediterranean, you know, 6,000 square foot, beautiful home and with the brand new kitchen, and it's got, you know, two washers too. Dryers and we have 11 beds total. So, six of our I'm sorry, we have six bedrooms, five of the bedrooms, have double beds. So, two queens and those rooms and then one has a single bed, that's our ada room, all of our bedrooms have their own bathroom and it's a really a home like home like experience. I think all of our patients would tell you, I hear this, I do it. Check out with every patient that comes through a program, I run groups and with them all the time, they always say that the entire experience was completely different than what they expected. You know, they were thinking this hospital setting this kind of rigid treatment where it was really instead it's like, hey, you come here and we help together create a supportive environment to get you back to the things you want to be doing in your life.

Kimberley Quinlan: Yeah, I love it. I mean, when I used to work in the eating disorder community, it's like a big family. Like and and I think for me from my experience of clients, going through residential programs is, I think they had this idea of What the other people would be like only to find out. Like, these are my people, like, these are my people and and I want to encourage people listening. I know it's scary, the idea of increasing your, at the level of care. But usually, when you increase the level of care, you meet more of your people which is like the silver lining, I don't know, that was just being my experience of people and…

Elizabeth McIngvale: I couldn't agree more,…

Kimberley Quinlan: what they've said,

Elizabeth McIngvale: you know, and we we see our patients and they leave. And we do this mentor support group where they can come back and run them into our group to the newer patients, or the patients currently in the program and it's so great to see. But I cannot tell you how many of our patients are great friends now and they go to the conference together and…

Kimberley Quinlan: Yeah.

Elizabeth McIngvale: they, you know, connect together and they run a support group for each other outside of when they leave here to keep and hold each other accountable. But you know one of the beauties is that in our home like setting you get to truly practice everything, right? And so you practice, the things you're gonna have to be doing at home, from cooking a meal doing your laundry, cleaning your room, right? All these sort of things that are important skills. We don't want to isolate and create this sterile environment. We want it to feel and to mimic your home. And so, there is so many memories and so much connection that's made when you're cooking together with your residence or when you're sitting in the living room together and watching them a movie, or going out to dinner in the community together and those are some of the most Important impactful and meaningful experiences and treatment, right? Not only because you make peers and connections, but you also get to encourage each other in the treatment process together.

00:35:00

Kimberley Quinlan: Mmm, I love that. Okay. So we've worked our way to the higher level of care. You've done the higher level of care. Let's make sure we finish this story. Well, right? It's like, it's like a movie plot to, the right is, How do we come down the level of care, right? So what does it look like for somebody who's done higher levels of care? What what is like you said at the beginning? It's not just like a one and done, you can sort of dust yourself off and maybe you can, I don't know. What is your experience? What's your suggestions in terms of reducing the level of care,

Elizabeth McIngvale: Yeah. So our goal from treatment is that anytime someone discharges from our program, their discharging to an outpatient level of care and at some times for some of our patients, they're going to discharge back to their outpatient provider and they may see them two or three days a week, a first couple weeks and then two days a week and then, you know, to kind of taper back down to traditional outpatient or whatever, their therapist has available. And so that's the goal. But getting there looks different for everyone. So some of our patients will do residential the whole time, they're with us 12 to 16 weeks. However, long, they're in treatment and go straight back to their outpatient level of care, especially if they live out of state, different things that may make the most sense for them, but some of our patients may actually discharge to our day program. So they may, you know, spend eight weeks with us in the residential. And then discharge to our day program, for the last four weeks, especially if they're local, but even if they're not, they may get an airbnb and discharge to that level of care because it might actually be recommended and warranted for them to really practice independent things outside of the treatment day without 24 hours support

Elizabeth McIngvale:  And then again be able to tailor or taper back down to an outpatient level of care. So for us that is always our goal. One of the questions I get a lot is like Well when will I know if I'm ready to leave Liz and What will that look like? And my response is always the same is that I don't expect or actually want patients to leave here without any OCD. If you're leaving here without any triggers or any anxiety or OCD, then we probably kept you too long, right? Because it's important to remember that. You only should be in this level of care for as long as it's warranted. We should not be keeping you and charging you and having you stay. If you're ready to go to an outpatient level of care at that point. And so, my response is always, I'm, I, I want people to discharge when they're at a place where the treatment team and the patient feels confident that they're going to be able to maintain their progress on an outpatient level. And so the goal is that you've gotten all the tools, you've got the skills, you understand the concepts, you know, the difference between feeding your OCD and fighting your OCD and what that looks

Elizabeth McIngvale:  Like, you've changed your relationship with anxiety and OCD and now you're ready to keep doing that on your own. And so for a lot of our patients, we recommend and have them do what's called a therapeutic absence. This is typically about three fourths through treatment. We'll ask you to go home for about three to five days. Practice your skills. See how you do, see where you got stuck? Come back. We'll tweak things will help kind of read those final things before you leave, but the goal is that you're gonna discharge to outpatient care and you're gonna discharge to a functioning structured schedule. So this is really important, right? I want you at discharge to have a clear plan for what you're going to be doing, we don't want you to go home without a plan and to, you know, potentially revert back to sleeping in staying in your room, right? Those sort of things we want you to go back to a schedule because one of the benefits of being in our program is how scheduled and structured. It is

Kimberley Quinlan: And I love this because as a treatment provider, anytime a client of mine has come back from residential or some kind of intensive treatment, the therapist that they were working with gives me this plan right? Or the The client brings me the plan and so I'm I hit the, what's The saying? Hit the ground running. Like I know what the plan is that we already have it.

Elizabeth McIngvale: Yep.

Kimberley Quinlan: It's not like we have to go and create a whole nother treatment plan. It's usually coming handed off really beautifully, which makes that process like so easy.

Elizabeth McIngvale:  that's,

Kimberley Quinlan: For an outpatient provider to to take that client back.

Elizabeth McIngvale: Our goal, right? Our goal is that if you referred someone to meet him, I'm gonna be talking to you before I start working with them and I'm certainly going to be talking to you as we're getting close to discharge and around the time of discharge to transition that care. Right? Seamless,…

Kimberley Quinlan: Right.

Elizabeth McIngvale: we want it to be smooth and we want the patient to feel like there's not an interruption in their treatment.

Kimberley Quinlan:  Right. Oh my gosh. So, good. Is there anything we've missed? Do you feel?

Elizabeth McIngvale: Not really, you know, I think I get this question a lot, you know, across the board everything we've talked about just because I've personally experienced this, I do this myself professionally and Here's what I'll tell you guys. Treatment is fair is scary No matter what. It doesn't matter if we're doing on outpatient level or an intensive level, right? We're being asked to face our fears or being asked to do things that terrify us I know and many of our listeners know that treatment can and will save your life. And so if you're questioning if you're ready, if it makes sense, you may not ever feel ready and it may not ever make sense. But what I can promise you is that if you put forth the work,…

00:40:00

Kimberley Quinlan: If?

Elizabeth McIngvale: the outcome is incredible. And I am someone who sits right here as

Elizabeth McIngvale: Someone who really believes in full circle moments. Because the program that I attended when I was 15 is the program. I now get to run every day.

Kimberley Quinlan:  It makes me want to cry.

Elizabeth McIngvale: And it is, it is I can tell you. I I love my job and every person at our team here at the Houston OCD Institute. We are driven by the opportunity to help individuals change their own life through treatment and it works. I wouldn't you know Kim those of us with lived experiences even if it's different we wouldn't be doing the work that we do. If we didn't know it worked What a friend,…

Kimberley Quinlan:  All right.

Elizabeth McIngvale: what a horrible life if I had to be a fraud every day pretending for didn't, you know, I couldn't but we do this, we make a career out of it and and we get to keep changing lives and keep hopefully doing for others. What some people did for us when we really needed it. And I'm very grateful that I have the opportunity to be at a…

Kimberley Quinlan: So beautiful.

Elizabeth McIngvale: where I can now help other people. And what I can promise you is that with the right treatment, you can be at a place where you can be doing, whatever it is. You're meant to be doing not what OCD wants you to be doing.

Kimberley Quinlan: So beautiful. My curiosity is killing me here. So I'm just gonna have to ask you one more question, is it the same location?

Elizabeth McIngvale: It is not. So when I was a patient it was impatient actually at the Meninger clinic. So it was in that hospital setting and they closed their program in 2008 and then it became an offset. And so it's now we're our own facility and a beautiful house. And we're in a beautiful neighborhood in the Heights that you can walk around in Houston.

Kimberley Quinlan: Yeah.

Elizabeth McIngvale: So it is not a hospital setting but it is the same program for all intensive purposes.

Kimberley Quinlan:  Right? That is so cool. I am so grateful for you. Thank you so much now um I know you've shared a little bit but do you want to tell us where people can get a hold of you, any social media websites, and so forth.

Elizabeth McIngvale: Yes. Yes, please feel free to reach out anytime y'all want my instagram and handle is Dr. Liz OCD. So you can always reach out there or find resources and support but for our website you can go to Houston OCDI.ORG or you can give us a call at 713-526-5055. And what I'll tell you is that I'm always available to help answer questions offer support and that doesn't mean you have to choose our program, but I would love to give good insight into what you should look for. And what I will say is, I know, can you talk about us all the time? You want to make sure the program that you're attending engages in evidence-based care so for OCD that's going to be ERP and often a combination of medication and that they really specialize in treating solely anxiety and OCD and OCD related disorders at the intens Or you want to be cautious? Not to go to a program. That's a really mixed program that says, they can also treat OCD. I don't think that'll be the same experience.

Kimberley Quinlan: Agreed agreed, So grateful for you. This I feel like this has been so beautifully. Put like in terms of like explaining the whole step, their questions. I will be I'll be referring patients to this episode all the time because these are common questions we get asked. So thank you so much for coming on.Elizabeth McIngvale:  Well, thank you for having me. Anything I can never offer. Please never hesitate to reach out, and thank you for all that you do in the awareness and education you spread in our field.

Depression is a liar. If you have depression, the chances are, it’s lying to you too. 

Depression is a very, very common mental health disorder, and it tends to be a very effective liar. My hope today is to get you to see the ways that it lies to you—the ways in which depression lies to you, and gets you to believe things that are not true. 

I believe that this part of depression, this component of managing depression is so important because the way in which depression lies to us, impacts how we see ourselves in the world, how we see the future, how we see other people, how we see our lives playing out. And that in and of itself can be devastating. 

Today, I want to talk about, number one, the ways in which depression lies to us and what we can do to manage that. Let’s get going. 

THEMES OF DEPRESSION

Before we start, let’s talk about the themes of depression. Now, the way it was trained to me is that there are three core themes of depression. The first one being hopelessness, the second one being helplessness, and the third being worthlessness. It will often target one, some, or all of these themes. Let’s go through those here and break it down. 

DEPRESSION LIES ABOUT THE FUTURE

This is where it can really make us feel very hopeless. Depression says your future won’t be good. You won’t amount to anything. You won’t be successful. You won’t have a relationship if that’s important to you. You won’t have kids if that’s important to you. It often will target the things that we deeply value and it’ll tell us you won’t get those things or you’ll be doing those things wrong. Or in some ways, something bad will happen. When it targets the future, that is often when we begin to feel very hopeless. When we think about the way the human brain works, our brain does things right now, even things it doesn’t want to do, knowing that it’ll get a benefit or a payoff or a wonderful, joyful result. But if your brain is telling you that the result is always going to be bad, that’s going to create an experience where you feel like there’s no point. What’s the point of doing this hard thing if my depression is telling me the future is going to be crummy anyway? What we want to do is get very skilled at catching it in its lies about the future. 

DEPRESSION LIES ABOUT THE PAST

Depression will tell you, you did something wrong. You’re terrible. That thing you did really ruined your life or ruined somebody else’s life, or is proof that you’re a bad person. Depression loves to ruminate on that specific event or an array of events. What we end up doing is cycling and gathering evidence. This is what depression does. It gathers evidence to back its point. What we end up doing is instead of seeing the event for what it is, which is both probably positive and negative, depression likes to magnify all of the things that you did wrong or that didn’t go well. And then it wants to disqualify the positive. Often patients of mine with depression will say, “Oh, I’m a terrible person. I did this terrible thing,” or “I made this terrible mistake or accident.” I’ll look and say, “Okay, but what about the other times where maybe you didn’t make a mistake and so forth?” They will disqualify that as if it means nothing to them. It does mean something to them, but often the way in fact depression functions is it keeps you looking at the negative. And that’s how you get stuck in that cycle of rumination on the negative—feeling worse and worse, feeling more shame, feeling more guilt, feeling more dread, feeling often numb because the depression is so, so strong. 

Now, this is where I’m going to offer to you to reframe things a little bit and look at helplessness. Depression will also tell us: “There is no one who can help you. There is no amount of support that can help you. You’re helpless.” Often when people come to me for their first time in session, they will say, “I’m here. I understand you can help me. But at the end of the day, I don’t even think you can help me.” Maybe they’ve read one of my articles on the internet or they’ve listened to a podcast and they go, “You’re speaking to exactly what I’m going through, but I still don’t even believe you can help me.” This is where I can give them all the science and show them that I can help them and that there’s treatment for depression, and it’s very science-based. The depression will still lie to them and say, “There’s no point. You’re helpless.”

Now, the last piece here is about worth, and I’ll touch on that here in just a little bit. Before we move into that, I want to share with you that the reason I was so excited to talk about this with you today is I’m in the process of creating a course for OCD. I’m contributing this to a bigger company and I will be creating it. You guys can have access to it too here very soon. As I was creating it, I was really starting to see and talk to a lot of people with depression and talk to people on social media. The biggest message people were saying is, “OCD lies to me. It tells me these things. My friends, my loved ones tell me that that can’t possibly be true. They don’t see any of these negative things, but to me, it feels so true.” I wanted to let you know that we do have an online course for depression. You can go to CBTSchool.com/depression to hear more about it. 

DEPRESSION LIES ABOUT YOUR WORTH. 

Remember, one of the themes of depression is worthlessness. What it does there is it tells you, you are bad. Now, we know this can be the voice of shame, but depression and shame go very well together. In fact, they can have a whole party together if we let it go on for too long, telling you, you are bad, there is something innately wrong with you. This is a lie depression will tell you over and over again. When I say it’s a lie, believe me, it is a lie. This is what I always will say with my patients—if we went to a court, we put it up with the jury and we said, “This person would like to claim that they are worthless.” Then the jury is going to say, “Where is your evidence?” We’re not really going to put you up in front of a jury. I don’t want that to frighten you. But if we were, they would say, “Show me the evidence.” Then the attorney would bring in all of the evidence of the facts that you’re a wonderful person, that you’re innately worthy, that you do these kind things, that you deeply care about other people, that you’re a human being, and just being a human being means you’re worthy. We would have all these people come in and bring evidence, but the person with depression, their OCD will gently or very meanly whisper in their ear, “That’s not true,” despite all the evidence. 

Now we know if this was an actual court case, the judge would throw this case out. They’d go, “There is a profound degree of evidence that this person is worthy. There is a profound degree of evidence that this person can rebuild their life and get their life back on track even if they’re really struggling and functioning with depression.” We know this to be true. I’ve seen it every day in my practice. I’ve seen people with depression manage it and go on to live wonderfully fulfilling lives. 

For you, I want you to keep that imagery in your mind, of that jury throwing your case out and that judge throwing your case out because the evidence does not support depression’s case. It wouldn’t last a second in court. Again, a lot of the points I made there are really important if you’re struggling with worthlessness. You being a human being makes you innately worthy. You’re not worthy one day because you did well on an exam but not worthy the next day because you crashed your car. It doesn’t work like that. We’re all worthy. So we have to remember that and keep that in the front of our mind, even if depression has a lot to say about that. 

DEPRESSION LIES ABOUT WHO YOU ARE 

Depression—not only does it lie about your future, not only does it lie about your past, not only does it lie about your worth, it lies about you in general.

Your job and my job as a therapist is to help our minds. My job as a human, I should say, is to help our minds by being able to observe and be aware of our thoughts and catch when it’s in the trend of these areas—worthlessness, hopelessness, and helplessness. If it’s got any theme of those and it’s very strong and very black and white, chances are, it’s depression. We can then work and get tools to manage that. 

OVERCOMING DEPRESSION

Now, as I said, I do have an online course because a lot of you will not be able to have therapy with me. First of all, I’m always going to encourage you, go and see a therapist if you can if you have depression. Over any course I could ever offer you, I would always encourage you to first see if you can get access to a mental health therapist. However, if you don’t have access to that, you can go to the course to get some tools, strategies, and depression tips that you could be practicing. We go through and look at changing your thoughts. We go through changing your behaviors, looking at your activity schedule, looking at motivation. We look at a lot of that, but that is not therapy. The course is not therapy. It is not a specific depression treatment. But I will teach you everything that I tell my patients in my office.

DEPRESSION TIPS & DEPRESSION TOOLS 

Now, before we end this, I want to first go through some depression tips & depression tools that I want to send you off with today so that you can get started right away. I really believe Your Anxiety Toolkit is all about giving as many anxiety and depression tips, tools and helpful skills as we can, so I want to send you away with some bite-size ideas on that you can start immediately. 

Tip #1: Start a self-compassion practice

The biggest thing that depression does is it bullies us. It says horrible, mean things that you would never say to not only a loved one, even someone you hate. You probably wouldn’t say as many mean things as depression has to say. Number one, start with a self-compassion and mindfulness practice. A part of your self-compassion practice is talking back to depression. Now remember, self-compassion is nurturing, it’s kind, but it also doesn’t set back and let people push you around. Self-compassion would never have you be bullied. If you were in a compassionate place and you saw someone else being bullied, chances are, you’d step in and say, “Hey, this isn’t right,” or you’d call someone who could come and assist them. Now, this goes for depression as well. 

Here I want you to remember, if depression is bullying you and telling you lies, you’re going to have to talk back to it. I will say, I do not mind if you swear. I do not mind if you have to get a little aggressive with it. I will share with you personally the most common depressive thought that I have, and I have it a lot—you cannot handle this. I hear it many times in the day. In fact, now it almost makes me laugh a little bit because it’s very boring. Depression needs to come up with some new jokes because this is the one it uses with me all the time. Often when it says that, no longer do I believe it and agree with it and go ahead and listen to what it has to say. Now, I come back with evidence and say, “You know what? I can handle it because I’ve handled it before. In fact, I’ve handled much worse than this. So depression, you can go and do whatever it is that you need to do, but you don’t get to bully me anymore.”

Some people find that it’s better to absolutely swear the biggest profanity and say, “FU, depression. Back off! You know nothing about me and you know nothing about my future and know nothing about my past, and I’m going to politely ask you to sit down because I got this.” You can talk to depression in whatever way is helpful to you as long as you’re talking to it as separate, not to you in the way where you’re saying and swearing at yourself. 

Now we also know there is some evidence that you can use your name by saying, “No, Kimberley can handle this. Thank you, depression.” Using the third person, we’ve got research and science to show that that is very empowering. I could say to depression, “Thank you, depression, but Kimberley has got this. She is going to do her best. She’s going to put one foot forward and please sit down because you don’t get to tell her what to do today.” That is how we can talk back to depression. 

Tip #2: Keep your expectations small

I know when you’re suffering and you’re starting to lose your functioning and depression is taking a lot from you. It’s taken your friendships, your time, taking you away from events. It’s made you miss being present with your children or your family or your loved ones. I know what it can feel like in that you feel like you have to catch up somehow. What I want to offer to you is, yes, I know you want to catch up, but the only way to catch up is to do baby steps. Please don’t try and push yourself with pressure to catch up at a rate where it doesn’t help you. In fact, when we put a lot of pressure on ourselves, we actually create a lot more depression because it feels scary, it feels more overwhelming, which your depression is already done to you.

What I want you to do is make small, realistic expectations for the day and work at keeping the expectations small and then build on them. As you do something that was just baby steps, your depression is going to say, “See, what a loser? You’re doing only small steps? You should be doing big steps.” This is where you’re going to go back and talk to depression and say, “Back off! I’m doing what I need to do today to take you over. I’m taking you down, depression, and I’m going to do it slowly and compassionately. It will work because I’m building habit upon habit, not just pushing myself out of self-punishment and self-judgment, and self-criticism.” We know that those behaviors make depression worse, so we’re actually going to cheer ourselves on. 

Tip #3 Celebrate your wins

That is the big piece that we need to remember. The best way to change the mindset over depression is to be kind and to cheer ourselves on, to motivate ourselves, to celebrate when you make a baby step. I celebrate you if you’re making baby steps. Even listening to this right now, I celebrate you. You’re investing in your well-being. We want to make sure we’re cheering you on. I call it the kind coach. It’s the voice that says, “You can do it. Just a little more. Keep going. I believe in you. Just a little more. What would be right for you? What do you need?” It takes into consideration that, of course, you’re going to have challenges. But when you have challenges, it’s there to say, “What can we do to strategize? Maybe we need to rethink this. How can we rethink this in a way that makes it possible for you just to get back on track?” Baby steps at a time.

I hope that was helpful. I really wanted to go over and really reinforce to you and hopefully get you to see that depression is a wire and depression is lying to you. A big part of that is you recognizing and being aware and observing and catching when it lies to you and having skills so that you can talk back to it, change the way you respond so that you’re not contributing and making the depression stronger. 

Have a wonderful day. You guys always know, I’m always going to say it is a beautiful day to do hard things. I hope that this was helpful and I hope you have a wonderful day.

Transcript

Kimberley Quinlan: Well welcome, I cannot believe this is so exciting. I've been looking forward to this episode all week. We have the amazing. Reverend Katie O’Dunne with us to talk all about scrupulosity and religious obsessions. So welcome, Katie.

Katie O'Dunne: Thank you. I'm so excited to be here and to chat about all things Faith and OCD. So thanks for having me.

Kimberley Quinlan: Yeah, so let me just quickly share in ERP school we have these underneath every training, every video. There's a little question and answer and I'm very confident in answering them, but when it comes to the specifics of religion, I always try to refer to someone who is, like an expert. And so this is so timely because I feel like you are perfect to answer some of these questions. Some of the questions we have here are from, ERP school. A lot of them are from social media and so I'm so excited to chat with you. 

Katie O'Dunne: Thank you.

Kimberley Quinlan: So tell us before we get into the questions, a little about your story and you know why you are here today?

Katie O'Dunne:  Yeah. So I've navigated OCD since before I can remember, but just like maybe a lot of folks listening. I was very private about that for a very long time. I had a lot of shame around, intrusive thoughts. I had a lot of shame around religious obsessions that I had, moral related obsessions, harm obsessions. And this shame particularly came because I was pursuing ministry and OCD really spiked in the midst of me going to graduate school, going to seminary. And when I was in seminary and I started really struggling, I wanted to seek treatment for the first time and was told really by a mentor that it would not help me to do that. In my ministry that I wouldn't pass my psych evaluations and that I shouldn't pursue treatment that I needed to keep that on the down low. So as many of us know, that might not get that effective evidence-based treatment I continued to get sicker

Katie O'Dunne: And had a really pretty full-blown OCD episode in my first role in ministry.

Katie O'Dunne: So I ended up in school chaplaincy working, with lots of students from different faith backgrounds, some of what we'll be talking about today, through an OCD lens. And I was trying to keep my OCD a secret, but in the midst of navigating, some difficult tragedies and traumas with students, my OCD latched on to every aspect of what I was navigating. And particularly in the midst of that, I was experiencing losses and mental health crises with students from different faith backgrounds. And when I came out of my own treatment, where exposure and response prevention, very much saved my life. I felt like, I had an obligation to those students that I worked with to let them know that their chaplain, that their faith leader had gone through mental health treatment and that there was no shame around doing that. And I went from the space, in seminary of being told that I shouldn't seek treatment to a space of having families call me for the first time and say, Oh now we can actually talk to you about what's going on in our life. Can you help us talk with our rabbi or our imam, or our priest about my child's diagnosis? How can we reconcile faith with treatment and that opened the door for me to continue this work in a full-time way. Where moving from those students that I love so much and  now work in the area of faith and OCD full-time helping folks, navigate religious scrupulosity and very much lean into evidence-based treatment while also reconnecting with their faith in ways that are value driven to them and not dictated by OCD.

Kimberley Quinlan: Hmm, it makes me teary. Just to hear you say  that folks were saying, Well, now, I can share with you. That is so interesting to me. You know, I think of a reverend, as like, you can go to them with anything, you know, and for them to say that you're disclosing has open some doors, that's incredible.

Katie O'Dunne: And particularly, I worked really heavily with my Hindu and Muslim students. And we had the chance to do some really awesome mental health initiatives for the South Asian community, where students started then doing projects actually in their own faith communities, and opening up about their own journeys, and then giving other space to do the same. And I really, I think about the work I do now, which is very much across faith traditions around OCD. And every person I work with, I think of those awesomely brave students, who started to come to me after my disclosure and say, Okay, we want help and also we want to share our stories and continues to inspire me.

DOES RELIGIOUS OCD/SCRUPULOSITY SHOW UP BEYOND THE CHRISTIAN RELIGION? 

Kimberley Quinlan: Yeah, so cool!  It leads me to my first question which is, does this for OCD religious scrupulosity, have you found, and I  definitely have,  that It goes outside of just the Christian religion. I know we hear a lot about just the Christian religion, but can you kind of give me your experience with some other religions you've had to work with?

00:05:00

Katie O'Dunne: Yeah. And so I always tell folks OCD is OCD, is OCD. And it always loves to latch on to those things that are the most significant and important to us. So it makes a lot of sense, that, that would happen with our faith tradition, whether you're Christian or Muslim or Buddhist or Sheik, or beyond or even atheist or agnostic can really transform into anything, particularly from what, you might be hearing from faith leaders and I always go back to this idea that OCD is just really gross ice cream with a lot of different gross flavors and those flavors might be in the form of the Christian faith or in the Jewish faith or in the Muslim faith. But the really big commonalities is the fact that it's not about what a person actually believes just like, with everything else with OCD. This is very much egoistonic. It's taking their beliefs. It's twisting them and it's actually pushing them further away from the tradition. So, it's just some examples.

Katie O'Dunne:  That we see, of course, in Christianity, you all might be familiar with obsessions around committing blasphemy against the Holy Spirit, or fear of going to hell or fear of sinning in some way. But we also see lots of different things in Islam, whether that's around not being fully focused during Friday prayers or not doing ritual washing in the appropriate way. In Judaism we see so many different things around dietary restrictions or breaking religious law. What if I'm not praying correctly? Hinduism, even what if I'm pronouncing shlokas or mantras incorrectly? What if I have done something to impact my karma or my dharma? What if I'm focusing too heavily on a particular deity or not engaging in puja correctly. or in Buddhism I see a lot of folks, really focusing on what if I never stop suffering, What if I've impacted my karma in some way? What if I don't have pure intention, alongside that action and…

Kimberley Quinlan: Right.

Katie O'Dunne: then all the way on the other side. We can see with any type of non-theism or atheism, agnosticism humanism What if I believe the wrong thing? What if I'm supposed to believe in God, what if I'll be punished for for not? So there are all different forms and then with any faith, tradition. I mean any form possible. That OCD could latch onto

Kimberley Quinlan: Yeah, absolutely I think there's just some amazing examples I had once a client who felt his frustrations weren't correct.

Katie O'Dunne:  Yes.

Kimberley Quinlan: And got stuck really continue and trying to perfect it so I think it can fall into any of those religions for sure. So you've already touched on this a little bit, but this was one of the questions that came from Instagram. Just basically there was saying like OCD makes me doubt my faith. Like why does it do that? Do you have any thoughts, on a specifically why OCD can make us doubt our faith?

Katie O'Dunne: Yeah. I mean OCD is the doubting disorder and we always say the content is irrelevant, but it definitely doesn't feel like it. I think for anybody navigating OCD, you're most likely in a space of saying I could accept uncertainty about any theme except the one that I have right now and that's very much true with faith. If your faith is something that's significant to you and at the center of your life, it makes sense that OCD would latch on to that and that OCD would twist that particularly…

Kimberley Quinlan:  Right.

Katie O'Dunne: because we really don't have a whole lot of certainty around faith to begin with and where there's a disorder that surrounds uncertainty and and doubt. That makes a lot of sense. And yet it's so so challenging, um, because we want to be able to answer all of these questions without OCD making us question every single thing we believe,

WHEN OCD DOUBTS MY FAITH

Kimberley Quinlan: Mmm. It's sort of like religious obsession. I mean relationship obsessions too in that and you're probably looking at people across the your religious faith hall or wherever going, but they are certain like why can't I get that certainty? Right. But it's like they've accepted a degree of uncertainty for them to feel certain in it. But when you have OCD, it's so hard to accept that uncertainty piece of it.

Katie O'Dunne: I'm so glad you said that I actually get this question a lot. And this, this might be a strange answer for folks to hear from a minister. But I always tell folks, I'm not certain I Have devoted my life to faith traditions. I'm ordained. I'm not certain about anything including about the divine.

Kimberley Quinlan: Yeah.

Katie O'Dunne: I have really strong beliefs, I have strong things that I lead lean into and practices that are meaningful to me. But it doesn't mean that I have certainty. And often, when you hear someone in a faith tradition, say that there are certain, I don't think it means the same thing as what we're thinking, it means from.

00:10:00

Kimberley Quinlan: Yeah. it's Yeah,…

Katie O'Dunne: a different context. They are accepting some level of uncertainty.

Kimberley Quinlan: that's why I compared it to relationship OCD, You're like, but I'm not sure if I love my partner enough and everybody else is really certain but when you really ask them, they're like, No I'm not completely certain,…

Katie O'Dunne: Yeah.

WILL GOD PUNISH ME FOR MY INTRUSIVE THOUGHTS?

Kimberley Quinlan: like I'm just certain for today or whatever it may be. So I think that that is very much a typical trade of OCD in that, it requires 100%, okay? So, so, This is actually really one of the first common questions we get when we're doing psychoeducation with clients. Which is why do I have a fear that God will punish me for my intrusive thoughts? You want to share a little about that.

Katie O'Dunne: Yeah, I mean there are so many, there are so many layers with this and again, latching on to what's the most important but also latching on to particular teachings. Whether it's in a church or a mosque or a synagogue where I always say there are particular scriptures, particular, teachings, particular sermons, where you might hear things that relate to punishment in some way, or relate to rigidity, but I think folks, with OCD hear those, through a very different lens than maybe someone else in that congregation and we might hear something once at age, five or six and for the rest of our lives latch on to this idea that we're doing something wrong or that God is going to punish us, we tend to always see everything through that really, really negative lens and maybe miss all of the other things that we hear about compassion and about love and forgiveness. And I think there's also this layer for individuals with OCD often holding themselves to a higher standard than everyone else and that includes the way that they see God as viewing them. So I'll often ask folks. How do you think, how do you imagine God, viewing a friend in the situation? Just like we might do a self compassion work and they're like, Well, I believe God would be really forgiving of my friend and that they might not be perfect but that they were created to live this beautiful life. And then when asking the same thing about themselves, It's but God called me to be perfect and I have to do all of these things right. I'll ask often ask folks, What does it look like to see yourself through the same loving eyes through which God sees you or which you imagine that God sees those around you which is something we don't often do with OCD.

Kimberley Quinlan: And what would they often say?

Katie O'Dunne: Ah well it's so I'll actually use self-compassion practices to to turn things around. And I'll say I'll ask someone to name three kind things about themselves and then to put their hand over their heart and actually say it through the lens of God saying that to them. So I'll have them say something like The Divine created me to be compassionate, the Divine believes that I am a kind person, the Divine wants me to have this beautiful life and to be a good runner or a good baseball player or whatever that is. And it's always really difficult at the beginning just like any self-compassion practice. And then I'll watch folks start to smile and say Well maybe God does see me in that way.

Kimberley Quinlan: That's lovely.

Katie O'Dunne: Maybe create me in a beautiful way.

DO NOT FEAR…SHOULD I TURN MY FEARS OVER TO GOD?

Kimberley Quinlan: Mmm. That's what it's bringing them. Back to their religion and their faith when they do that, which is so beautiful, isn't it? Mmm. Okay, This question is very similar but I really think it was important to to address is there are some scriptures where people here that they aren't allowed to fear or that they must turn their fears over to God. Do you have any thoughts or you know, responses that you would typically use for that concern?

Katie O'Dunne: Mm-hmm.

Katie O'Dunne:  Yeah, I think, you know, it looks very different across faith traditions and across scriptures and individuals, of course, view Scripture and in very different ways but depending on their denomination, or depending on their sect, but I think sometimes, unfortunately, those scriptures are used out of context. We see this often where there might be a particular verse that's pulled that from a translation perspective isn't necessarily really about anxiety in the same way that we're defining anxiety through an OCD lens or isn't really about intrusive thoughts, in the way that we're defining it through the lens of OCD. And I think it's really unfortunate when we hear religious leaders or folks in communities say, Well, you aren't allowed to fear or if you just prayed a little bit harder, your anxieties would be able to be turned over to God. And I think we're hearing that or they're using that and maybe a different way than the passage was intended. And then we're hearing this through a whole nother another layer where it actually could be flipped. And instead, when you're you're saying, Don't fear. I always tell folks. So what does it look like instead to not fear treatment or to do it  even if you're afraid. To ask God, to give you strength in the midst of that fear  and to approach that in a different way. But I think sometimes those who are taking particular passages out of context, might not fully understand the weight of OCD, or what comes with that condition.

00:15:00

HOW DO I KNOW IF IT IS OCD OR IN LINE WITH THE RULES OF MY FAITH?

Kimberley Quinlan: Right. Right. I love that. Thank you for sharing. That was actually the most common question, I think. So like four or five people off the same question. So I know that's a such an important question that we addressed. Quite a few people also asked how to differentiate like, you know with OCD treatment, it's about sort of understanding and being aware of when OCD is present and how it plays its games, and it's tricks in its tools that it uses. How would people know whether something is OCD or actually in line with the rules of their faith? Do you have any sort of suggestions for people who are struggling with that?

Katie O'Dunne:  Yeah, so I'll actually often show folks a chart when we start to work together and we'll put things in different buckets of what are things that you're doing, because they are meaningful because they bring you hope because they bring you comfort because they bring you joy. And then on the other hand, What are things that you're doing out of fear? Out of anxiety things, that feel urgent things that are really uncomfortable. And of course, there is never any certainty around anything, which is very much one of the tricky parts with with treatment, right? We want to have certainty but I invite folks to really make the assumption that probably those things that bring joy and meaning and hope and passion and connection are the authentic versions of their faith. Versus the things that we're doing out of fear or anxiety. And, you know, I was doing a training, a couple months ago for clinicians in this area and I was, I was talking about how, you know, we don't necessarily want folks to pray out a fear and someone had a really great question. They said. Okay. But if a plane is going down and someone's praying because they're afraid like that's not because it's OCD, I'm like No that's that's very true. But in that situation they are praying because they're afraid to bring meaning and hope they're not praying because they're afraid of not praying and…

Kimberley Quinlan: Yeah.

Katie O'Dunne: there's a very big distinction there. Are you doing the practice? Because you're afraid of not doing it or not or you're afraid of not doing it perfectly, or are you engaging in that practice even in moments that are tough in order to bring you peace and meaning and joy and comfort.

WHEN PRAYER BECOMES A COMPULSION 

Kimberley Quinlan:  And that if that, maybe I've got this wrong so please check me on this, but it feels like too, when people often ask me that similar question but not around compulsive praying of like, but if there is a problem, shouldn't I actually do something about it? And I'm like, Well, this that's a difference between doing something about something when there is an actual problem compared to doing something because maybe something might happen in the future, right? It's such a trick that OCD plays. Is it gets you to do things just in case. So would that be true of that as well?

Katie O'Dunne: Okay. Yeah. And I often tell folks just again because it's just another form of OCD that's latching on to something that significant very similar. I tell folks, if it's really a problem that you need to address, most likely you would do it without asking the question to begin with. But it's I think the unfortunate thing that the other example I give is well, if we think most traditions we think of God as a parent figure and I ask folks, who are our parents to imagine their relationship with their own child, and do you want your child to connect with you throughout the day out of meaning and out of hope and out of genuine, a genuine desire for love or because they're afraid of not talking to you and…

Kimberley Quinlan: Right.

Katie O'Dunne: those are two. Those are two very, very different things.

Kimberley Quinlan:  Right. As it's like a disciplinarian figure. Yeah, that's a really great example. I love that. Yeah. Okay. This is, this was one of the questions that I got, but it's actually one of the cases that I have had in my career, as well, which is around the belief that thoughts are equal to deeds, right? Like that. If I think it, it must mean, I love it, I like it, or I want it or I've done it. Can you give some perspective to that from from specifically related to religious obsessions?

Katie O'Dunne: 

00:20:00

Katie O'DunneYeah this can be really hard for folks and of course with OCD thought actions fusion can be really challenging anyway and there is often, for folks in a faith context this belief that because I had this though, because I had what might be perceived as a sinful thought, I must be committing blasphemy, or I must be committing this particular sin and that can make it really really tought to do diffusion work with you clinician because its like I had this thought it must actually mean that I have done this thing that is in opposition to God and I always tell folks that of course I am not going to reassure you fully that those things are completely separate but I would invite you to lean into the possibility that a thought is just a thought. Just like any other aspect of OCD we have a jillion different thoughts a day that pass into and out of our minds and I actually think from a faith perspective that it is pretty cool that our brains produce alot of different thoughts, that we see things and make different associations. Ill tell folks way to do God we see things and make all sorts of connections. But, having thought doesn't equate to having a particular action even if we are looking on the form of most scriptures. It is really referencing things that we are doing, ways that we are actually engaging with those thoughts and taking that into our actions. And again from the pulpit, you might hear someone talk about thoughts or intrusive thoughts in ways that are not equivalent to how we're talking about them through an OCD lens,…

Kimberley Quinlan:  Mm-hmm.

Katie O'Dunne: something very different and they're really talking about more of an intentional act, in something that you're you're doing, as opposed to what we're thinking about. It's just a biological process of thoughts, moving through your mind.

ARE THOUGHTS EQUAL TO DEEDS?

Kimberley Quinlan:  Right. And and what I be right in clarifying here, is it important to differentiate between a thought you had compared to a thought that's intrusive, is that an important piece or do we not need to go to that level?

Katie O'Dunne: Do you mean, in the religious context? I, I don't know. I mean, I, I'm curious what you think from a clinical I go back to thoughts or thoughts or thoughts and…

Kimberley Quinlan: Yeah.

Katie O'Dunne: they are intrusive because we're labeling them as intrusive. Unfortunately, sometimes in religious context, and I hear this a lot, someone might go to… I hear actually from sermons all the time, where someone is saying that intrusive thoughts or in some way sinful and really what they're thinking are just regular thoughts that people are giving value to and…

Kimberley Quinlan:  Yeah. Yeah.

Katie O'Dunne: it makes it makes it really challenging for folks where they're giving more value to their thoughts and then thinking, well my preacher said that if I have a thought that's quote unquote bad that it means something about me.

EXPOSURE & RESPONSE PREVENTION (ERP) FOR RELIGIOUS OBSESSIONS/SCRUPULOSITY

Kimberley Quinlan:  I think you just hit the nail on the head,  when we apply judgment to a thought as good or bad, then we're in trouble, right. That's when things start to go sticky. Yeah. Okay, excellent. Okay. Let's talk about specific treatment for religious obsessions and exposure examples. I know for those listening we have done an episode with Jud  Steve,  I will link that in the show notes. He did go over some but I just love for you to go over like what are some examples of exposures? And how might we approach exposure and response prevention, specifically related to these religious obsessions?

Katie O'Dunne: Yeah, so his health folks, I'm not I'm not a clinician, but I work alongside a lot of really amazing clinicians in religious scrupulosity to develop exposure hierarchies. And one of the big fears when I'm working with someone is often, how could I possibly engage in exposure and response prevention because what if someone asked me to do something that's in opposition to my faith? And I want to go ahead and just put that on the table right now… I know that's a big fear and I want you to know that a good OCD specialist or an ERP therapist is really gonna work with you not to go against or to oppose your faith. But to do some things that are a little bit uncomfortable in service of you, being able to get back to your faith in a value-driven way.

Katie O'Dunne: I really believe we are never going to be incredibly excited about exposures. When I was on my own exposure and response, prevention journey, I never once walked into the office and said, Yes, I get to do this really scary exposure today. It's gonna be so fun. Well, I guess I did say that because my therapist made me pretend to be excited about exposures, but that's different. That's a different conversation was not necessarily genuine. And so i’ll often ask folks, I know that this isn't something that you want to do, but why don't you want to do it? And if the answer is well, I'm afraid that it might upset God or I'm afraid something bad might happen. That’s probably a good exposure. If the immediate response is Well, no, I'm not gonna do that. No one else in my tradition would do that. That's completely in opposition to everything we believe, probably not something that that we would ask you to do and often clinicians will use the 80/20 rule of what would 80% of the folks within your congregation be willing to do and that can be really helpful working with a faith leader as well or with other folks within your particular sect or denomination to establish that.

00:25:00

Katie O'Dunne:  The same time there. Oh my goodness, so many different exposures that we can go into. But a lot of things that I see folks commonly working on are things like praying imperfectly maybe speaking or speaking of blasphemous thought aloud or thinking through that in an intentional way, writing an aspect of that, not completing ritual washing again and again only doing it once and even thinking through the fact that it might not have been perfect that time or maybe even intentionally diverting your attention in the midst of a prayer. Sometimes for folks who are avoiding Scripture that is intentionally reading that aspect of Scripture and then maybe thinking intentionally about something that they've thought as a bad thought or that they've defined in that way. But again it very much depends for each person and I really want folks to know that it doesn't mean that you are going to be asked to eat something that goes against your dietary restrictions or to deface a religious text. Those are the two things I hear folks, very fearful of and that isn't something that you need to do in order to get better. It's about having conversation and handing over the keys to your clinician to do some uncomfortable stuff in favor of getting back to your faith in a value-driven way.

Kimberley Quinlan: Yeah, I love that. I'll tell a quick story, when I was a new intern treating OCD having no clue really what I was doing. I'm very happy to disclose that was the facts, but I had amazing supervisors and I grew up in an Episcopalian denomination and I had a client who was of similar denomination in the Christian faith. And my supervisor said, Well, okay, you're gonna have him go and say the blasphemous words and in my mind, this being my first case going like are we allowed, like side eye.And he said Okay this is your first go around. I want you to ask your client to go and speak with their religious leader and say, This is what I'm struggling with. AndI have this diagnosis and this is the treatment, it's the gold standard and Kimberley's gonna go with you and do we have permission to proceed and the minister was so wonderful. He said, If that is what's gonna bring you closer to your faith, go as hard as you can. And for me, it was just such a beautiful experience as a new clinician to have. He knew nothing about OCD but he was like if that's what you need to do to get closer, go. Like he had so much Faith himself in, I know it'll bring you to the right place and so it's so beautiful for me and that kind of helped me guide my clients to this day. Like go and get permission speak to your minister if that helps you to move forward, do you have any thoughts on that?

Katie O'Dunne: Oh yes, and this is really my favorite thing that I get to do with folks in addition to working with clinicians and clients and developing exposures, also in faith traditions that are not my own, but then I might have studied make connections to other faith leaders so we can talk about what makes the most sense in this particular set so that someone can fully live into their faith tradition while well, maybe being a little uncomfortable in this moment or doing something tough and I deeply believe whatever that looks like for you, even if the exposure seems a little bit scary, that God can handle our exposures. Across faith traditions. We see the divine as this big, wonderful powerful all knowing force and with everything going on in the world, I deeply believe theologically that the exposure that we're doing over here, which might seem really hard for us, that God can handle that as a way for us to get back to doing the things that we were actually created to do. And in that way, similar to the minister that you talked with that said, Hey, go for it. I'll even tell folks, I see ERP as a spiritual practice because a spiritual practice is defined as anything that helps you to reconnect or get closer with the divine and in that way, doing ERP really does that because it's breaking down the OCD so that you almost stop worshiping OCD and actually reconnect with God in a way that's value driven for you. That's actually what I'm getting ready to start. My doctoral research on is actually redefining ERP as a spiritual practice across faith traditions in ways that are accessible for a diverse population.

Kimberley Quinlan: And that's so beautiful, I love that. Okay, let's see. Okay, This is actually the last question, but this is actually the one I'm most excited to ask. This is actually from someone I deeply care about. They have written in and said, When I get anxious, I try to submit it to God knowing of his love and power. So, by writing a script, which is an ERP practice, for those of you who don't know, it seems I'm in conflict with my religious belief. Do you have any like points, final points, you want to make about that?

00:30:00

Katie O'Dunne: Yeah. So two big things, one going off of what I was just sharing a second ago. I would encourage you to know, or maybe not to know, for sure but, we can lean into uncertainty around this right? But to accept all of the uncertainty, while also leaning in and believing that God can handle this difficult script that you're writing or this difficult exposure that you're doing in favor of you getting to live the life that you were created to live. Not defined by OCD and that you still can pray and ask for God's support as a part of that. I would never ask someone not to continue to connect with God during some of sometimes, the most difficult process of their life which treatment can be, I know it was for me, it was incredibly scary. But rather than asking for reassurance, or asking for God, to undo any of that exposure work we're doing or or saying, oof, disregard this script I just did. We're not, we're not going to do any of those things, but rather, I would invite you to say, in whatever way makes sense to you, Dear God, please help me to lean into the uncertainty, please help me to sit with this discomfort associated with this exposure, on the way to getting back to this big, beautiful, awesome life that you've created me to live. It's really hard right now. This is really tough, but please walk with me as I sit with all of it, helping me not to push away that anxiety, but rather to be with it as I reclaim my life. Amen. Or something of that nature. Yeah.

Kimberley Quinlan:  Yeah, that's beautiful. So thank you, really. I get teary again, this is such a beautiful conversation. Okay, so number one, thank you so much for coming on, really, it's a blessing to have you here and you know, I think this will help so many folks. Is there something that we didn't cover that you you know that point that you just made alone, I feel like it's like mic drop. But is there anything else you want to add before we finish up?

Katie O'Dunne: Yeah, um, and just, and this is a little bit more Christocentric, but I think it goes across faith traditions, I often talk about the recovery Trinity and just to leave folks with this as well. That I deeply believe that it's possible to have faith in yourself, faith in the divine and faith in your treatment all at the same time and that those three pieces coming together, allowing those to be together, actually can be a huge key with religious scrupulosity, and taking a step towards your life during treatment.

Kimberley Quinlan: That's beautiful. And I've never heard that before. That is so beautiful. I'll be sure to get my staff all trained up in that as well. Thank you. oh, Katie,…

Katie O'Dunne: Oh sorry, one more thing. Sorry, as I say that and I know we're closing out. I also always want folks to know that ERP. This is, this really is my last thing. I promise.

Kimberley Quinlan:  Oh no, no. Go for it. You've got the mic go.

Katie O'Dunne:  No. Um that I've worked with a lot of folks across traditions with religious scroup and I would say um a majority of the folks that I've worked with have moved through ERP and at the other side actually have a deeper relationship with their faith then maybe they did before and I would encourage you to hear that that actually leaning into that uncertainty translates far beyond OCD sometimes into a closer relationship with God. And I've worked with folks who have moved through ERP that end up going into ministry because that's meaningful to them in a way that isn't driven by OCD. So just knowing that it doesn't ever mean, you're stepping away from your faith, you're taking actually this leap of faith to reconnect with it in a way that's actually authentic to you.

Kimberley Quinlan: Mmhm. I'm so grateful that you added that. Isn't that some of the truth, with OCD in general, like the more you want certainty, the less of it you have. And the more you let go of it, the more you can kind of have that value driven life. I love it. Okay, I can't thank you enough, really, this has been such a beautiful conversation. I probably nearly cried like four times and I don't, I don't often get to that. It's just so, so beautiful and deep. And I think it's, it's wonderful. Thank you. Where will people hear about, you get to know you reach out to you and so forth.

Katie O'Dunne: Yeah, so folks are more than welcome to reach out to me via Instagram at @RevkRunsBeyondOCD or on my website at RevKatieO'dunne.com. I do lots of work again with clinicians and faith, leaders and clients but also have free weekly faith and OCD support groups along with interfaith prayer services for folks navigating what it means to lean into their faith traditions from a space of uncertainty and an inclusive environment. And then I would also encourage folks to check out our upcoming Faith and OCD conference with the Iocdf in May along with a really awesome resource page that we were so proud to put out last year. I had the chance to work with a really great team of clinicians and faith leaders to create a resource page for all of you to see what scrupulosity might look like in your faith tradition along with resources. So check out all of those wonderful things.

00:35:00

Kimberley Quinlan: Amazing. We will have all that linked in the show notes. Thank you, Katie, really! It's such an honor to have you on the show.Katie O'Dunne: Thank you. This was lovely. Thank you so much.

5 TIPS FOR HEALTH ANXIETY DURING A DRS VISIT

If you want my five tips for health anxiety during a Drs visit, especially if you have a medical condition that concerns you, this is the episode for you.

Hello and welcome back everybody. Today, I’m going to share some updates about a recent medical issue I have had, and I’m going to share specific tips for dealing with health anxiety (also known as hypochondria). 

A lot of you who have been here with me before know I have postural orthostatic tachycardic syndrome. I also have a lesion on my left cerebellum and many other ups and downs in my medical history where I’ve had to get really good at managing my health anxiety. I wanted to share with you some real-time tips that I am practicing as I deal with another medical illness or another medical concern that I wanted to share with you. 

Here I’m going to share with you five specific tips, but I think in total, there’s 20-something tips all woven in here. I’ve done my best to put them into just five. But do make sure you listen to the end of the podcast episode because I’m also going to give some health anxiety journal prompts or questions that you can ask yourself so that you can know how to deal with health anxiety if you’re experiencing that at this time. 

Before we get into it, let me give you a little bit of a backstory. Several months ago, I did share that I’ve been having these what I call surges. They’re like adrenaline surges. They wake me up. My heart isn’t racing. It’s not like it’s racing fast, but the only way I can explain it is I feel like I have like a racehorse’s heart in my chest, like this huge heart that’s beating really heavily. Of course, that creates anxiety. And so then I would question like, is it the heartbeat or is it just my anxiety? You go back and you go forward trying to figure out which is which. But because this was a symptom that was persisting and was also showing up when I wasn’t experiencing a lot of stress or anxiety, I thought the right thing to do is to go and see the doctor. 

WHAT HEALTH ANXIETY FEELS LIKE

Before we get started, be sure to make sure you’re not avoiding doctors. Make sure you’re not dismissing symptoms. We do have to find a very, very wise balance between avoiding doctors but also not overdoing it with doctors. We’ll talk about that a little bit here in a minute. But first, I wanted to just share with you what health anxiety feels like for me. Because for me, I’m very, very skilled at identifying what is anxiety and what is not. I’ve become very good at catching that by experience, folks. It’s not something that comes naturally, but by experience, I can identify what is health anxiety and what is a real medical condition or what is something worthy of me getting checked out. 

For me, for the health anxiety piece, it’s really this sort of anxiety that is a sense of catastrophization and it’s usually in the form of thoughts like, what if this is cancer? What if this is a stroke? All the worst-case scenarios. What if this is life-threatening? What if I miss this and you are responsible, you should have picked it up. These are very common health anxiety intrusive thoughts or health anxiety thoughts that I think you really need to be able to catch and be aware and mindful of. First of all, that is the biggest symptom for me. 

The other thing is when you have health anxiety, you do tend to hyper-fixate on the symptom and all of the surrounding symptoms that are going with that. And then you can really catastrophize those like, “Well, my heart’s beating really heavily and I feel dizzy. Oh my gosh. And I’ve been having a headache. Yeah, you’re right, I’ve been having a headache. Oh my gosh.” I call it ‘gathering.’ That’s not an actual clinical term, but I do use it with my clients. We gather data that is catastrophic to make it seem like, yeah, we actually have a really big point, and this is actually a catastrophe. 

Some other health anxiety symptom that I experience is panic. When you notice a symptom, it is very common to start panicking. And then again, you go back to this chicken or the egg or is it the horse or the carriage in terms of I’m panicking, and now the panic has all these symptoms. Are these symptoms an actual medical condition or are they actually just anxiety and panic? You could spend a lot of time stuck in that cycle trying to figure that out. 

Let’s now talk about how to manage these symptoms and some tips and tools that you can use. 

Tip #1: No Googling

Let me tell you what has recently happened to me. I’ve been having these symptoms. I made an appointment to see my cardiologist. It was two months out and I was like, “It’s not a big deal. I can handle these symptoms.” I’m feeling super confident about my ability now to just ride out some pretty uncomfortable sensations and not catastrophize. I go in for my checkup, they do an echocardiogram, and it’s taking a long time. She’s asking me these strange questions like, “Why are you here again,” as she’s doing it. She’s checking, she’s looking, she’s squinting at the screen. “Why are you here again? What are your symptoms?” Click, click, click, looking at the heart, whatever. Again, I’m in my mind going, “Kimberley, let your brain have whatever thoughts it wants. We’re not going to catastrophize.” I was doing really, really well. I got up and I answered her questions. I did the whole appointment. She cleaned me off when I was done and said, “Great, you’ve got 24 hours and then the doctor will email you with your results.”

And then yesterday afternoon, I get a call from the nurse saying, “We need to book you a video appointment with the doctor to discuss your results.” As you can imagine, my brain went berserk. My health anxiety thoughts were saying, “This is really bad. Why would he need to make a video appointment? This can only end badly. This must be cancer. This must be heart problems. Am I going to have a heart attack and so forth?” Of course, my brain did that. I’m grateful my brain does that because that’s my brain being highly functioning and aware. 

But the number one rule I made with myself in that exact moment, even though that was very anxiety-producing, is no Googling. Kimberley, you are not allowed to pick up the computer or the iPhone and Google anything about this.

That is tip #1 for you. I’ll tell you why. A lot of my patients say, “But why? It’s no harm. I’m not doing any harm.” And I’ll say, “Yes.” I’ve actually just seen my cardiologist. But now that I’ve had my appointment, he encouraged me to do a little research. What was hilarious to me is every single website is different and some catastrophize and some don’t. Some go, “This could be very normal.” Other ones say, “This could be cancer, cancer, cancer, cancer.”

This is why I’m telling my patients all the time, don’t Google because what you read is different. It’s not like this is going to be a factual thing. Most of the time people who have articles that rank high on Google searches are the ones who have optimized their website to be very easy to Google. The reason they have become number one on the Google algorithm is because they’ve included keywords like cancer for blah, blah, blah, and all of these health issues and health names. The ones that are at the top, some of them are very reasonable, helpful, and accurate, but a lot of them are not. They’ve just really done a great job of putting in lots and lots of keywords that makes them highly searchable and come up high on the algorithm.

Please, number one, do not Google. Go to your doctor for questions if you have any. Unless they’ve encouraged you to do research, do not Google.

TIP #2: FOLLOW IMPORTANT HEALTH ANXIETY CBT TECHNIQUES

I’ve actually categorized this in a bigger category and I’ve called it important health anxiety CBT techniques, because there are some important CBT tools that you’re going to need here and here we go. 

While I was in getting my echocardiogram, I was laying and I was having some anxiety because she was squinting and asking some strange questions, not in the normal of what I’d experienced. I could feel the pull to check her face for reassurance like, does she look concerned? Does she look relaxed? What’s going on with her? I wonder what she meant. 

What I want to encourage you to do is acknowledge and catch when you’re checking their face to try to decipher what the nurse or the assistant or the doctor is doing and saying. Because really, all I’m doing there is mind reading because I have no idea what she’s thinking. I was laughing at myself because she was squinting and looking concerned. I was like, “I wonder if she’s trying not to pass gas.” We could mind read that she thinks I have cancer and that there’s a big problem, or maybe she’s just trying not to pass gas right now. Maybe she’s thinking about a fight she just had with her partner. My attempt to analyze her facial expression is a complete waste of my time. You could use that tip anytime you want. 

The next tip for you is no reassurance seeking with nurses or doctors. Now, I actually felt almost into this trap. If I’m being completely honest, I did fall into this trap, but I caught myself really quickly. As she was finishing up, she took off her gloves and got ready to discharge me, and I said, “So, you’d let me know if there was...” I paused because what I was going to say is, “You’ll let me know if there’s something wrong, right?” I was going to say that. And then I was like, “No, no, no.” I stopped myself and said, “You know what? I know the deal. I’ve done these enough times. I know I have to wait for the doctor.” But I caught myself wanting to get confirmation from the nurse and I already know that nurses are not allowed to give me any diagnosis anyway. I caught myself wanting to get some expression of relief from her like, “No, you’re fine. Everything looks good,” or whatever. Sometimes they accidentally give you that reassurance. But I caught myself seeking reassurance from her. 

In addition to that—let me talk to you a little later about how we do that with doctors as well—often if you’re in the office with a doctor, you may find yourself at the end of the session going, “I’ll be fine, right? It’s not bad, right?” It’s okay, we’re all going to ask some of those questions. I’m not going to be the reassurance-seeking police with you. But what I want you to do is really drop down into catching when we’re engaging in reassurance seeking and using it too much to reduce our own anxiety about it, to take away our own anxiety or fear.

Now, another CBT technique or sort of rule that we often set in clinical work when I’m talking with my clients who have health anxiety is also not swaying the doctor or the nurse to answer things in the way that you want. A lot of people fall into this trap. For me, I just had my doctor’s appointment. We are working through and there are some little problems that we will work out. But I caught myself there wanting to sway him to be very positive. We had talked about it ultimately. He had said, “There are some issues. It could be this, it could be that, it could be this.” He listed off three or four options. Some were very, very small, and of course, the third one is always like, it could be cancer. They always say at the end, like whatever.

When they give you these three or four or five options on what the problem might be, it’s very important that you be mindful and aware of how you’re trying to sway the doctor to give you certainty. This is what my doctor said, and I’m going to be brief. I’m not going to bore you with my medical stuff, but he’ll say, “It could be that you recently had COVID or an illness or a virus. It could also be this other condition, which is common, and if it’s so, we’ll treat that. It could also be that there could be some rheumatoid arthritis and that’s a longer treatment. And then the final thing, which we don’t think so, but it also could be cancer. “Let’s say he lists off these four options. 

Now, this is very common. Doctors will do this often because their job is to educate us on all of the possibilities so that we can create a treatment plan that doesn’t ignore big issues, but we have to be careful that we don’t spend their time and our time going, “You think it’s the first one, right? It’s probably just the first one. I probably just had a virus, right?” I’m really swaying him towards giving an answer when he’s already told us that he or she doesn’t know yet. He’s already said, “I don’t know yet. We’re going to need to do extra tests.”

Catch yourself trying to get them to reassure you and confirm that it’s definitely not the C word. The cancer word is what I’m saying there. Catch yourself when you’re doing those behaviors in the office with either the nurses or the technician or the doctors. Very, very important. 

Now, one other thing I want you to also catch is if you’re coming to them with something, let’s say you are coming to them with a concern that you’ve pretty much know is your health anxiety, but you want reassurance that it’s not, also be careful that you don’t overly list things to convince them that something is wrong. A lot of you don’t do this, I know, but I have had a lot of clients who’ve come back to me after seeing the doctor and said, “Do you have any other symptoms,” and they would list even minor symptoms that they had a month ago that they knew had nothing to do with it. But they felt like if they didn’t say it all, if they didn’t include every symptom, every stomach ache, every headache, everything, they could miss something. So also keep an eye out for that.

That’s some sort of overall general CBT techniques we use for health anxiety that help guide people into not engaging in those health anxiety compulsions.

TIP #3: HEALTH ANXIETY HELP DURING YOUR DOCTOR’S VISIT

This is a really important part of it. From the minute that I got the call from the nurse that he wanted a video call with me, my mind went to, again, the worst-case scenario. It just does. It just does. I think that that is actually really, really normal. I really do. I think that is what happens naturally for anybody. First of all, I don’t want to even go too over in terms of pathologizing that. I think that’s a normal thing for anybody to experience. 

The first thing I want you to practice is validating your anxiety. It’s a part of self-compassion practice. It’s going, “It makes complete sense, Kimberley, that this is concerning you.” That’s one of the most important self-compassionate statements you could make for yourself. “It makes complete sense that this is hard, this is scary. Of course, it’s making you uncomfortable.” It’s validating. 

You might even move to a common humanity, going, “Anybody in this situation would have anxiety.” Then you can also move into mindfulness skills, which is—this was one that I hold very true—just because I feel anxious doesn’t mean there’s danger or there’s a catastrophe. It’s my body’s natural response to create anxiety when it feels threatened. That keeps me alive. That’s a good thing. But just because I’m anxious and having thoughts about scary things doesn’t mean they’re facts. Remember, thoughts are not facts.

The next thing here is also being able to just observe them, again, while you’re sitting in the waiting room. They were playing the movie, what’s it called? Moana. And I love Moana. I remember watching it as a child. I’m sitting in the seat and my mind is offering me all of these health anxiety intrusive thoughts, and my mind really wants me to pay attention to them. 

A part of my mindfulness practice was to go, “I am noticing I’m having these catastrophic thoughts, but I’m also noticing Moana, and I’m going to choose which one I give my attention to.” I’m not going to push them away. I’m not going to make the thoughts go away because they’re naturally going to be there. I basically knew from yesterday afternoon until 9:00 AM this morning that the thoughts were going to be there and I accepted them there. I didn’t go in saying, “Oh gosh, I hope the next 24 hours aren’t filled with thoughts.” I was like, they’re going to be, “Hello thoughts, welcome. I know you’re going to be here,” and I’m going to train my brain to put attention on what matters to me. In this case, I’m not going to make these thoughts important. I’m going to watch Moana. I’m going to look at the colors, I’m going to listen to the sounds, I’m going to notice whatever it is that I notice. I’m going to notice the fabric of the seat underneath me as I’m waiting in the room. Last night as I went to bed, I’m just going to notice the feeling of the cushions underneath me. This is mindfulness and this is so important—being present and paying attention to what is currently happening instead of the worst-case scenario.

There’s one important point here, which is my mind kept saying, “By nine o’clock tomorrow, your life might change.” You guys know what? If you’re listening, I’m guessing you know what that’s like. You’re like, “After this appointment, this appointment may change your life for the worse.” My job was to go, “Maybe, maybe not. It could be that he just wants to tell me everything’s okay.”

It is what it is. It will be what it will be. I will work through it and solve it when it happens. I’m not going to live the next 24 hours or the next 12 hours coming from a place of the worst-case scenario until I have actual evidence of that. So we are not going to live your life as you wait for your appointment. We’re not going to live your life through the lens of the worst case. We’re going to live through it through being uncertain and accepting that in this moment, nothing is wrong. Until we know, we don’t know. 

MEDITATION FOR HEALTH ANXIETY

Now, other options for you, I’m just going to add a couple here, is I have found meditation for health anxiety to be very, very helpful, particularly when health anxiety is taking over. That has been very beneficial for me—to find a meditation that can actually sometimes give me some concrete skills to use in the moment to stay present. We are not going towards staying calm because maybe you’re going to have some anxiety. That’s okay. Really what we want to do is we want to be working in the most skillful fashion as we can. 

And then the last one, this one’s a little controversial. Some people don’t agree with this piece of advice, so take what you need and leave what doesn’t help. But for me, when I’m anxious, I tend to shallow breathe a lot. I hold my breath a lot. For me, it was just reminding myself just to breathe. Not breathe in any particular fashion or deep breathing, but just be like, “Take a breath, Kimberley, when you need. Take a breath when you need.”

TIP #4: WHAT TO DO WHEN HEALTH ANXIETY TAKES OVER?

Tip #4 is what to do when anxiety takes over in the biggest way, and that ultimately means, what can you do when your brain is setting on the full alarm. Now in this case, I’m just going to say it’s basically what to do if you’re panicking and the advice goes the same as it is whether there’s a health anxiety panic attack or a regular non-health anxiety panic attack, which is do not try to push the anxiety away. Let’s break it down.

If you’re having anxiety, and you are saying, “This is bad, I don’t want it, it shouldn’t be here,” you’re actually telling your brain that the anxiety is dangerous. Not just the health issue, but also the presence of anxiety is dangerous, which means it’s going to pump out more and more anxiety because you’ve told it that anxiety is dangerous. Your job here is to let the anxiety be there. Try not to push it away. What we know is what you try to push away comes stronger. 

You can talk to your anxiety. There’s actually research to show that when you talk to your anxiety and you talk to yourself in the third person, it can actually empower you and feel more of a sense of empowerment and mastery over that experience. For me, unfortunately, I’ve had quite the 24 hours. We actually had a very large earthquake last night here in southern California, which woke me up, so I had some anxiety related to that. And then of course, my brain was like, “Oh yeah, and by the way, you might have cancer. Ha-ha-ha!” You know what I mean? Of course, your brain’s going to tell you that. 

In that moment, I used the skill and the research around talking to myself in the third person. I said, “Kimberley, there’s nothing you can do right now. It makes total sense that you have anxiety. Let’s not push it away. Let’s bring your attention to what you can control, which is how kind you are to yourself, whether you’re clenching your body up, whether you’re breathing, whether what you’re putting your attention on. You can’t control anything. You can’t control this earthquake. You can’t control what’s happening tomorrow. All you can do is be here now.” Using a third person, using your name as the third person like, “Kimberley...” and saying what you need to do. Coaching yourself has been incredibly helpful for me and I know for a lot of people because that’s actually science-based. 

TIP #5: ENGAGE IN VALUE-BASED BEHAVIORS

The next thing I want you to do, and this is the final one before we go through some questions that I want you to ask yourself, is to engage in value-based behaviors. Now what that means is when we’re anxious, when we have health anxiety, it’s very normal for us to want to engage in safety behaviors. One for me was every morning, I drop my daughter off and my husband drops my son off at school and I could feel my anxiety wanting to stay home. I don’t want to go out. And so I almost was starting to say, “Maybe I’ll ask my husband to drop off my daughter and my son so I can stay home.” I recognize that would be me doing a fear-based behavior. I would be doing that only because I don’t want to face fear today. I just want to make it small. 

Number one, it’s okay. If you need to do that, that’s totally okay. But for me personally, I caught myself and I said, “No, you value being someone who drops off your daughter and shows up and doesn’t let anxiety win. You love dropping off your daughter. If you stayed home, you’d only be doing the dishes, circling around, maybe catastrophizing, just trying to get past time. You love taking your daughter to drop off.” And so engage in that. 

Another value-based behavior for me personally is humor. I’m texting friends and I’m telling them jokes about what I’m going to do to my doctor if he says something wrong or something, or I’m making jokes about some of the questions and statements that the nurses made. I’m making jokes about it, not to catastrophize, not to put them down, not to minimize my own discomfort, but humor is a very big part of my values. I’m making jokes about what we’ll do if it’s cancer and will you come to my funeral and silly things. Again, I really want to make sure you understand, I’m not doing that as depressed bad things are going to happen. I’m doing it because I’m literally saying, it will be what it will be. Let’s just move forward and let’s actually bring some light and joy and some laughter to this. 

Now you might not like that. If that’s not your values, don’t do it, but identify, what would the non-anxious me do right now? What would I do if this fear wasn’t here? And then do those behaviors. It’s really, really important that you make sure you hit this in as many ways as you can because fear can cause us just to clam up and sit still and ruminate. It’s very important that you practice not just ruminating and cycling and going over and over and over and over all of the worst-case scenarios because your brain will take you to some very dark places.

HEALTH ANXIETY JOURNAL PROMPTS

This is really important. I know I’ve given you the top five, but that’s more like 20 points. Let’s talk about some hypochondria or health anxiety journal prompts or questions you can ask yourself to stay as skilled as you can. 

• What is in my control right now? 

What is in my control? My behaviors, my reactions. That’s ultimately what is in your control. What’s not in your control is how much anxiety you have and what thoughts you have about them. 

• What is not in my control? 

You can be very specific here. In my case, it’s like, what’s not in my control is what the doctor says. What’s not in my control is what my health condition is. What’s not in my control is when he calls. You know what I mean? What’s not in my control is the treatment plan. I’m going to have to wait for him to do that. I’m identifying what is in my control and what is not. 

• How am I going to gain a sense of control that is helpful to both my long-term health anxiety recovery goals and my health anxiety treatment plan? 

For me, I know that Googling is going to be a full sense of control and doesn’t help my long-term recovery, so I’m not going to do it. I know that me ruminating and doing tons of mental compulsions is going to give me a sense of control, but it’s not helpful. It’s not helpful. It doesn’t help my long-term recovery, it doesn’t help my long-term mental health, so I’m not going to do it. 

What will help my long-time health anxiety goals, it’s going to be all the tips that we covered today—no Googling, no checking faces, no reassurance seeking, no swaying the doctor, practicing my mindfulness, being as compassionate as I can, maybe taking some breaths. All of those are going to make me stronger in my health anxiety recovery instead of weaker the ones which would be ruminating and doing all of these. Not very helpful safety behaviors. 

• How willing am I to be uncertain right now? 

You guys are going to have to tolerate a lot of uncertainty. That’s what this is all about. From the minute I got the call from that nurse saying that I needed to have this video appointment, from the minute he got onto the video appointment, all I had to focus on is, am I willing to be uncomfortable? Am I willing to be uncertain? Because the only reason I would’ve Googled was because I wanted certainty. Really, really important. 

• What would the non-anxious me do right now? 

She’d get up and she’d go and drop her daughter off, and then she’d call your friend because that’s what you do every Wednesday morning. She’d respond to emails, she’d call. Do whatever it is that you’re doing. What would the non-anxious you do?

• How can I be kind and gentle towards myself as I navigate this experience? 

Another code question for that is, what do I need right now that is skillful? What do you need? The most beautiful thing about this is my husband. He is the most gorgeous man. He sits down. He doesn’t reassure me, he just says, “I got you.” If your partner is giving you a lot of reassurance, you might want to mention to them, “That actually doesn’t help my long-term health anxiety. I just need you to be next to me and support me.” And so it’s very important that we make sure our partners aren’t giving us a whole bunch of reassurance and a whole bunch of certainty-seeking behaviors that keep us stuck. 

That’s it guys. There are my five tips for health anxiety which turned out to be more like 20, I know, but I try to always overdeliver. I really wanted to jam in as many skills as I could.

I hope you have a wonderful day. Please do not worry about me. I am actually fine. There’s a joke between my best friend and I. We say, “Are you fine number one or fine number two?” Fine number one is you actually are fine and fine number two is you’re not fine, but you’re saying you are, and I am fine number one. I actually have a lot of faith in my doctors. I have a lot of faith in my ability to handle these things and these are just another bump on the road in terms of being someone who has postural orthostatic tachycardic syndrome. So all is well. All is well. I am fine number one and I hope you are fine number one as well. 

I am sending you so much love. Do not forget, it is a beautiful day to do all the hard things, and I’ll see you next week.

5 TIPS FOR HEALTH ANXIETY DURING A DRS VISIT

If you want my five tips for health anxiety during a Drs visit, especially if you have a medical condition that concerns you, this is the episode for you.

Hello and welcome back everybody. Today, I’m going to share some updates about a recent medical issue I have had, and I’m going to share specific tips for dealing with health anxiety (also known as hypochondria). 

A lot of you who have been here with me before know I have postural orthostatic tachycardic syndrome. I also have a lesion on my left cerebellum and many other ups and downs in my medical history where I’ve had to get really good at managing my health anxiety. I wanted to share with you some real-time tips that I am practicing as I deal with another medical illness or another medical concern that I wanted to share with you. 

Here I’m going to share with you five specific tips, but I think in total, there’s 20-something tips all woven in here. I’ve done my best to put them into just five. But do make sure you listen to the end of the podcast episode because I’m also going to give some health anxiety journal prompts or questions that you can ask yourself so that you can know how to deal with health anxiety if you’re experiencing that at this time. 

Before we get into it, let me give you a little bit of a backstory. Several months ago, I did share that I’ve been having these what I call surges. They’re like adrenaline surges. They wake me up. My heart isn’t racing. It’s not like it’s racing fast, but the only way I can explain it is I feel like I have like a racehorse’s heart in my chest, like this huge heart that’s beating really heavily. Of course, that creates anxiety. And so then I would question like, is it the heartbeat or is it just my anxiety? You go back and you go forward trying to figure out which is which. But because this was a symptom that was persisting and was also showing up when I wasn’t experiencing a lot of stress or anxiety, I thought the right thing to do is to go and see the doctor. 

WHAT HEALTH ANXIETY FEELS LIKE

Before we get started, be sure to make sure you’re not avoiding doctors. Make sure you’re not dismissing symptoms. We do have to find a very, very wise balance between avoiding doctors but also not overdoing it with doctors. We’ll talk about that a little bit here in a minute. But first, I wanted to just share with you what health anxiety feels like for me. Because for me, I’m very, very skilled at identifying what is anxiety and what is not. I’ve become very good at catching that by experience, folks. It’s not something that comes naturally, but by experience, I can identify what is health anxiety and what is a real medical condition or what is something worthy of me getting checked out. 

For me, for the health anxiety piece, it’s really this sort of anxiety that is a sense of catastrophization and it’s usually in the form of thoughts like, what if this is cancer? What if this is a stroke? All the worst-case scenarios. What if this is life-threatening? What if I miss this and you are responsible, you should have picked it up. These are very common health anxiety intrusive thoughts or health anxiety thoughts that I think you really need to be able to catch and be aware and mindful of. First of all, that is the biggest symptom for me. 

The other thing is when you have health anxiety, you do tend to hyper-fixate on the symptom and all of the surrounding symptoms that are going with that. And then you can really catastrophize those like, “Well, my heart’s beating really heavily and I feel dizzy. Oh my gosh. And I’ve been having a headache. Yeah, you’re right, I’ve been having a headache. Oh my gosh.” I call it ‘gathering.’ That’s not an actual clinical term, but I do use it with my clients. We gather data that is catastrophic to make it seem like, yeah, we actually have a really big point, and this is actually a catastrophe. 

Some other health anxiety symptom that I experience is panic. When you notice a symptom, it is very common to start panicking. And then again, you go back to this chicken or the egg or is it the horse or the carriage in terms of I’m panicking, and now the panic has all these symptoms. Are these symptoms an actual medical condition or are they actually just anxiety and panic? You could spend a lot of time stuck in that cycle trying to figure that out. 

Let’s now talk about how to manage these symptoms and some tips and tools that you can use. 

Tip #1: No Googling

Let me tell you what has recently happened to me. I’ve been having these symptoms. I made an appointment to see my cardiologist. It was two months out and I was like, “It’s not a big deal. I can handle these symptoms.” I’m feeling super confident about my ability now to just ride out some pretty uncomfortable sensations and not catastrophize. I go in for my checkup, they do an echocardiogram, and it’s taking a long time. She’s asking me these strange questions like, “Why are you here again,” as she’s doing it. She’s checking, she’s looking, she’s squinting at the screen. “Why are you here again? What are your symptoms?” Click, click, click, looking at the heart, whatever. Again, I’m in my mind going, “Kimberley, let your brain have whatever thoughts it wants. We’re not going to catastrophize.” I was doing really, really well. I got up and I answered her questions. I did the whole appointment. She cleaned me off when I was done and said, “Great, you’ve got 24 hours and then the doctor will email you with your results.”

And then yesterday afternoon, I get a call from the nurse saying, “We need to book you a video appointment with the doctor to discuss your results.” As you can imagine, my brain went berserk. My health anxiety thoughts were saying, “This is really bad. Why would he need to make a video appointment? This can only end badly. This must be cancer. This must be heart problems. Am I going to have a heart attack and so forth?” Of course, my brain did that. I’m grateful my brain does that because that’s my brain being highly functioning and aware. 

But the number one rule I made with myself in that exact moment, even though that was very anxiety-producing, is no Googling. Kimberley, you are not allowed to pick up the computer or the iPhone and Google anything about this.

That is tip #1 for you. I’ll tell you why. A lot of my patients say, “But why? It’s no harm. I’m not doing any harm.” And I’ll say, “Yes.” I’ve actually just seen my cardiologist. But now that I’ve had my appointment, he encouraged me to do a little research. What was hilarious to me is every single website is different and some catastrophize and some don’t. Some go, “This could be very normal.” Other ones say, “This could be cancer, cancer, cancer, cancer.”

This is why I’m telling my patients all the time, don’t Google because what you read is different. It’s not like this is going to be a factual thing. Most of the time people who have articles that rank high on Google searches are the ones who have optimized their website to be very easy to Google. The reason they have become number one on the Google algorithm is because they’ve included keywords like cancer for blah, blah, blah, and all of these health issues and health names. The ones that are at the top, some of them are very reasonable, helpful, and accurate, but a lot of them are not. They’ve just really done a great job of putting in lots and lots of keywords that makes them highly searchable and come up high on the algorithm.

Please, number one, do not Google. Go to your doctor for questions if you have any. Unless they’ve encouraged you to do research, do not Google.

TIP #2: FOLLOW IMPORTANT HEALTH ANXIETY CBT TECHNIQUES

I’ve actually categorized this in a bigger category and I’ve called it important health anxiety CBT techniques, because there are some important CBT tools that you’re going to need here and here we go. 

While I was in getting my echocardiogram, I was laying and I was having some anxiety because she was squinting and asking some strange questions, not in the normal of what I’d experienced. I could feel the pull to check her face for reassurance like, does she look concerned? Does she look relaxed? What’s going on with her? I wonder what she meant. 

What I want to encourage you to do is acknowledge and catch when you’re checking their face to try to decipher what the nurse or the assistant or the doctor is doing and saying. Because really, all I’m doing there is mind reading because I have no idea what she’s thinking. I was laughing at myself because she was squinting and looking concerned. I was like, “I wonder if she’s trying not to pass gas.” We could mind read that she thinks I have cancer and that there’s a big problem, or maybe she’s just trying not to pass gas right now. Maybe she’s thinking about a fight she just had with her partner. My attempt to analyze her facial expression is a complete waste of my time. You could use that tip anytime you want. 

The next tip for you is no reassurance seeking with nurses or doctors. Now, I actually felt almost into this trap. If I’m being completely honest, I did fall into this trap, but I caught myself really quickly. As she was finishing up, she took off her gloves and got ready to discharge me, and I said, “So, you’d let me know if there was...” I paused because what I was going to say is, “You’ll let me know if there’s something wrong, right?” I was going to say that. And then I was like, “No, no, no.” I stopped myself and said, “You know what? I know the deal. I’ve done these enough times. I know I have to wait for the doctor.” But I caught myself wanting to get confirmation from the nurse and I already know that nurses are not allowed to give me any diagnosis anyway. I caught myself wanting to get some expression of relief from her like, “No, you’re fine. Everything looks good,” or whatever. Sometimes they accidentally give you that reassurance. But I caught myself seeking reassurance from her. 

In addition to that—let me talk to you a little later about how we do that with doctors as well—often if you’re in the office with a doctor, you may find yourself at the end of the session going, “I’ll be fine, right? It’s not bad, right?” It’s okay, we’re all going to ask some of those questions. I’m not going to be the reassurance-seeking police with you. But what I want you to do is really drop down into catching when we’re engaging in reassurance seeking and using it too much to reduce our own anxiety about it, to take away our own anxiety or fear.

Now, another CBT technique or sort of rule that we often set in clinical work when I’m talking with my clients who have health anxiety is also not swaying the doctor or the nurse to answer things in the way that you want. A lot of people fall into this trap. For me, I just had my doctor’s appointment. We are working through and there are some little problems that we will work out. But I caught myself there wanting to sway him to be very positive. We had talked about it ultimately. He had said, “There are some issues. It could be this, it could be that, it could be this.” He listed off three or four options. Some were very, very small, and of course, the third one is always like, it could be cancer. They always say at the end, like whatever.

When they give you these three or four or five options on what the problem might be, it’s very important that you be mindful and aware of how you’re trying to sway the doctor to give you certainty. This is what my doctor said, and I’m going to be brief. I’m not going to bore you with my medical stuff, but he’ll say, “It could be that you recently had COVID or an illness or a virus. It could also be this other condition, which is common, and if it’s so, we’ll treat that. It could also be that there could be some rheumatoid arthritis and that’s a longer treatment. And then the final thing, which we don’t think so, but it also could be cancer. “Let’s say he lists off these four options. 

Now, this is very common. Doctors will do this often because their job is to educate us on all of the possibilities so that we can create a treatment plan that doesn’t ignore big issues, but we have to be careful that we don’t spend their time and our time going, “You think it’s the first one, right? It’s probably just the first one. I probably just had a virus, right?” I’m really swaying him towards giving an answer when he’s already told us that he or she doesn’t know yet. He’s already said, “I don’t know yet. We’re going to need to do extra tests.”

Catch yourself trying to get them to reassure you and confirm that it’s definitely not the C word. The cancer word is what I’m saying there. Catch yourself when you’re doing those behaviors in the office with either the nurses or the technician or the doctors. Very, very important. 

Now, one other thing I want you to also catch is if you’re coming to them with something, let’s say you are coming to them with a concern that you’ve pretty much know is your health anxiety, but you want reassurance that it’s not, also be careful that you don’t overly list things to convince them that something is wrong. A lot of you don’t do this, I know, but I have had a lot of clients who’ve come back to me after seeing the doctor and said, “Do you have any other symptoms,” and they would list even minor symptoms that they had a month ago that they knew had nothing to do with it. But they felt like if they didn’t say it all, if they didn’t include every symptom, every stomach ache, every headache, everything, they could miss something. So also keep an eye out for that.

That’s some sort of overall general CBT techniques we use for health anxiety that help guide people into not engaging in those health anxiety compulsions.

TIP #3: HEALTH ANXIETY HELP DURING YOUR DOCTOR’S VISIT

This is a really important part of it. From the minute that I got the call from the nurse that he wanted a video call with me, my mind went to, again, the worst-case scenario. It just does. It just does. I think that that is actually really, really normal. I really do. I think that is what happens naturally for anybody. First of all, I don’t want to even go too over in terms of pathologizing that. I think that’s a normal thing for anybody to experience. 

The first thing I want you to practice is validating your anxiety. It’s a part of self-compassion practice. It’s going, “It makes complete sense, Kimberley, that this is concerning you.” That’s one of the most important self-compassionate statements you could make for yourself. “It makes complete sense that this is hard, this is scary. Of course, it’s making you uncomfortable.” It’s validating. 

You might even move to a common humanity, going, “Anybody in this situation would have anxiety.” Then you can also move into mindfulness skills, which is—this was one that I hold very true—just because I feel anxious doesn’t mean there’s danger or there’s a catastrophe. It’s my body’s natural response to create anxiety when it feels threatened. That keeps me alive. That’s a good thing. But just because I’m anxious and having thoughts about scary things doesn’t mean they’re facts. Remember, thoughts are not facts.

The next thing here is also being able to just observe them, again, while you’re sitting in the waiting room. They were playing the movie, what’s it called? Moana. And I love Moana. I remember watching it as a child. I’m sitting in the seat and my mind is offering me all of these health anxiety intrusive thoughts, and my mind really wants me to pay attention to them. 

A part of my mindfulness practice was to go, “I am noticing I’m having these catastrophic thoughts, but I’m also noticing Moana, and I’m going to choose which one I give my attention to.” I’m not going to push them away. I’m not going to make the thoughts go away because they’re naturally going to be there. I basically knew from yesterday afternoon until 9:00 AM this morning that the thoughts were going to be there and I accepted them there. I didn’t go in saying, “Oh gosh, I hope the next 24 hours aren’t filled with thoughts.” I was like, they’re going to be, “Hello thoughts, welcome. I know you’re going to be here,” and I’m going to train my brain to put attention on what matters to me. In this case, I’m not going to make these thoughts important. I’m going to watch Moana. I’m going to look at the colors, I’m going to listen to the sounds, I’m going to notice whatever it is that I notice. I’m going to notice the fabric of the seat underneath me as I’m waiting in the room. Last night as I went to bed, I’m just going to notice the feeling of the cushions underneath me. This is mindfulness and this is so important—being present and paying attention to what is currently happening instead of the worst-case scenario.

There’s one important point here, which is my mind kept saying, “By nine o’clock tomorrow, your life might change.” You guys know what? If you’re listening, I’m guessing you know what that’s like. You’re like, “After this appointment, this appointment may change your life for the worse.” My job was to go, “Maybe, maybe not. It could be that he just wants to tell me everything’s okay.”

It is what it is. It will be what it will be. I will work through it and solve it when it happens. I’m not going to live the next 24 hours or the next 12 hours coming from a place of the worst-case scenario until I have actual evidence of that. So we are not going to live your life as you wait for your appointment. We’re not going to live your life through the lens of the worst case. We’re going to live through it through being uncertain and accepting that in this moment, nothing is wrong. Until we know, we don’t know. 

MEDITATION FOR HEALTH ANXIETY

Now, other options for you, I’m just going to add a couple here, is I have found meditation for health anxiety to be very, very helpful, particularly when health anxiety is taking over. That has been very beneficial for me—to find a meditation that can actually sometimes give me some concrete skills to use in the moment to stay present. We are not going towards staying calm because maybe you’re going to have some anxiety. That’s okay. Really what we want to do is we want to be working in the most skillful fashion as we can. 

And then the last one, this one’s a little controversial. Some people don’t agree with this piece of advice, so take what you need and leave what doesn’t help. But for me, when I’m anxious, I tend to shallow breathe a lot. I hold my breath a lot. For me, it was just reminding myself just to breathe. Not breathe in any particular fashion or deep breathing, but just be like, “Take a breath, Kimberley, when you need. Take a breath when you need.”

TIP #4: WHAT TO DO WHEN HEALTH ANXIETY TAKES OVER?

Tip #4 is what to do when anxiety takes over in the biggest way, and that ultimately means, what can you do when your brain is setting on the full alarm. Now in this case, I’m just going to say it’s basically what to do if you’re panicking and the advice goes the same as it is whether there’s a health anxiety panic attack or a regular non-health anxiety panic attack, which is do not try to push the anxiety away. Let’s break it down.

If you’re having anxiety, and you are saying, “This is bad, I don’t want it, it shouldn’t be here,” you’re actually telling your brain that the anxiety is dangerous. Not just the health issue, but also the presence of anxiety is dangerous, which means it’s going to pump out more and more anxiety because you’ve told it that anxiety is dangerous. Your job here is to let the anxiety be there. Try not to push it away. What we know is what you try to push away comes stronger. 

You can talk to your anxiety. There’s actually research to show that when you talk to your anxiety and you talk to yourself in the third person, it can actually empower you and feel more of a sense of empowerment and mastery over that experience. For me, unfortunately, I’ve had quite the 24 hours. We actually had a very large earthquake last night here in southern California, which woke me up, so I had some anxiety related to that. And then of course, my brain was like, “Oh yeah, and by the way, you might have cancer. Ha-ha-ha!” You know what I mean? Of course, your brain’s going to tell you that. 

In that moment, I used the skill and the research around talking to myself in the third person. I said, “Kimberley, there’s nothing you can do right now. It makes total sense that you have anxiety. Let’s not push it away. Let’s bring your attention to what you can control, which is how kind you are to yourself, whether you’re clenching your body up, whether you’re breathing, whether what you’re putting your attention on. You can’t control anything. You can’t control this earthquake. You can’t control what’s happening tomorrow. All you can do is be here now.” Using a third person, using your name as the third person like, “Kimberley...” and saying what you need to do. Coaching yourself has been incredibly helpful for me and I know for a lot of people because that’s actually science-based. 

TIP #5: ENGAGE IN VALUE-BASED BEHAVIORS

The next thing I want you to do, and this is the final one before we go through some questions that I want you to ask yourself, is to engage in value-based behaviors. Now what that means is when we’re anxious, when we have health anxiety, it’s very normal for us to want to engage in safety behaviors. One for me was every morning, I drop my daughter off and my husband drops my son off at school and I could feel my anxiety wanting to stay home. I don’t want to go out. And so I almost was starting to say, “Maybe I’ll ask my husband to drop off my daughter and my son so I can stay home.” I recognize that would be me doing a fear-based behavior. I would be doing that only because I don’t want to face fear today. I just want to make it small. 

Number one, it’s okay. If you need to do that, that’s totally okay. But for me personally, I caught myself and I said, “No, you value being someone who drops off your daughter and shows up and doesn’t let anxiety win. You love dropping off your daughter. If you stayed home, you’d only be doing the dishes, circling around, maybe catastrophizing, just trying to get past time. You love taking your daughter to drop off.” And so engage in that. 

Another value-based behavior for me personally is humor. I’m texting friends and I’m telling them jokes about what I’m going to do to my doctor if he says something wrong or something, or I’m making jokes about some of the questions and statements that the nurses made. I’m making jokes about it, not to catastrophize, not to put them down, not to minimize my own discomfort, but humor is a very big part of my values. I’m making jokes about what we’ll do if it’s cancer and will you come to my funeral and silly things. Again, I really want to make sure you understand, I’m not doing that as depressed bad things are going to happen. I’m doing it because I’m literally saying, it will be what it will be. Let’s just move forward and let’s actually bring some light and joy and some laughter to this. 

Now you might not like that. If that’s not your values, don’t do it, but identify, what would the non-anxious me do right now? What would I do if this fear wasn’t here? And then do those behaviors. It’s really, really important that you make sure you hit this in as many ways as you can because fear can cause us just to clam up and sit still and ruminate. It’s very important that you practice not just ruminating and cycling and going over and over and over and over all of the worst-case scenarios because your brain will take you to some very dark places.

HEALTH ANXIETY JOURNAL PROMPTS

This is really important. I know I’ve given you the top five, but that’s more like 20 points. Let’s talk about some hypochondria or health anxiety journal prompts or questions you can ask yourself to stay as skilled as you can. 

• What is in my control right now? 

What is in my control? My behaviors, my reactions. That’s ultimately what is in your control. What’s not in your control is how much anxiety you have and what thoughts you have about them. 

• What is not in my control? 

You can be very specific here. In my case, it’s like, what’s not in my control is what the doctor says. What’s not in my control is what my health condition is. What’s not in my control is when he calls. You know what I mean? What’s not in my control is the treatment plan. I’m going to have to wait for him to do that. I’m identifying what is in my control and what is not. 

• How am I going to gain a sense of control that is helpful to both my long-term health anxiety recovery goals and my health anxiety treatment plan? 

For me, I know that Googling is going to be a full sense of control and doesn’t help my long-term recovery, so I’m not going to do it. I know that me ruminating and doing tons of mental compulsions is going to give me a sense of control, but it’s not helpful. It’s not helpful. It doesn’t help my long-term recovery, it doesn’t help my long-term mental health, so I’m not going to do it. 

What will help my long-time health anxiety goals, it’s going to be all the tips that we covered today—no Googling, no checking faces, no reassurance seeking, no swaying the doctor, practicing my mindfulness, being as compassionate as I can, maybe taking some breaths. All of those are going to make me stronger in my health anxiety recovery instead of weaker the ones which would be ruminating and doing all of these. Not very helpful safety behaviors. 

• How willing am I to be uncertain right now? 

You guys are going to have to tolerate a lot of uncertainty. That’s what this is all about. From the minute I got the call from that nurse saying that I needed to have this video appointment, from the minute he got onto the video appointment, all I had to focus on is, am I willing to be uncomfortable? Am I willing to be uncertain? Because the only reason I would’ve Googled was because I wanted certainty. Really, really important. 

• What would the non-anxious me do right now? 

She’d get up and she’d go and drop her daughter off, and then she’d call your friend because that’s what you do every Wednesday morning. She’d respond to emails, she’d call. Do whatever it is that you’re doing. What would the non-anxious you do?

• How can I be kind and gentle towards myself as I navigate this experience? 

Another code question for that is, what do I need right now that is skillful? What do you need? The most beautiful thing about this is my husband. He is the most gorgeous man. He sits down. He doesn’t reassure me, he just says, “I got you.” If your partner is giving you a lot of reassurance, you might want to mention to them, “That actually doesn’t help my long-term health anxiety. I just need you to be next to me and support me.” And so it’s very important that we make sure our partners aren’t giving us a whole bunch of reassurance and a whole bunch of certainty-seeking behaviors that keep us stuck. 

That’s it guys. There are my five tips for health anxiety which turned out to be more like 20, I know, but I try to always overdeliver. I really wanted to jam in as many skills as I could.

I hope you have a wonderful day. Please do not worry about me. I am actually fine. There’s a joke between my best friend and I. We say, “Are you fine number one or fine number two?” Fine number one is you actually are fine and fine number two is you’re not fine, but you’re saying you are, and I am fine number one. I actually have a lot of faith in my doctors. I have a lot of faith in my ability to handle these things and these are just another bump on the road in terms of being someone who has postural orthostatic tachycardic syndrome. So all is well. All is well. I am fine number one and I hope you are fine number one as well. 

I am sending you so much love. Do not forget, it is a beautiful day to do all the hard things, and I’ll see you next week.

5 TIPS FOR HEALTH ANXIETY DURING A DRS VISIT

If you want my five tips for health anxiety during a Drs visit, especially if you have a medical condition that concerns you, this is the episode for you.

Hello and welcome back everybody. Today, I’m going to share some updates about a recent medical issue I have had, and I’m going to share specific tips for dealing with health anxiety (also known as hypochondria). 

A lot of you who have been here with me before know I have postural orthostatic tachycardic syndrome. I also have a lesion on my left cerebellum and many other ups and downs in my medical history where I’ve had to get really good at managing my health anxiety. I wanted to share with you some real-time tips that I am practicing as I deal with another medical illness or another medical concern that I wanted to share with you. 

Here I’m going to share with you five specific tips, but I think in total, there’s 20-something tips all woven in here. I’ve done my best to put them into just five. But do make sure you listen to the end of the podcast episode because I’m also going to give some health anxiety journal prompts or questions that you can ask yourself so that you can know how to deal with health anxiety if you’re experiencing that at this time. 

Before we get into it, let me give you a little bit of a backstory. Several months ago, I did share that I’ve been having these what I call surges. They’re like adrenaline surges. They wake me up. My heart isn’t racing. It’s not like it’s racing fast, but the only way I can explain it is I feel like I have like a racehorse’s heart in my chest, like this huge heart that’s beating really heavily. Of course, that creates anxiety. And so then I would question like, is it the heartbeat or is it just my anxiety? You go back and you go forward trying to figure out which is which. But because this was a symptom that was persisting and was also showing up when I wasn’t experiencing a lot of stress or anxiety, I thought the right thing to do is to go and see the doctor. 

WHAT HEALTH ANXIETY FEELS LIKE

Before we get started, be sure to make sure you’re not avoiding doctors. Make sure you’re not dismissing symptoms. We do have to find a very, very wise balance between avoiding doctors but also not overdoing it with doctors. We’ll talk about that a little bit here in a minute. But first, I wanted to just share with you what health anxiety feels like for me. Because for me, I’m very, very skilled at identifying what is anxiety and what is not. I’ve become very good at catching that by experience, folks. It’s not something that comes naturally, but by experience, I can identify what is health anxiety and what is a real medical condition or what is something worthy of me getting checked out. 

For me, for the health anxiety piece, it’s really this sort of anxiety that is a sense of catastrophization and it’s usually in the form of thoughts like, what if this is cancer? What if this is a stroke? All the worst-case scenarios. What if this is life-threatening? What if I miss this and you are responsible, you should have picked it up. These are very common health anxiety intrusive thoughts or health anxiety thoughts that I think you really need to be able to catch and be aware and mindful of. First of all, that is the biggest symptom for me. 

The other thing is when you have health anxiety, you do tend to hyper-fixate on the symptom and all of the surrounding symptoms that are going with that. And then you can really catastrophize those like, “Well, my heart’s beating really heavily and I feel dizzy. Oh my gosh. And I’ve been having a headache. Yeah, you’re right, I’ve been having a headache. Oh my gosh.” I call it ‘gathering.’ That’s not an actual clinical term, but I do use it with my clients. We gather data that is catastrophic to make it seem like, yeah, we actually have a really big point, and this is actually a catastrophe. 

Some other health anxiety symptom that I experience is panic. When you notice a symptom, it is very common to start panicking. And then again, you go back to this chicken or the egg or is it the horse or the carriage in terms of I’m panicking, and now the panic has all these symptoms. Are these symptoms an actual medical condition or are they actually just anxiety and panic? You could spend a lot of time stuck in that cycle trying to figure that out. 

Let’s now talk about how to manage these symptoms and some tips and tools that you can use. 

Tip #1: No Googling

Let me tell you what has recently happened to me. I’ve been having these symptoms. I made an appointment to see my cardiologist. It was two months out and I was like, “It’s not a big deal. I can handle these symptoms.” I’m feeling super confident about my ability now to just ride out some pretty uncomfortable sensations and not catastrophize. I go in for my checkup, they do an echocardiogram, and it’s taking a long time. She’s asking me these strange questions like, “Why are you here again,” as she’s doing it. She’s checking, she’s looking, she’s squinting at the screen. “Why are you here again? What are your symptoms?” Click, click, click, looking at the heart, whatever. Again, I’m in my mind going, “Kimberley, let your brain have whatever thoughts it wants. We’re not going to catastrophize.” I was doing really, really well. I got up and I answered her questions. I did the whole appointment. She cleaned me off when I was done and said, “Great, you’ve got 24 hours and then the doctor will email you with your results.”

And then yesterday afternoon, I get a call from the nurse saying, “We need to book you a video appointment with the doctor to discuss your results.” As you can imagine, my brain went berserk. My health anxiety thoughts were saying, “This is really bad. Why would he need to make a video appointment? This can only end badly. This must be cancer. This must be heart problems. Am I going to have a heart attack and so forth?” Of course, my brain did that. I’m grateful my brain does that because that’s my brain being highly functioning and aware. 

But the number one rule I made with myself in that exact moment, even though that was very anxiety-producing, is no Googling. Kimberley, you are not allowed to pick up the computer or the iPhone and Google anything about this.

That is tip #1 for you. I’ll tell you why. A lot of my patients say, “But why? It’s no harm. I’m not doing any harm.” And I’ll say, “Yes.” I’ve actually just seen my cardiologist. But now that I’ve had my appointment, he encouraged me to do a little research. What was hilarious to me is every single website is different and some catastrophize and some don’t. Some go, “This could be very normal.” Other ones say, “This could be cancer, cancer, cancer, cancer.”

This is why I’m telling my patients all the time, don’t Google because what you read is different. It’s not like this is going to be a factual thing. Most of the time people who have articles that rank high on Google searches are the ones who have optimized their website to be very easy to Google. The reason they have become number one on the Google algorithm is because they’ve included keywords like cancer for blah, blah, blah, and all of these health issues and health names. The ones that are at the top, some of them are very reasonable, helpful, and accurate, but a lot of them are not. They’ve just really done a great job of putting in lots and lots of keywords that makes them highly searchable and come up high on the algorithm.

Please, number one, do not Google. Go to your doctor for questions if you have any. Unless they’ve encouraged you to do research, do not Google.

TIP #2: FOLLOW IMPORTANT HEALTH ANXIETY CBT TECHNIQUES

I’ve actually categorized this in a bigger category and I’ve called it important health anxiety CBT techniques, because there are some important CBT tools that you’re going to need here and here we go. 

While I was in getting my echocardiogram, I was laying and I was having some anxiety because she was squinting and asking some strange questions, not in the normal of what I’d experienced. I could feel the pull to check her face for reassurance like, does she look concerned? Does she look relaxed? What’s going on with her? I wonder what she meant. 

What I want to encourage you to do is acknowledge and catch when you’re checking their face to try to decipher what the nurse or the assistant or the doctor is doing and saying. Because really, all I’m doing there is mind reading because I have no idea what she’s thinking. I was laughing at myself because she was squinting and looking concerned. I was like, “I wonder if she’s trying not to pass gas.” We could mind read that she thinks I have cancer and that there’s a big problem, or maybe she’s just trying not to pass gas right now. Maybe she’s thinking about a fight she just had with her partner. My attempt to analyze her facial expression is a complete waste of my time. You could use that tip anytime you want. 

The next tip for you is no reassurance seeking with nurses or doctors. Now, I actually felt almost into this trap. If I’m being completely honest, I did fall into this trap, but I caught myself really quickly. As she was finishing up, she took off her gloves and got ready to discharge me, and I said, “So, you’d let me know if there was...” I paused because what I was going to say is, “You’ll let me know if there’s something wrong, right?” I was going to say that. And then I was like, “No, no, no.” I stopped myself and said, “You know what? I know the deal. I’ve done these enough times. I know I have to wait for the doctor.” But I caught myself wanting to get confirmation from the nurse and I already know that nurses are not allowed to give me any diagnosis anyway. I caught myself wanting to get some expression of relief from her like, “No, you’re fine. Everything looks good,” or whatever. Sometimes they accidentally give you that reassurance. But I caught myself seeking reassurance from her. 

In addition to that—let me talk to you a little later about how we do that with doctors as well—often if you’re in the office with a doctor, you may find yourself at the end of the session going, “I’ll be fine, right? It’s not bad, right?” It’s okay, we’re all going to ask some of those questions. I’m not going to be the reassurance-seeking police with you. But what I want you to do is really drop down into catching when we’re engaging in reassurance seeking and using it too much to reduce our own anxiety about it, to take away our own anxiety or fear.

Now, another CBT technique or sort of rule that we often set in clinical work when I’m talking with my clients who have health anxiety is also not swaying the doctor or the nurse to answer things in the way that you want. A lot of people fall into this trap. For me, I just had my doctor’s appointment. We are working through and there are some little problems that we will work out. But I caught myself there wanting to sway him to be very positive. We had talked about it ultimately. He had said, “There are some issues. It could be this, it could be that, it could be this.” He listed off three or four options. Some were very, very small, and of course, the third one is always like, it could be cancer. They always say at the end, like whatever.

When they give you these three or four or five options on what the problem might be, it’s very important that you be mindful and aware of how you’re trying to sway the doctor to give you certainty. This is what my doctor said, and I’m going to be brief. I’m not going to bore you with my medical stuff, but he’ll say, “It could be that you recently had COVID or an illness or a virus. It could also be this other condition, which is common, and if it’s so, we’ll treat that. It could also be that there could be some rheumatoid arthritis and that’s a longer treatment. And then the final thing, which we don’t think so, but it also could be cancer. “Let’s say he lists off these four options. 

Now, this is very common. Doctors will do this often because their job is to educate us on all of the possibilities so that we can create a treatment plan that doesn’t ignore big issues, but we have to be careful that we don’t spend their time and our time going, “You think it’s the first one, right? It’s probably just the first one. I probably just had a virus, right?” I’m really swaying him towards giving an answer when he’s already told us that he or she doesn’t know yet. He’s already said, “I don’t know yet. We’re going to need to do extra tests.”

Catch yourself trying to get them to reassure you and confirm that it’s definitely not the C word. The cancer word is what I’m saying there. Catch yourself when you’re doing those behaviors in the office with either the nurses or the technician or the doctors. Very, very important. 

Now, one other thing I want you to also catch is if you’re coming to them with something, let’s say you are coming to them with a concern that you’ve pretty much know is your health anxiety, but you want reassurance that it’s not, also be careful that you don’t overly list things to convince them that something is wrong. A lot of you don’t do this, I know, but I have had a lot of clients who’ve come back to me after seeing the doctor and said, “Do you have any other symptoms,” and they would list even minor symptoms that they had a month ago that they knew had nothing to do with it. But they felt like if they didn’t say it all, if they didn’t include every symptom, every stomach ache, every headache, everything, they could miss something. So also keep an eye out for that.

That’s some sort of overall general CBT techniques we use for health anxiety that help guide people into not engaging in those health anxiety compulsions.

TIP #3: HEALTH ANXIETY HELP DURING YOUR DOCTOR’S VISIT

This is a really important part of it. From the minute that I got the call from the nurse that he wanted a video call with me, my mind went to, again, the worst-case scenario. It just does. It just does. I think that that is actually really, really normal. I really do. I think that is what happens naturally for anybody. First of all, I don’t want to even go too over in terms of pathologizing that. I think that’s a normal thing for anybody to experience. 

The first thing I want you to practice is validating your anxiety. It’s a part of self-compassion practice. It’s going, “It makes complete sense, Kimberley, that this is concerning you.” That’s one of the most important self-compassionate statements you could make for yourself. “It makes complete sense that this is hard, this is scary. Of course, it’s making you uncomfortable.” It’s validating. 

You might even move to a common humanity, going, “Anybody in this situation would have anxiety.” Then you can also move into mindfulness skills, which is—this was one that I hold very true—just because I feel anxious doesn’t mean there’s danger or there’s a catastrophe. It’s my body’s natural response to create anxiety when it feels threatened. That keeps me alive. That’s a good thing. But just because I’m anxious and having thoughts about scary things doesn’t mean they’re facts. Remember, thoughts are not facts.

The next thing here is also being able to just observe them, again, while you’re sitting in the waiting room. They were playing the movie, what’s it called? Moana. And I love Moana. I remember watching it as a child. I’m sitting in the seat and my mind is offering me all of these health anxiety intrusive thoughts, and my mind really wants me to pay attention to them. 

A part of my mindfulness practice was to go, “I am noticing I’m having these catastrophic thoughts, but I’m also noticing Moana, and I’m going to choose which one I give my attention to.” I’m not going to push them away. I’m not going to make the thoughts go away because they’re naturally going to be there. I basically knew from yesterday afternoon until 9:00 AM this morning that the thoughts were going to be there and I accepted them there. I didn’t go in saying, “Oh gosh, I hope the next 24 hours aren’t filled with thoughts.” I was like, they’re going to be, “Hello thoughts, welcome. I know you’re going to be here,” and I’m going to train my brain to put attention on what matters to me. In this case, I’m not going to make these thoughts important. I’m going to watch Moana. I’m going to look at the colors, I’m going to listen to the sounds, I’m going to notice whatever it is that I notice. I’m going to notice the fabric of the seat underneath me as I’m waiting in the room. Last night as I went to bed, I’m just going to notice the feeling of the cushions underneath me. This is mindfulness and this is so important—being present and paying attention to what is currently happening instead of the worst-case scenario.

There’s one important point here, which is my mind kept saying, “By nine o’clock tomorrow, your life might change.” You guys know what? If you’re listening, I’m guessing you know what that’s like. You’re like, “After this appointment, this appointment may change your life for the worse.” My job was to go, “Maybe, maybe not. It could be that he just wants to tell me everything’s okay.”

It is what it is. It will be what it will be. I will work through it and solve it when it happens. I’m not going to live the next 24 hours or the next 12 hours coming from a place of the worst-case scenario until I have actual evidence of that. So we are not going to live your life as you wait for your appointment. We’re not going to live your life through the lens of the worst case. We’re going to live through it through being uncertain and accepting that in this moment, nothing is wrong. Until we know, we don’t know. 

MEDITATION FOR HEALTH ANXIETY

Now, other options for you, I’m just going to add a couple here, is I have found meditation for health anxiety to be very, very helpful, particularly when health anxiety is taking over. That has been very beneficial for me—to find a meditation that can actually sometimes give me some concrete skills to use in the moment to stay present. We are not going towards staying calm because maybe you’re going to have some anxiety. That’s okay. Really what we want to do is we want to be working in the most skillful fashion as we can. 

And then the last one, this one’s a little controversial. Some people don’t agree with this piece of advice, so take what you need and leave what doesn’t help. But for me, when I’m anxious, I tend to shallow breathe a lot. I hold my breath a lot. For me, it was just reminding myself just to breathe. Not breathe in any particular fashion or deep breathing, but just be like, “Take a breath, Kimberley, when you need. Take a breath when you need.”

TIP #4: WHAT TO DO WHEN HEALTH ANXIETY TAKES OVER?

Tip #4 is what to do when anxiety takes over in the biggest way, and that ultimately means, what can you do when your brain is setting on the full alarm. Now in this case, I’m just going to say it’s basically what to do if you’re panicking and the advice goes the same as it is whether there’s a health anxiety panic attack or a regular non-health anxiety panic attack, which is do not try to push the anxiety away. Let’s break it down.

If you’re having anxiety, and you are saying, “This is bad, I don’t want it, it shouldn’t be here,” you’re actually telling your brain that the anxiety is dangerous. Not just the health issue, but also the presence of anxiety is dangerous, which means it’s going to pump out more and more anxiety because you’ve told it that anxiety is dangerous. Your job here is to let the anxiety be there. Try not to push it away. What we know is what you try to push away comes stronger. 

You can talk to your anxiety. There’s actually research to show that when you talk to your anxiety and you talk to yourself in the third person, it can actually empower you and feel more of a sense of empowerment and mastery over that experience. For me, unfortunately, I’ve had quite the 24 hours. We actually had a very large earthquake last night here in southern California, which woke me up, so I had some anxiety related to that. And then of course, my brain was like, “Oh yeah, and by the way, you might have cancer. Ha-ha-ha!” You know what I mean? Of course, your brain’s going to tell you that. 

In that moment, I used the skill and the research around talking to myself in the third person. I said, “Kimberley, there’s nothing you can do right now. It makes total sense that you have anxiety. Let’s not push it away. Let’s bring your attention to what you can control, which is how kind you are to yourself, whether you’re clenching your body up, whether you’re breathing, whether what you’re putting your attention on. You can’t control anything. You can’t control this earthquake. You can’t control what’s happening tomorrow. All you can do is be here now.” Using a third person, using your name as the third person like, “Kimberley...” and saying what you need to do. Coaching yourself has been incredibly helpful for me and I know for a lot of people because that’s actually science-based. 

TIP #5: ENGAGE IN VALUE-BASED BEHAVIORS

The next thing I want you to do, and this is the final one before we go through some questions that I want you to ask yourself, is to engage in value-based behaviors. Now what that means is when we’re anxious, when we have health anxiety, it’s very normal for us to want to engage in safety behaviors. One for me was every morning, I drop my daughter off and my husband drops my son off at school and I could feel my anxiety wanting to stay home. I don’t want to go out. And so I almost was starting to say, “Maybe I’ll ask my husband to drop off my daughter and my son so I can stay home.” I recognize that would be me doing a fear-based behavior. I would be doing that only because I don’t want to face fear today. I just want to make it small. 

Number one, it’s okay. If you need to do that, that’s totally okay. But for me personally, I caught myself and I said, “No, you value being someone who drops off your daughter and shows up and doesn’t let anxiety win. You love dropping off your daughter. If you stayed home, you’d only be doing the dishes, circling around, maybe catastrophizing, just trying to get past time. You love taking your daughter to drop off.” And so engage in that. 

Another value-based behavior for me personally is humor. I’m texting friends and I’m telling them jokes about what I’m going to do to my doctor if he says something wrong or something, or I’m making jokes about some of the questions and statements that the nurses made. I’m making jokes about it, not to catastrophize, not to put them down, not to minimize my own discomfort, but humor is a very big part of my values. I’m making jokes about what we’ll do if it’s cancer and will you come to my funeral and silly things. Again, I really want to make sure you understand, I’m not doing that as depressed bad things are going to happen. I’m doing it because I’m literally saying, it will be what it will be. Let’s just move forward and let’s actually bring some light and joy and some laughter to this. 

Now you might not like that. If that’s not your values, don’t do it, but identify, what would the non-anxious me do right now? What would I do if this fear wasn’t here? And then do those behaviors. It’s really, really important that you make sure you hit this in as many ways as you can because fear can cause us just to clam up and sit still and ruminate. It’s very important that you practice not just ruminating and cycling and going over and over and over and over all of the worst-case scenarios because your brain will take you to some very dark places.

HEALTH ANXIETY JOURNAL PROMPTS

This is really important. I know I’ve given you the top five, but that’s more like 20 points. Let’s talk about some hypochondria or health anxiety journal prompts or questions you can ask yourself to stay as skilled as you can. 

• What is in my control right now? 

What is in my control? My behaviors, my reactions. That’s ultimately what is in your control. What’s not in your control is how much anxiety you have and what thoughts you have about them. 

• What is not in my control? 

You can be very specific here. In my case, it’s like, what’s not in my control is what the doctor says. What’s not in my control is what my health condition is. What’s not in my control is when he calls. You know what I mean? What’s not in my control is the treatment plan. I’m going to have to wait for him to do that. I’m identifying what is in my control and what is not. 

• How am I going to gain a sense of control that is helpful to both my long-term health anxiety recovery goals and my health anxiety treatment plan? 

For me, I know that Googling is going to be a full sense of control and doesn’t help my long-term recovery, so I’m not going to do it. I know that me ruminating and doing tons of mental compulsions is going to give me a sense of control, but it’s not helpful. It’s not helpful. It doesn’t help my long-term recovery, it doesn’t help my long-term mental health, so I’m not going to do it. 

What will help my long-time health anxiety goals, it’s going to be all the tips that we covered today—no Googling, no checking faces, no reassurance seeking, no swaying the doctor, practicing my mindfulness, being as compassionate as I can, maybe taking some breaths. All of those are going to make me stronger in my health anxiety recovery instead of weaker the ones which would be ruminating and doing all of these. Not very helpful safety behaviors. 

• How willing am I to be uncertain right now? 

You guys are going to have to tolerate a lot of uncertainty. That’s what this is all about. From the minute I got the call from that nurse saying that I needed to have this video appointment, from the minute he got onto the video appointment, all I had to focus on is, am I willing to be uncomfortable? Am I willing to be uncertain? Because the only reason I would’ve Googled was because I wanted certainty. Really, really important. 

• What would the non-anxious me do right now? 

She’d get up and she’d go and drop her daughter off, and then she’d call your friend because that’s what you do every Wednesday morning. She’d respond to emails, she’d call. Do whatever it is that you’re doing. What would the non-anxious you do?

• How can I be kind and gentle towards myself as I navigate this experience? 

Another code question for that is, what do I need right now that is skillful? What do you need? The most beautiful thing about this is my husband. He is the most gorgeous man. He sits down. He doesn’t reassure me, he just says, “I got you.” If your partner is giving you a lot of reassurance, you might want to mention to them, “That actually doesn’t help my long-term health anxiety. I just need you to be next to me and support me.” And so it’s very important that we make sure our partners aren’t giving us a whole bunch of reassurance and a whole bunch of certainty-seeking behaviors that keep us stuck. 

That’s it guys. There are my five tips for health anxiety which turned out to be more like 20, I know, but I try to always overdeliver. I really wanted to jam in as many skills as I could.

I hope you have a wonderful day. Please do not worry about me. I am actually fine. There’s a joke between my best friend and I. We say, “Are you fine number one or fine number two?” Fine number one is you actually are fine and fine number two is you’re not fine, but you’re saying you are, and I am fine number one. I actually have a lot of faith in my doctors. I have a lot of faith in my ability to handle these things and these are just another bump on the road in terms of being someone who has postural orthostatic tachycardic syndrome. So all is well. All is well. I am fine number one and I hope you are fine number one as well. 

I am sending you so much love. Do not forget, it is a beautiful day to do all the hard things, and I’ll see you next week.

Today, we’re talking about the Top 5 Relationship Rules I have that have changed my life. This episode was inspired by a letter I wrote to all of you. For those of you who signed up for my newsletter, I give you tools and tips, and stories, and I tell you funny jokes sometimes. But I was writing the newsletter while I was in Australia just before I left when I was there in December, and I was reflecting on how beautiful my relationships are with my family now. And I was reflecting on why. Why are they so beautiful? Well, number one, they’re beautiful people. But number two, more importantly, I have learned these relationship rules, which have allowed me to have the most beautiful relationship with my family and the most beautiful relationship with my husband, my kids, my friends, and you guys.

Now, that doesn’t mean there are no bumps. That doesn’t mean there are no arguments. A few weeks ago, I wrote in the newsletter about how I had an argument with my husband. Of course, I was joking about how wrong he was and how right I was. But it doesn’t mean we don’t have conflict, but we get to coexist because of these relationship rules, and I want to share them with you. 

Before we proceed, I want to say, these mightn’t work for you. I think they work well, but I don’t want you to feel guilty, ashamed, embarrassed, angry, or whatever the feelings are if you feel like these don’t match you. So take what you need here. Leave what isn’t helpful for you; if it’s useful for you, wonderful. If it doesn’t sit right, one of them doesn’t sit right, that is not a problem. It’s totally okay to use what helps you. When I’m talking on this podcast, I’m giving you ideas, so be curious and consider them, but it doesn’t mean that I’m always right, I think I’m right, or I know what’s right for you. 

All right, here we go. I’m going to go through them quickly and then elaborate a little later once we get through, okay? But I want to remind you that these relationship rules help me stay solid in my relationships, and they’ve gotten me through some of the hardest periods and seasons of my life. So, let’s see if they’re helpful for you. 

1. It is not your job or my job to manage our family’s emotions. 

Their emotions are their responsibility, and it is their job to regulate their emotions when they’re upset with us. And it’s our job to regulate and manage our emotions when we are upset. Now, what does regulate mean? It means you’re allowed to have them. We’re not saying that no one’s allowed to be upset, but we have to communicate and share with them and regulate by not throwing things, lashing out, saying unkind things, saying things that aren’t true, saying ‘you’ statements like, “You’re so blah, blah, blah.” We want to use ‘I’ statements like, “I feel this way about that,” or “I would like this thing to happen.” So, we want to regulate as best as we can. Our job is to regulate what shows up for us, and their job is to regulate what shows up for them. 

2. It is not your job to please the people you are in relationship with.

Now, they get to have expectations and they get to communicate with you on what their expectations are, and you get to have expectations and you get to communicate their expectations. Now, this is so important, then we can have a respectful conversation. A lot of the time these days, I see people in relationships or even online where somebody disagrees and they’re so hurt. They’re like, “You’ve harmed me by saying that. I’m so hurt by what you said.” But the person gets to have their thoughts and their feelings. It’s not our job to manage it, and it’s not our job to please them either. So you get to have your beliefs and thoughts and ideas, and you get to disagree with other people as well. It’s as long as we’re able to do it respectfully. And when I say respectful, I’m not saying it in a people-pleasing way either. It is not our job to please people. It’s just not. 

Here’s a deeper one. Let me just jump into this a little: I’m still working on this and I get therapy. I have a lot of practice and I’ve read about the idea of my happiness. That’s my job. My happiness is my job. And I easily get caught up in, “No, if my partner would just do A, B, and C, then I can be happy,” or “If my kids just do A, B, and C, then I can be happy.” And that is true to a degree. But the problem with that rule, if you want to keep that rule, is you have no empowerment and no responsibility. It’s all up to them. Your life is in their hands. Your happiness is in their hands. 

And so, I like to think about, yeah, people can’t always please me, like I just said, and people are going to upset me. And then it’s my job to decide what I want to do with that, and it’s my job to determine how I’m going to cope today with the fact that they may not be living up to the way I want them to. So that’s really important. 

3. They are allowed to have their feelings about our choices. 

This is a big one for my husband and I. We say this to each other all the time. It’s like, “You’re allowed to have your feelings about that and so am I.” This one is so hard for me, especially in my marriage because if I upset him, I’d be like, “You shouldn’t be upset.” And he’s like, “I’m allowed to be upset. I’m allowed to have my feelings about it.” And I’m like, “No, but you shouldn’t.” And he’s like, “Yeah, but I am. I do.”

It is okay if they don’t like everything about us and if they disagree. It is our job to live according to our values, which doesn’t always align with their expectations of us. Our job is to go and live our lives and let them have their feelings about it. Then, we can communicate respectfully about our misalignment. “But that has been so beautiful for me.” To say, “You’re allowed to have your feelings about me, specifically me as a public person.” When I used to speak at a conference, or online or on Instagram, and someone would say something negative, I used to be like, “Oh, how dare they say something so mean? How could they disagree with me or not like me?” It was so painful because I had made this rule that they should only have good feelings about me. 

And now I’m okay. You can have all your feelings about me. You might like me, or you might hate me. You might like me one day and not like me the next. You might agree or not agree, and you get to have your feelings about me. I give you permission. It is so freeing to say, “I’m going to let everyone have permission to have their feelings about me.” That’s okay. I’m not for everyone. That sentence literally has healed me on the deepest level, probably more than any sentence. You’re allowed to have your feelings about me. So important.

4. It is okay if they struggle to understand us. 

In fact, I encourage you to accept that they will not always understand us. Sometimes people won’t have the capacity to understand us, and that doesn’t make us wrong. And it also doesn’t mean that you won’t be able to find a way to coexist and still love each other unconditionally. That’s so true. 

I always tell my patients, let’s say I come in and I’m wearing my favorite boots, which are a bit sassy, and you come in, and you’re like, “I hate your boots. They’re the ugliest boots ever.” I could even say, “Ah, you’re supposed to love my boots.” Or I could say, “That’s cool. You don’t have to love my boots. You get to have your feelings about them. And it’s okay if you don’t understand how rocking my boots are.” 

Now, this also goes for who you are. They get to have their feelings about who you are. They get to not like who we are, as long as they’re respectful, they don’t cross any boundaries, and they’re not abusive. They get to be upset, and it’s okay that they don’t understand us. As I said, some people can’t understand us. So important.

5. You get to (and they get to) change their mind or change, period. 

Again, this one was so hard for me. Now, for those of you who don’t know me, I’ve been married almost 20 years. It will be 20 years this year, which means my husband’s done a ton of changing, and so have my family, my friends, and so have you guys. There’s a lot of change. But they get to change. If somebody changes, we can’t go, “Wait, that’s not fair. I didn’t go into this relationship with you being this new version of you. You have to be the old version of you.” That’s not a real relationship. That’s saying you must stay the same and can’t express and be who you are. 

We could say, “You’ve changed, and these are my feelings about it,” as long as I’m doing it, not in a judgmental way or not in a way that’s trying to change them back because people get to change. They get to change their mind. So that’s another big one for me, is if someone says, “I like this,” and then they come back and say, “I actually really don’t,” I have to remind myself they’re allowed to change their mind because they’re allowed to have their feelings. And it’s okay that they don’t understand us, and they’re going to manage their own emotions, and I’m going to manage mine. 

We can’t hold ourselves to the expectation that will never change. As we go through different seasons in our life, we will change. And that might feel scary. But we can try using our mindfulness skills and our regulation skills to navigate the change and the emotions you have to feel. 

So those are the five relationship rules that have changed my life. Now, here’s the kicker. None of it is fun. None of it. This is some hard work. I nearly said that S word, which is fine. I’m allowed to swear, but it’s some hard shit. This is some terrible stuff to work through, but with it comes stronger and more unconditionally loving relationships. 

When I gave my husband permission to have his feelings about me, he was happier, and he loved me more because it meant that he didn’t have to pretend to be somebody else or he didn’t have to pretend to like something and get resentful because he actually didn’t like it. When I allowed myself to be different from my family, and I accepted that they might have feelings about that, and I gave them permission to have feelings about that, there wasn’t a problem anymore. 

The biggest problem, the biggest pain, the most suffering came when I was like, “No, they shouldn’t feel this way about me. That’s not fair”! But, it is fair. They get to have their feelings based on their own personal and their upbringing and their own incapacities and their own limitations. They get to have their feelings. It mightn’t be perfect, but I’m not perfect. 

You guys, I could add a fifth or sixth one here. I didn’t write this one in the email, but  I’m not perfect, and neither are they, and that’s okay. Sometimes I would say, “No, but they need to be this way because that’s the right way. This is the right way to be.” And I get it. Yeah, there is sometimes real right and wrong, like you shouldn’t harm people or say horrible things or critical things or racist things or misogynist things. We get that, and I agree with all that. But at the end of the day, the people in our lives will be imperfect, and we have to get better about not being black and white and cutting them off because they did a “bad” thing. 

I think cancel culture has taught us a lot in this idea of like, “You’re dead to me. You’re done. You’re canceled.”  Relationships don’t work like that. We’re human beings. We make mistakes. I’ve made a million mistakes. I’ve actually-- okay, now I’m going on and on. But we also have to learn to accept that we make mistakes and be willing to apologize for it. It’s a humble thing to do. It’s not fun, not fun at all, but we can also say we’re sorry too. 

So that’s it, you guys. There’s a humbling; there’s a humanity that we connect with when we can allow everyone to have their feelings, when we can allow ourselves to have our feelings when we can have limits and boundaries and clearly communicate that with our loved ones, but then also understand that sometimes they may not get it. 

Now there will be situations if you say, “I don’t like that,” and they will not respect you. You may need to make a limit and a boundary with them where they don’t have as much access to you. That’s 100% valid. And again, I’m not here telling you to accept other people’s bad behavior. Absolutely not. But we can accept that they have some feelings about it, as long as they’re communicating respectfully, kindly, compassionately, or at least they’re trying. At least they’re trying. 

So that’s it, folks. The five relationship rules that have literally changed my life and my relationships. I hope it’s helpful. It is a beautiful day to do hard things, and I will see you next week.

Today, we’re talking about the Top 5 Relationship Rules I have that have changed my life. This episode was inspired by a letter I wrote to all of you. For those of you who signed up for my newsletter, I give you tools and tips, and stories, and I tell you funny jokes sometimes. But I was writing the newsletter while I was in Australia just before I left when I was there in December, and I was reflecting on how beautiful my relationships are with my family now. And I was reflecting on why. Why are they so beautiful? Well, number one, they’re beautiful people. But number two, more importantly, I have learned these relationship rules, which have allowed me to have the most beautiful relationship with my family and the most beautiful relationship with my husband, my kids, my friends, and you guys.

Now, that doesn’t mean there are no bumps. That doesn’t mean there are no arguments. A few weeks ago, I wrote in the newsletter about how I had an argument with my husband. Of course, I was joking about how wrong he was and how right I was. But it doesn’t mean we don’t have conflict, but we get to coexist because of these relationship rules, and I want to share them with you. 

Before we proceed, I want to say, these mightn’t work for you. I think they work well, but I don’t want you to feel guilty, ashamed, embarrassed, angry, or whatever the feelings are if you feel like these don’t match you. So take what you need here. Leave what isn’t helpful for you; if it’s useful for you, wonderful. If it doesn’t sit right, one of them doesn’t sit right, that is not a problem. It’s totally okay to use what helps you. When I’m talking on this podcast, I’m giving you ideas, so be curious and consider them, but it doesn’t mean that I’m always right, I think I’m right, or I know what’s right for you. 

All right, here we go. I’m going to go through them quickly and then elaborate a little later once we get through, okay? But I want to remind you that these relationship rules help me stay solid in my relationships, and they’ve gotten me through some of the hardest periods and seasons of my life. So, let’s see if they’re helpful for you. 

1. It is not your job or my job to manage our family’s emotions. 

Their emotions are their responsibility, and it is their job to regulate their emotions when they’re upset with us. And it’s our job to regulate and manage our emotions when we are upset. Now, what does regulate mean? It means you’re allowed to have them. We’re not saying that no one’s allowed to be upset, but we have to communicate and share with them and regulate by not throwing things, lashing out, saying unkind things, saying things that aren’t true, saying ‘you’ statements like, “You’re so blah, blah, blah.” We want to use ‘I’ statements like, “I feel this way about that,” or “I would like this thing to happen.” So, we want to regulate as best as we can. Our job is to regulate what shows up for us, and their job is to regulate what shows up for them. 

2. It is not your job to please the people you are in relationship with.

Now, they get to have expectations and they get to communicate with you on what their expectations are, and you get to have expectations and you get to communicate their expectations. Now, this is so important, then we can have a respectful conversation. A lot of the time these days, I see people in relationships or even online where somebody disagrees and they’re so hurt. They’re like, “You’ve harmed me by saying that. I’m so hurt by what you said.” But the person gets to have their thoughts and their feelings. It’s not our job to manage it, and it’s not our job to please them either. So you get to have your beliefs and thoughts and ideas, and you get to disagree with other people as well. It’s as long as we’re able to do it respectfully. And when I say respectful, I’m not saying it in a people-pleasing way either. It is not our job to please people. It’s just not. 

Here’s a deeper one. Let me just jump into this a little: I’m still working on this and I get therapy. I have a lot of practice and I’ve read about the idea of my happiness. That’s my job. My happiness is my job. And I easily get caught up in, “No, if my partner would just do A, B, and C, then I can be happy,” or “If my kids just do A, B, and C, then I can be happy.” And that is true to a degree. But the problem with that rule, if you want to keep that rule, is you have no empowerment and no responsibility. It’s all up to them. Your life is in their hands. Your happiness is in their hands. 

And so, I like to think about, yeah, people can’t always please me, like I just said, and people are going to upset me. And then it’s my job to decide what I want to do with that, and it’s my job to determine how I’m going to cope today with the fact that they may not be living up to the way I want them to. So that’s really important. 

3. They are allowed to have their feelings about our choices. 

This is a big one for my husband and I. We say this to each other all the time. It’s like, “You’re allowed to have your feelings about that and so am I.” This one is so hard for me, especially in my marriage because if I upset him, I’d be like, “You shouldn’t be upset.” And he’s like, “I’m allowed to be upset. I’m allowed to have my feelings about it.” And I’m like, “No, but you shouldn’t.” And he’s like, “Yeah, but I am. I do.”

It is okay if they don’t like everything about us and if they disagree. It is our job to live according to our values, which doesn’t always align with their expectations of us. Our job is to go and live our lives and let them have their feelings about it. Then, we can communicate respectfully about our misalignment. “But that has been so beautiful for me.” To say, “You’re allowed to have your feelings about me, specifically me as a public person.” When I used to speak at a conference, or online or on Instagram, and someone would say something negative, I used to be like, “Oh, how dare they say something so mean? How could they disagree with me or not like me?” It was so painful because I had made this rule that they should only have good feelings about me. 

And now I’m okay. You can have all your feelings about me. You might like me, or you might hate me. You might like me one day and not like me the next. You might agree or not agree, and you get to have your feelings about me. I give you permission. It is so freeing to say, “I’m going to let everyone have permission to have their feelings about me.” That’s okay. I’m not for everyone. That sentence literally has healed me on the deepest level, probably more than any sentence. You’re allowed to have your feelings about me. So important.

4. It is okay if they struggle to understand us. 

In fact, I encourage you to accept that they will not always understand us. Sometimes people won’t have the capacity to understand us, and that doesn’t make us wrong. And it also doesn’t mean that you won’t be able to find a way to coexist and still love each other unconditionally. That’s so true. 

I always tell my patients, let’s say I come in and I’m wearing my favorite boots, which are a bit sassy, and you come in, and you’re like, “I hate your boots. They’re the ugliest boots ever.” I could even say, “Ah, you’re supposed to love my boots.” Or I could say, “That’s cool. You don’t have to love my boots. You get to have your feelings about them. And it’s okay if you don’t understand how rocking my boots are.” 

Now, this also goes for who you are. They get to have their feelings about who you are. They get to not like who we are, as long as they’re respectful, they don’t cross any boundaries, and they’re not abusive. They get to be upset, and it’s okay that they don’t understand us. As I said, some people can’t understand us. So important.

5. You get to (and they get to) change their mind or change, period. 

Again, this one was so hard for me. Now, for those of you who don’t know me, I’ve been married almost 20 years. It will be 20 years this year, which means my husband’s done a ton of changing, and so have my family, my friends, and so have you guys. There’s a lot of change. But they get to change. If somebody changes, we can’t go, “Wait, that’s not fair. I didn’t go into this relationship with you being this new version of you. You have to be the old version of you.” That’s not a real relationship. That’s saying you must stay the same and can’t express and be who you are. 

We could say, “You’ve changed, and these are my feelings about it,” as long as I’m doing it, not in a judgmental way or not in a way that’s trying to change them back because people get to change. They get to change their mind. So that’s another big one for me, is if someone says, “I like this,” and then they come back and say, “I actually really don’t,” I have to remind myself they’re allowed to change their mind because they’re allowed to have their feelings. And it’s okay that they don’t understand us, and they’re going to manage their own emotions, and I’m going to manage mine. 

We can’t hold ourselves to the expectation that will never change. As we go through different seasons in our life, we will change. And that might feel scary. But we can try using our mindfulness skills and our regulation skills to navigate the change and the emotions you have to feel. 

So those are the five relationship rules that have changed my life. Now, here’s the kicker. None of it is fun. None of it. This is some hard work. I nearly said that S word, which is fine. I’m allowed to swear, but it’s some hard shit. This is some terrible stuff to work through, but with it comes stronger and more unconditionally loving relationships. 

When I gave my husband permission to have his feelings about me, he was happier, and he loved me more because it meant that he didn’t have to pretend to be somebody else or he didn’t have to pretend to like something and get resentful because he actually didn’t like it. When I allowed myself to be different from my family, and I accepted that they might have feelings about that, and I gave them permission to have feelings about that, there wasn’t a problem anymore. 

The biggest problem, the biggest pain, the most suffering came when I was like, “No, they shouldn’t feel this way about me. That’s not fair”! But, it is fair. They get to have their feelings based on their own personal and their upbringing and their own incapacities and their own limitations. They get to have their feelings. It mightn’t be perfect, but I’m not perfect. 

You guys, I could add a fifth or sixth one here. I didn’t write this one in the email, but  I’m not perfect, and neither are they, and that’s okay. Sometimes I would say, “No, but they need to be this way because that’s the right way. This is the right way to be.” And I get it. Yeah, there is sometimes real right and wrong, like you shouldn’t harm people or say horrible things or critical things or racist things or misogynist things. We get that, and I agree with all that. But at the end of the day, the people in our lives will be imperfect, and we have to get better about not being black and white and cutting them off because they did a “bad” thing. 

I think cancel culture has taught us a lot in this idea of like, “You’re dead to me. You’re done. You’re canceled.”  Relationships don’t work like that. We’re human beings. We make mistakes. I’ve made a million mistakes. I’ve actually-- okay, now I’m going on and on. But we also have to learn to accept that we make mistakes and be willing to apologize for it. It’s a humble thing to do. It’s not fun, not fun at all, but we can also say we’re sorry too. 

So that’s it, you guys. There’s a humbling; there’s a humanity that we connect with when we can allow everyone to have their feelings, when we can allow ourselves to have our feelings when we can have limits and boundaries and clearly communicate that with our loved ones, but then also understand that sometimes they may not get it. 

Now there will be situations if you say, “I don’t like that,” and they will not respect you. You may need to make a limit and a boundary with them where they don’t have as much access to you. That’s 100% valid. And again, I’m not here telling you to accept other people’s bad behavior. Absolutely not. But we can accept that they have some feelings about it, as long as they’re communicating respectfully, kindly, compassionately, or at least they’re trying. At least they’re trying. 

So that’s it, folks. The five relationship rules that have literally changed my life and my relationships. I hope it’s helpful. It is a beautiful day to do hard things, and I will see you next week.