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.

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.

One of the most common questions I get asked is what do I do during or after an exposure? 

Number One, it’s so scary to do an exposure, and number two, there’s so many things that people have brought up as things to do, even me, this being Your Anxiety Toolkit. Maybe you get overwhelmed with the opportunity and options for tools that it gets too complicated. So, I want to make this super easy for you, and I want to go through step by step, like what you’re supposed to do during or after an exposure.

Now, I think it’s important that we first look at, there is no right. You get to choose, and I’m going to say that all the way through here, but I’m going to give you some really definitive goals to be going forward with as you do an exposure, as you face your fear. Now, make sure you stick around to the end because I will also address some of the biggest roadblocks I hear people have with the skills that I’m going to share. 

Now, a lot of you know, I have ERP School if you have OCD and I have Overcoming Anxiety and Panic if you have panic, and I have BFRB School if you have hair pulling and skin picking. These are all basically courses of me teaching you exactly what I teach my patients. So, if you want a deeper in-depth study of that, you can, by all means, get the steps there of how to build an exposure plan, how to build a response prevention plan. Today, I’m going to complement that work and talk about what to do during and after an exposure. So here we go. 

Let’s say you already know what you’re going to face. Like I said, you’ve already created an exposure plan. You understand the cycle of the disorder or the struggle that you are handling, and you’ve really identified how you’re going to break that cycle and you’ve identified the fear that you’re going to face. Or just by the fact of nature being the nature, you’ve been spontaneously exposed to your fear. What do you do?

Now, let’s recap the core concepts that we talk about here all the time on Your Anxiety Toolkit, which is, number one, what we want to do is practice tolerating whatever discomfort you experience. What does that mean? It means being open and compassionate and vulnerable as you experience discomfort in your body. A lot of people will say, “But what am I supposed to do?” And this is where I’m going to say, this is very similar to me trying to teach you how to ride a bike on this podcast. Or I’ll tell you a story. My 11-year-old daughter was sassing me the other day and I was telling her I wanted her to unpack the dishwasher, and she said, “How?” She was just giving me sass, joking with me. And I was saying to her, “Well, you raise your hand up and you open your fist and you put your hand over the top of the dishwasher and you pull with your muscles down towards your--” I’m trying giving her like silly-- we’re joking with each other, like step by step.

Now, it’s very hard to learn how to do that by just words. Usually—let’s go back to the bike example—you have to get on the bike and feel the sensation of falling to know what to do to counter the fall as you start to lean to the left or lean to the right. And so, when it comes to willingly tolerating your discomfort, it actually just requires you practicing it, and if I’m going to be quite honest with you, sucking at it, because you will suck at it. We all suck at being uncomfortable. But then working at knowing how to counter that discomfort. Again, you’re on the bike, you’re starting to feel yourself move to the right and learning to lean to the left a little to balance it out. And that’s what learning how to be uncomfortable is about too. It’s having the discomfort, noticing in your body it’s tightening, and learning to do the opposite of that tightening. It is very similar to learning how to ride a bike. And it’s very similar in that it’s not just a cognitive behavior, it’s a physical thing. It’s noticing, “Oh, I’m tight.” For me, as I get anxious, I always bring my shoulders up and it’s learning to counter that by dropping them down. So, it’s tolerating discomfort. 

Now, often beyond that-- I’m going to give you some more strategy here in a second. But beyond that, it’s actually quite simple in that you go and do whatever it is that you would be doing if you hadn’t faced this hard thing. 

Here is an example. The other week during the holidays, one of my family members-- I’ll tell you the story. My mom and dad took a trip to Antarctica. This is a dream trip for them. They’re very well-traveled and they were going through what’s called the Drake Passage, which is this very scary passage of water. It took them 36 hours to sail through it and it can be very dangerous. And I noticed that the anxiety I was feeling in my body about the uncertainty of where they are and how far they’ve got to go and are they safe and all these things is I was sitting on the couch and I wasn’t engaging in anything. My kids were trying to talk to me and I was blowing them off. And I was scrolling on my phone instead of doing the things I needed to do. I was stuck and I was holding myself in this stuckness because I didn’t want to let go of the fear, but I did want to let go of the fear. It was this really weird thing where I was just stuck in a sense of freeze mode. And I had to remind myself, “Kimberley, they’re sailing through the Drake Passage. There’s nothing you can do. Go and live your life. Holding yourself on this couch is not going to change any outcome. You thinking about it is not going to change any outcome. Just go ahead with your life.”

And so, what I want to offer to you is—I’ve said this to my patients as well when they say, “What am I supposed to do now? I’ve done the exposure. What am I supposed to do?”—I say, do nothing at all. Just go about your day. What would you do if anxiety wasn’t here? What would you be doing if you didn’t do this exposure? What would the non-anxious you go and do? And as you do that-- so let’s say you’re like, “Well, I need to do the dishes or I need to unpack the dishwasher,” as you do that, you will notice discomfort rise and fall. And just like riding a bike, you are going to practice not contracting to it. Just like if you were riding a bike and you started to lean to the right, you would be practicing gently leading to the left. And if you go too far to the left, you would practice gently leading to the right. And that’s the work of being uncomfortable.

Now, you’re not here to make the discomfort go away. You’re here to practice willingly allowing it and not tensing up against it while you go and live your life. And I literally could leave the podcast there. I could sign off right now and be like, “That’s all I need you to know,” because that is all I need you to know, is practice not contracting. Meaning not tensing your muscles, not trying to think it away, fight it away, push it away. What you’re really doing is allowing there to be uncertainty in your life or discomfort or anxiety in your life and just go and do what you love to do. 

To be honest, the biggest finger, like the bird, I don’t know what you call it. Like the biggest in-your-face to anxiety, whatever anxiety you’re suffering, is to go and live your life. And so, I could leave it at that, but because I want to be as thorough as I can, I want to just check in here with a couple of things that you need to know. Often when, and we go through this extensively in ERP School and in Overcoming Anxiety and Panic, is when you are uncomfortable, there are a set of general behaviors that humans engage in that you need to get good at recognizing and create a plan for. And these are the things we usually do to make our discomfort go away. So, the first one is a physical compulsion. “I’m uncomfortable. How can I get it to go away? I’ll engage in a behavior.” 

So, remember here that exposures are really only as good as the response prevention. Now for those of you who don’t know what response prevention is, it’s ultimately not doing a behavior to reduce or remove the discomfort you feel that’s resulted from the exposure. So, you do an exposure, you’re uncomfortable, what behaviors would you usually do to make that discomfort go away? Response prevention is not doing those behaviors. 

So, the first one is physical compulsions. So, if you notice that you’re doing these physical repetitive behaviors, chances are, you’re doing a compulsion of what we call a safety behavior and you’re doing them to make the discomfort go away. So, we want to catch and be aware of those. 

We also want to be aware of avoidance. Often people will say, “Okay, I faced the scary thing, but I don’t want to make it any worse so I’m going to avoid these other things until this discomfort goes away.” Now, first of all, I’m going to say, good job. That’s a really good start. But we want to work at not doing that avoidant behavior during or after the exposure as well. In addition, we want to work at not doing reassurance-seeking behaviors during or after an exposure. 

So, an example that that might be, let’s say you’re facing your fear of going to the doctor. But as you’re facing your fear of going to the doctor, you’re sitting there going through WebMD or any other health Google search engine and you’re trying to take away your discomfort by searching and researching and getting reassurance or texting a friend going, “Are you sure I’m going to be okay? Are you sure bad things aren’t going to happen?”

Now, one of the things that are the most hardest to stop when you’ve done an exposure or during an exposure is mental compulsions. So, I want to slow down here for you and I want to say, this is a work in progress. We’re going to take any win that we can and celebrate it, but also acknowledge that we can slowly work to reduce these mental compulsions. Now a mental compulsion is rumination, problem-solving, thinking, thinking, thinking. Like I said to you, when I was on the couch, I was just sitting there going over all the scenarios going, “I wonder if they’re going up or down or what they’re doing. And I hope they’re avoiding the big waves and I hope they’re not stuck and I hope they’re not scared and I hope they’re okay.” All the things. All that I hope they are was me doing mental compulsions. 

And so, you won’t be able to prevent these all the time. But for me, it was observing again, when I’m contracting. The contraction in this case was mental rumination. And then again, just like a bike, noticing, I’m focusing in, very, very zoomed in on this one thing. How can I zoom out, just like it would be leaning from left to right if I was riding a bike—zoom out into what’s actually happening, which is my son’s right in front of me asking me to play Minecraft or play Pokemon or whatever it is that he was asking, and the dishes need doing. And I would really love to read some poetry right now because that’s what I love to do. 

So, it’s catching that and being aware of that. And again, it’s not something I can teach you, it’s something you have to practice and learn for yourself in that awareness of, “Ooh, I’m contracting. Ooh, I’m zooming in. I need to zoom out and look at the big picture here. I need to look at what my values are, engage in what I want to be doing right now.”

The last way that we contract is self-punishment. We start to just beat ourselves up. So, you did the exposure, you’re feeling uncertain, you might be feeling other emotions like guilt and shame and embarrassment and all the emotions. And so, in effort to avoid that, we just beat ourselves up. 

I have a client who does amazing exposures, but once they’ve done the exposure, they beat themselves up for not having done the exposure earlier. It’s like, ouch. Wow. So, you’re doing this amazing thing, facing this amazing fear, practicing not contracting, doing actually a pretty good job, but then engaging in punishing themselves. “Why didn’t I do this earlier? I should have done this years ago. I could have saved myself so much suffering. I could have recovered earlier. I could have gotten to college earlier. I could have succeeded more.” Again, that’s a contraction that we do during exposure to fight or react to the fact that you have discomfort in your body. 

And what I really want to offer you, again, let’s go back to basics—this is just about you learning to be a safe place while you have discomfort. So, you’re having discomfort, you’re riding the bike. Please don’t just use this podcast as a way to fill your brain with all the tools and not implement it. I will not be able to teach you to metaphorically ride a bike until you put your little tush on the bike seat and you give it a go and you fail a bunch of times. 

And so again, this is you learning to sit on the bike metaphorically, doing an exposure, noticing you’re falling to the right and learning to be aware of that and learning what the skill you need to use in that moment and then learn how to adjust in that moment. And that’s the work. That’s the work—gently, kindly, compassionately, tending to what shows up to you as if you really matter because you really, really matter. 

Let me say that again. You’re going to tend to yourself. I’m saying it twice because I need you to hear me. You’re going to tend to yourself compassionately because you matter. This matters. You are doing some pretty brave things. Right now, I’m wearing my “It’s a beautiful day to do hard thing” t-shirt. It’s what I wear every Wednesday because it’s my favorite day to record podcasts and to do this with you. So yeah, that’s what we’re going to do. We’re going to sit together, we’re going to do the hard thing, we’re going to do it kindly. 

But again, let me come back to the real simplicity of this, is just go do you and let it be imperfect. Exposures are not going to be perfect. You’re not going to do them perfect. Just like if I learn to ride a bike for the first time, probably going to crash, but the crashes will teach me what to do next time I’m almost about to crash.

Now, as I promised you, there are some common roadblocks, I would say, that get in the way and they usually are thoughts. Now if you have OCD, we go through this extensively in ERP School because it does tend to show up there the most, but it does show up with panic as well a lot, is there are roadblocks or thoughts that pull us back into contraction because when we think them, we think they’re real. An example would be, what if I lose control and go crazy? That’s a really common one. A lot of times, that thought alone can make us go, “Nope, I refuse to tolerate that risk,” and we contract, and we end up doing compulsions. And the compulsion or the safety behavior takes away the benefit of that initial exposure. 

Another one is, what if I push myself too hard, like have a heart attack or my body can’t take it and I implode? As ridiculous as it sounds, I can’t tell you how many of my patients and clients in the 10-plus years I’ve been practicing—way more, close to 15 years—I’ve been practicing as a therapist, clients have said, “I’ve completely ejected from the exposure because of the fear I will implode,” even though they know that that’s, as far as we know, not possible. Again, I’ve never heard of it before, I’ve never seen it before, except on cartoons. 

So, again, it’s being able to identify, I call them roadblocks, but there are things that come up that make us eject out of the exposure like you’re in Top Gun. I loved that movie, by the way. But that whole idea of like, you pull a little lever and you just boom, eject out of the exposure like you’re ejecting out of an airplane or a flight, fast jet, because of a thought they had. And so, your job, if you can, again, is to be aware of how you contract around thoughts that are catastrophic.

A lot of people, depending on the content of their obsessions, every little subtype of anxiety, every different disorder have their own little content that keep us stuck. Your job is to get really good at being aware of, specifically, I call them allowing thoughts. They’re thoughts that we have that give us permission to do, to pull the eject handle. I call them allowing thoughts. So, it might be, “No, you’ve done enough. You probably will lose control if you do that. So, you can do the safety behavior or the compulsion.” That’s an allowing thought. Your job is to get used to yours and know yours and be familiar with them so that you can learn to, again, have good skills at countering that and responding. Again, think of the bike. That allowing thought is you tilting to the right a little bit when you’re like, “Oops, nope, I’m going to fall if I keep tilting. I’m going to have to work at going against that common behavior I use that is continually contracting against tolerating discomfort.” 

Other bigger roadblocks are fear of panic, which is a common one. Again, mostly, people’s thoughts around “I can’t handle this.” You’re going to have specific ones. Again, I don’t want to put everyone in the same category. Everyone’s going to have different ones. But please get used to your roadblocks or become aware of them, okay? 

And that’s it, you guys. I feel silly saying it, but that is it. Your job is to lean in. 

One other thing I would say, and I often give my patients the option, is I’ll say to them, “Here are your choices. You’ve done an exposure. You ultimately have three choices.” 

So, let’s pretend—we’ll do a role-play—we’re in the room together or we’re on Zoom, and the client has willingly done the exposure and then they start to freak out, let’s say, in one specific situation. And I’ll say, okay, you got three choices. You could go and do a compulsion and get rid of it. Go and make this discomfort go away if that’s in fact possible for you. The other option is you could practice this response prevention and practice not contracting. That’s another option for you. You get to choose. And there is this very sneaky third option, and I will offer this to you as well. The third option is, you could go and make it worse. And I have hats off to you if you want to choose that option. So, the go and make it worse would be to find something else to expose yourself to in that moment. Make it worse. Bring it on. How can we have more? What thoughts can I have that would make this even more scary? How could I do flooding? How could I find ways to literally say to your fear, “Come on fear, let’s do this. I have so much more fear facing to do and I am not afraid and I’m going to do it.” 

So you have three options. Please be compassionate about all three because you may find that you’re choosing the first or the second or the third depending on the day, but they’re yours to choose. There is no right. There is more ideal and effective. Of course, the latter two options are the most effective options. But again, when we learn to ride a bike, no one does it perfectly. We fall a lot. Sometimes if you’ve ridden a bike for a very long time and you are a skilled bike rider-- in fact, we have evidence that even bike riders who do the Tour de France still fall off their bike sometimes for ridiculous reasons, and we are going to offer them compassion. And if you are one of those who are skilled at this, but fall off your bike sometimes, that’s not because anything’s wrong with you. That’s because you’re a human being. Okay? 

So that is what I’m going to offer you. The question, what do I do after and during I’ve done an exposure, is be aware of your contractions in whatever form they may be. Be kind. And if all else fails, just go and live your life. Go and do the thing you would do if you hadn’t have that, didn’t have that fear. It doesn’t matter if you’re shaking, doesn’t matter if you’re panicking, doesn’t matter if you’re having tightness of breath, you’re dizzy, all the things. Be gentle, be kind, keep going. Do what you can in that moment, and you get to choose. You get to choose. 

So, that is what I want you to hear from me today. I hope it has been helpful. I feel so good about making an episode just about this. Number one, I get asked a lot, so I really want to have a place to send them. And number two, I admit to making the mistake of sometimes saying go do an exposure and not actually dropping down into these very common questions that people have. 

For those of you who are interested, we do have ERP School, Overcoming Anxiety and Panic, BFRB School. We’ve got time management courses, all kinds of courses that you can get. The link will be in the show notes. I do encourage you to go check them out if you’re wanting step by step structural trainings to help you put together a plan. If you’ve got a therapist already or you’re just doing this on your own, that’s fine too. Hopefully, this will help lead you in the direction that’s right for you. 

All right. You know I’m going to say it. It’s a beautiful day to do hard things. And so, I hope that’s what you’re doing. I am sending you so much love and so much well wishes and loving-kindness. Have a wonderful day and I’ll see you next week with a very exciting piece of news.

MINDFULLY TENDING TO ANGER & RESENTMENT

Welcome back. I am so happy to have you here with me today to talk about mindfully tending to feelings of anger and resentment. 

Sometimes when we have relentless anxiety and intrusive thoughts, anger can feel like the only emotion we can access.  

For those of you who don’t know me, well, you might be surprised to hear maybe not to know that I actually have quite a hot temper. I get hot really quick emotionally, and I don’t know if it’s because as a child I didn’t really allow myself to feel anger. I think societally, I was told I shouldn’t be angry. And so, when it comes up inside me, it heats up really quick to a boiling point. And my goal for this year is not—let me be very clear—is not to say I am going to stop being angry because that is actually the problem. It is not to say I can’t feel angry and I shouldn’t feel angry. It’s actually to tend to my anger and start to listen to what anger is trying to communicate to me. My goal with you today is to walk you through how you can do that. And I’d love if you would stay with me for a short meditation where we mindfully tend to anger and resentment. 

IS ANGER & RESENTMENT HEALTHY?

I think the first thing I want to mention here is that anger and resentment are actually really normal healthy emotions. Nothing to be guilty of, ashamed of, annoyed by, nothing to judge, that the anger and resentment are actually healthy emotions. They come from a place of wishing things could be better or improved, and they usually show up when we experience some kind of injustice in the world or in our daily life. Maybe someone hurt your feelings or they acted in a way that made you feel unsafe. Maybe someone stopped you from succeeding. Maybe somebody judged you and you experienced that as a threat.

WHY DO I FEEL SO ANGRY? 

Anger can show up for many reasons. Maybe it’s because you’re noticing the injustices in the world and that makes you angry. That political things can really make people show up in anger. And again, that doesn’t mean there’s anything wrong, but expressing it in a healthy way can be really useful because bottling it up, it usually numbs other feelings, it can wear down your mental health, and it can mean—and I have learnt this the hard way—is that we then explode and end up saying things we don’t mean, or doing things we don’t want to do that don’t align up with our values or showing up the way that we want. And for me, that’s a big part of my goal this year. 

Now, the reason I actually am doing this, this is not a scheduled podcast, is yesterday my husband and I were having a disagreement. And sometimes I have to remind myself like, disagreements aren’t a problem. Because in my mind, disagreement is like, “Oh my gosh, terrible things are about to happen and I’m very scared. Please love me forever.” You know what I mean? And my husband has to keep gently saying like it’s okay that we don’t agree on everything. 

We were having a disagreement and I could feel the anger showing up in my body. And I was trying to really focus on just being mindful of that experience, because when I don’t do that, my immediate response is, “Fight. Let’s go to war. Let me show you how you are wrong. Let me be very clear in my boundary that you cannot cross,” which is all fine. Again, none of that’s wrong, but I could feel myself heating to a boiling point in a very, very short amount of time. I’ve been really trying to instead of acting on anger in certain situations-- again, there’s nothing wrong if you need to act on anger.

WHEN IS ANGER APPROPRIATE? 

Sometimes if you’re in a dangerous position, you need to act on anger. But I’m really working on allowing anger, befriending and tending to anger. Anger can be our friend. Like, what’s the problem? Let’s actually have it, Kimberley. Let’s actually feel it. Let’s actually feel it go through my body. Let’s allow it to burn itself off. And let’s do that, not because we got to make our point and make sure they know we’re right, but because you actually felt it. You allowed it, you rode the wave of it, it burnt off. And it always burns off. That’s the thing. That’s mindfulness—to recognize that everything is temporary. 

If you say-- I’m talking to myself here. If you say what you say when you’re angry, you mightn’t have said it in a way that is effective as if you had said that thing a few moments later when you’ve let a little bit of that anger burn off. Again, I’m not saying here that there’s anything wrong with just saying what you need to say, but for me personally, I’m really trying this year. One of my biggest goals is respect through my words. Respect through my words. Really pausing and being really intentional with my words. And I know that when I’m angry, that is absolutely not happening. 

So, we know that expressing anger is fine. We know that bottling it in is usually problematic. Pretending you’re not mad is also inauthentic. Sometimes my husband’s like, “You’re so clearly mad.” And I’m like, “No, I’m not.” And he’s like, “Yeah, it’s all over your face, my friend.” People can sense it. And then they’re questioning like, “Why isn’t she being honest with me?” 

WHY DOES ANGER FEEL DANGEROUS? 

But I want to acknowledge that anger can feel like an emotional rollercoaster. It does stress out the body. Anger can feel very dangerous sometimes. It can feel very scary to some people, particularly if you have anxiety about it. Some people are really afraid of what they’ll do if they get angry and so they avoid anger and they avoid confrontation and they avoid setting boundaries in fear that anger will come up. 

Now, there are a few ways you can bring mindfulness to anger, and that is, first, to recognize it, to observe it. Another way you can diffuse anger is to use your body. This is a big one for me because when I’m angry, I have so much adrenaline pumping through my body, which is a healthy response. We need that. Like if there was a burglar at my door, anger would show up and my brain would send out adrenaline and that would allow me to either fight or run away or wrestle him or whatever it may be. So, I feel a lot of that adrenaline in my body and it does take time to burn off. And so, sometimes moving my body can be really helpful—stretching, taking a walk, taking some breaths, which we’re going to do today. Some people want to journal, chat with a friend. That irritation and frustration that we feel in our body, it’s okay to move your body and tend to it in that way. 

The last thing I would add is often when we are angry or if we haven’t been mindful in the emotion and sensations and experiences that lead up to anger, we can actually notice that our thoughts are very distorted. Here is an example. 

My husband and I are having a disagreement about a very normal thing. It was a very pretty non-issue issue. But in my mind I could. Once I was really being mindful, I could notice thoughts like, we should agree, we’re going to always fight if we don’t agree. It’s like, okay, that doesn’t have to be the case. I was also having thoughts like if he doesn’t agree, well then, I won’t get my way and then I’ll be held down. I’m having this very catastrophic thought—I’ll be held down and ruled by my husband. It’s like, well, that’s not true either. He’s never going to do that. I’m noticing all these thoughts. If he disagrees with me, that means he’s judging me and thinking I’m bad. Can we actually look at that distortion as well? Because maybe that’s me mind reading.

I’m just giving you some examples. I’m not saying these are all ways happening, but these are some examples. Sometimes we have thoughts like, no, you should not think that way. You need to think my way. My way is the only way. PS, I do that a lot sometimes. I’m just telling you the truth here. But again, that doesn’t mean we have to act on those thoughts. If we can just acknowledge them and be like, “Okay, let’s be in choir.” Is that in fact true? Do we all have to agree? How wonderful is it that my husband and I don’t agree on some things because he has actually taught me how to change the way I think about some things that have benefited me. It just took a lot of stubbornness on my part to be flexible enough to see his side of the story. 

And so, if we can observe the distortions of our thinking, sometimes that can be really helpful. But let’s also reserve some space here for the situations where you don’t have any distortions and the person is being very unkind and they are hurting you. That’s different. Then, what we can do is we can use that anger as information so that we know what we need to do to protect ourselves. Sometimes it’s setting a boundary. “You can’t speak to me like that.” Sometimes it’s saying, “You can’t come into my house and do these things to me.” Sometimes it’s saying, “I’m going to not follow you on Instagram if it makes me angry.” Or if you’re seeing a bunch of things that’s not helpful to your mental health and is making you compare and get angry, maybe you might want to not follow that person anymore. 

And so, anger, again, if you can see it for what it is, is an opportunity to listen to what is going on and be mindful and just acknowledge, and then if need be, make some changes gently that line up with your values. And so, that’s really important for us to recognize. 

IS ANGER MASKING ANOTHER EMOTION? 

Now there’s one-- again, I keep saying that. There’s one other thing I want you to think about, which is, sometimes underneath anger is another emotion—fear, shame, guilt. For me, I actually realized about a month ago, and I’ll just share this with you, sorry, is I was noticing a lot of resentment showing up, particularly—if I’m being completely honest with you all, which I always want to be—a lot of resentment around the fact that I live in America. And I was noticing it showing up and going, “This is really weird. Why is resentment showing up? I chose to live here. I knew that was my choice, but a lot of resentment was showing up.” And through talking with a dear friend underneath this anger and resentment, and I felt myself having a tantrum over it, I realized I was deeply grieving and missing my family. Usually, I just feel miss like I’m missing them and I feel sad, but the anger and resentment was masking me from it. And when I acknowledged that, I realized I’m staying in anger because the sadness was “too painful.” In my mind, it felt unbearable. And so, my brain presented to me an opportunity to stay in resentment and anger and really cycle and ruminate on that instead of dropping down into the sadness that I felt. 

So, again, anger is complex but also quite simple if we talk about it, like two opposing things at the same time. But what I want to offer to you is, all of these feelings are completely normal. If we can just simply acknowledge them with a sense of kindness, if we can stay with the sensation, if we can stay in compassion for ourselves, we can actually write out these emotions and they can be, what I say to myself, it’s not a problem. That’s my new thing. I keep saying to myself like, “Oh, I’m noticing anger. That’s not a problem. It’s totally okay for you to feel this, Kimberley.” “Oh, I’m noticing anxiety. That’s totally not a problem, Kimberley. Let’s stay with it. Let’s feel it.”

ANGER AND RESENTMENT MEDITATION

And so, let’s begin with a short meditation to where you may practice that. Now, if you’re driving, number one, please do not close your eyes. Number two, if you’re feeling an urge to turn off this podcast now and be like, “I got what I needed,” please just listen. You don’t even have to practice. I just want you to listen to what I’m saying and see if anything lands.

Here we go. We’re going to mindfully tend to feelings of anger and resentment. 

Bring your awareness to whatever is going on for you right now... and allow your body to rest as you feel the pool of gravity down on the chair or the bed or whatever it is that you’re resting on. 

And as you are aware of your weight sinking down to that point of contact between you and the floor, the chair, or the bed, I want you to notice what sensations are you noticing right now. Where does anger show up for you? Where does resentment show up for you? Are they the same or are they different? And just take some time to notice any resistance towards noticing anger and resentment. 

And if you notice any tension or resistance, gently turn towards them. Maybe you offer a gentle hello to them. Good morning. Good evening. 

And as you notice them rise and fall in your body, offer some acceptance as best as you can that they’re there. If you notice that you’re tensing up around them with each outbreath, see if you can let go or release any tension in your muscles or in your mind. Again, not trying to get rid of them, but also not holding on to them. Soften your body as best as you can, bringing acceptance to those sensations. Continuing to breathe in no particular fashion at all, except whatever feels easy for you. 

Notice any thoughts as they arise and they pass through your mind. Notice if there’s any thoughts of blame or shame or guilt or aggression. And notice them for what they are, which is emotions, sensations. See if you can let them come and go, rise and fall without over-identifying with the content of those thoughts, without engaging with the content. Just note them. “Oh, I’m noticing blame. I’m noticing the urge to punish that person. I’m noticing the urge to create justice. I’m noticing the experience or urge to neutralize the pain they’ve caused me by punishing them.” And see if you can just notice them, maybe as clouds in the sky just floating by. No need to rip them out of the sky. Just notice them.

And as you notice they’re floating by, can you let go of them? Can you let go of needing to control them or make them go away? And we want to do this kindly and gently. Sometimes it’s helpful to gently bring the sides of your mouth up and gently smile. Not to make the feelings again go away, but to let your brain know that you’re here, that you’re not going to judge it for what it’s experiencing, and that you’ve got your back here. 

And now, allow your awareness to broaden and gather the whole experience of breathing into your body with ease. As you breathe in, knowing that you’re breathing in, and breathing out, knowing that you’re breathing out. 

Can you feel an awareness that flows through you as you breathe? And can your breath be an anchor in this present moment? Noticing each breath as you inhale and exhale. Noticing any judgment you have for yourself as you have these sensations, any self-criticism. Again, just note them, acknowledge them. Try to remind yourself that anger is a normal and healthy emotion. 

You may also want to congratulate yourself for tending to your anger in this moment, instead of internalizing it or displacing it onto other people. And every time you notice your mind has wandered, gently bring your mind back to the breath or the awareness of these sensations in your body. 

Now again, expand your awareness back to feeling gravity pull you down as it sits and stands or lies. If there’s anything left behind here, some pain, some discomfort, let’s set the intention to keep this practice going where we’re going to be non-judgmental and compassionate towards this experience. We’re going to cultivate acceptance and acknowledgment of this and your entire experience. 

Gently allow the breath to bring you back to the present. 

I want to thank you for having the courage to do this exercise with me. The more you offer this practice to your mind, the more the mind will start to see anger again as nothing but an emotion that is knowledge and information for us to make decisions about how we want to move forward. It’s a healthy action towards decision-making, boundary-setting, self-compassion, acceptance. And you’re doing this for the benefit of yourself and for the benefit of others. 

Slowly come back. Open your eyes. Notice what’s around you. And I’m going to offer to you to keep going into the day with this practice. 

Okay. Thank you for practicing with me today. I wish you nothing but a beautiful day of joy and kindness and warmth and love. Please also remember, it is a beautiful day to do hard things. I will look forward to seeing you next week. Thank you for spending your very valuable time with me today. I hope this was helpful.

In this week's podcast, I talked with Lynn Lyons about her new book, The Anxiety Audit (7 Sneaky Ways Anxiety Takes Hold and How to Escape Them).

We discuss: 

• How repetitive negative thinking disguises itself as problem-solving 
• How catastrophic thinking makes the world a dangerous place and demands you react accordingly 
• How big conclusions and an all-or-nothing approach make the world smaller and harder to navigate. 
• How a fear of judgment isolates and disconnects us from people 
• How being busy and overscheduled both adds and masquerade anxiety and stress 
• How we blame others when we are irritable
• How self-care becomes not self-care at all

Transcript

This editable transcript was computer generated and might contain errors. People can also change the text after it is created.

Kimberley Quinlan: Okay, good. Well, welcome, Lynn Lyons. I am so thrilled to have you on the show today. Okay, so very exciting.

Lynn Lyons: Oh well, thanks for having me.

Kimberley Quinlan: You just wrote another book. I will say another book. It's amazing. Please tell me before we get started. Why did you choose that as the title?

Lynn Lyons:  Well, what happened was we have a podcast called flusterclux. And I do that with my sister-in-law Robin; she's married to my brother. And during the pandemic, one of the courses we created together, she called it the anxiety on it because we wanted to go through the patterns that maybe people were experiencing and they didn't, they didn't have words to them, they didn't know what was going on. And so we did this course, and we put it out there, and then my publisher said, Do you want to write a book? And I said, “Oh, okay”. And Robin and I said, Well, why don't you just make the course we did into a book? It'll be easy because she's never written a book before. Um, so that sort of was the genesis of it. So the publisher like the title, the anxiety on it. So the book ended up being much more expanded than the original course, but the title was from Robin. And the course we did for the podcast.

Kimberley Quinlan: Right. And I loved it because there is a degree of going through your book. We're going to talk today about the seven sneaky ways anxiety takes hold and how to escape that, but I love how it is. It feels like an audit, right? You're kind of auditing through these sneaky ways anxiety can take hold. So, I love that. So, let's go through today's those seven points, and then we will go deeper if we have time. Can you tell me a little about this first main concept of how repetitive thinking disguises itself as the problem?

Lynn Lyons: Yeah, it disguises itself as problem-solving. So when you are doing repetitive negative thinking,…

Kimberley Quinlan:  Aha.

Lynn Lyons is just the lingo we use to describe worrying and ruminating. We generally distinguish between worrying and ruminating in which direction and time they head. So if you are a worrier, you tend to worry about things that haven't happened yet. And if you're a ruminator, you're going back over things, which tends to be both. It can feel pretty obsessive. A ruminator will go back over things and ask those questions. And did I say the right thing? Did I do the right thing? Did I buy the right refrigerator? Did I make the right decision?

Lynn Lyons:  Repetitive Negative thinking. The problem with it is that the thinking feels like the solution. Remember, anxiety seeks that certainty.  If I just go over it, if I just think about it, if I just talk about it, if I just ask people about it, if I just get more information about it, that will lead me to a solution. But what we know is that the thinking is actually the problem because when you overthink,

Lynn Lyons: You're caught in that repetitive cycle. You're seeking that certainty. So you don't move forward, and you don't take action. It just feels like you're doing something productive. But unfortunately, you're when people go to therapy, if they have this kind of obsessive thinking and they get caught in it, is that the therapist will unknowingly say, Well, let's think about this, or Let's talk about this, some more. Let's explore this. Or What could that mean and the anxieties? Like, Yeah, I love this lady. Now we get to do our thing. 

Lynn Lyons:  What we know about people that tend to overthink and get into this repetitive negative thinking is that they are less likely to act on a solution if they come across one in their thinking. So they're saying, “Oh, I'm thinking to figure this out,” but then they never take the necessary action. Yeah. So it's a way to trick you into thinking you're doing the right thing. When you're just feeding your rumination feeding your worry,

Kimberley Quinlan: I love it, and you mentioned in your book Chewing the mental card, which I thought was just classic and…

Lynn Lyons: Mmm. M.

Kimberley Quinlan: hilarious. I grew up on a farm, so that was very appropriate. I love it. Let's go to number two, how catastrophic thinking makes a world, the world a dangerous place and demands. You react accordingly,…

Lynn Lyons: Sure. So catastrophic thinking this is like the meat of the anxiety sandwich…

Kimberley Quinlan: do you want to share about that?

Lynn Lyons: You're always wondering, worrying about, or vividly imagining the worst thing that could happen. And again, this feels like a solution. So if you are a parent and you have this catastrophic way of thinking, you're thinking, all right, so if I can imagine every bad thing that could happen to my child, then I can be ready for it. I can prepare for it; I can prevent it. But what we know is that the more catastrophic you are, the more you think about the bad things that could happen.

00:05:00

Lynn Lyons: The more fearful you are, doesn't mean that you're better prepared to manage things; it means that you start to avoid and remove things from your life. So, Yeah. So it just becomes again. It becomes this way of the anxiety dictating what you do and don't do.

Kimberley Quinlan: Right? You talked in this chapter about the pain. The Pain Catastrophizing Scale and…

Lynn Lyons:  Mmm.

Kimberley Quinlan: that's something that I didn't know a lot about, which I found. Very fascinating. Do you want to share your little thoughts on that?

Lynn Lyons: Sure. So what we know from pain and pain is such an interesting phenomenon, isn't it? It's such a rich place for research and study. If you could testify about your pain. So if you anticipate that your pain is going to be terrible, You will respond as if the pain is worse than it is. And one of the things that's interesting is I work a lot with kids and a lot with families and parents. One of the fascinating things is that, say, you've got a child in pain, and you ask the parent to rate the child's pain. Say the child rates their pain as a four. The parent weighs the child's pain as an eight.

Lynn Lyons: The parent's rating of the pain is a predictor of impairment in the child.

Kimberley Quinlan: Huh.

Lynn Lyons: Completely independent of, you know, maybe the child says Oh my pain is a two and the parent says, Oh the truck might try. I'm so worried about my child. I think their pain is an eight that parents catastrophizing about the pain. Predicts whether or not that child goes to school whether or not they predict an activities how much of their life is impaired by the pain. Even though the child is saying, Well like that, my mom thinks the pain is a lot worse than it is. It's the parents' catastrophizing that actually has the impact. Yeah.

Kimberley Quinlan: That is so interesting. And so what what really showed up for me was is that also true of like the pain of the suffering of anxiety, right? Like is if we are catastrophizing how painful the anxiety will be does that? That still the same concept scientifically

Lynn Lyons: Well, I don't know about the research in terms of the way they lay it out, so clearly with with pain but here's what we do know. Catastrophic parents being a catastrophic parent about anything. Is a high risk factor for developing anxiety as a chart for children. So, if you have a catastrophic parent, it increases your risk of creating an anxious child. We also know that parents who are anxious have a six to seven times greater risk of having an anxious child. We've got some genetics in there…

Kimberley Quinlan: Right.

Lynn Lyons: but there's an awful lot of modeling. So when we when we look at how parents talk about the world. one of the things that when parents talk about the world as a dangerous place, when they talk about their child as being incapable of functioning,

Lynn Lyons: When they step in so that their child doesn't have the opportunity to get to the other side, doesn't have the opportunity to independently problem solve, all of those things increased anxiety. And because we know that anxiety, untreated is one of the top predictors of depression, by the time you hit adolescence and young adulthood, we know that that that's that cycle is just going to continue. So when I am,…

Kimberley Quinlan: Mmm.

Lynn Lyons: when I am working with families and I am trying to interrupt this cycle, one of the things just as you said, one of the things I want to really target is, Is this parent catastrophizing?

Lynn Lyons:  About their child's ability to function and it may be catastrophizing about their mood catastrophizing about them, being upset or being nervous, right? So so my child is so anxious about this. There's no way I can send them off on this field trip or there's no way I can send them off to this summer camp because look they're so anxious. It absolutely is contagious for sure.

00:10:00

Kimberley Quinlan: And that's true of ourselves too. So if we're catastrophizing, when less likely to go on the field trip, ourselves is correct. Yeah.

Lynn Lyons: That's right. Yeah, well, so say, say you're gonna get on an airplane. And you're thinking, Oh gosh I'm going go on this airplane and you start catastrophizing and imagining bad things happening on the plane or the plane crashing and you activate your whole system. So you're having these symptoms and your your stomach feels weird and your heart is pounding. You say to yourself, Oh my gosh, if I feel this bad just thinking about getting on the airplane, it's going to be horrible. When I actually get on the airplane, I better not do it. Right. So we're just watching this scary movie and…

Kimberley Quinlan: Yeah.

Lynn Lyons: it makes sense if you're sitting there watching a terrible movie with a horrible outcome, Of course you want to avoid that thing but we have to recognize that that catastrophic thinking is a pattern of thinking not an actual predictor of outcome. Yeah.

Kimberley Quinlan:  Right.

Kimberley Quinlan: Yeah, and you talked about that about sleep as well.

Lynn Lyons:  Oh, yeah, well, the thing that most the thing, that people who are have difficulty sleeping people with insomnia, the number one thing they worry about is sleeping, right? So you can't sleep. And then you start worrying about not being able to sleep and off off the cycle goes. Yep.

Kimberley Quinlan: Yeah. Yeah of for me actually I remember when I had my newborn baby. It was the fear of being tired.

Lynn Lyons:  Mmm.

Kimberley Quinlan: So I would I would pressure myself to sleep because I'd catastrophized, what tiredness was gonna feel like,…

Lynn Lyons: Yes. Yes,…

Kimberley Quinlan: right. Yeah.

Lynn Lyons: I've certainly many people have that. I interestingly had this client long ago who catastrophized the feeling of being hungry. That she couldn't tolerate feeling hungry so you can you can grab onto anything in catastrophize about it for sure.

Kimberley Quinlan:  Right.

Kimberley Quinlan: Yeah. Fantastic. I agree. Yeah. Okay. Now this is cool and we've talked a little bit about this in the show before but let's just go over it really quick. How big conclusions and all or nothing approach make the world smaller and harder to navigate.

Lynn Lyons:  Mm-hmm.

Kimberley Quinlan: You talk about going global. Do you want to share a little bit about that?

Lynn Lyons:  Yeah. So so global thinking, so if you have a global attributional style or a global cognitive style it means that you come to big conclusions. Usually about yourself or other people, right? So oh I never get what I want or I always screw up or nobody understands me. These are these big huge words that then if you believe that well nobody likes me. Well then you're not gonna you're not gonna step out there and take any kind of risks or reach out to people because you've already come to the conclusion. So when people are global in their thinking, they're much more likely to one break things down into parts, so they can recognize, well, there's a sequence to making friends or there's a sequence to getting a new job, or there's a sequence to cleaning out my basement. So they, they get into this place of like, Well, it's a disaster. I, you know, I can't do it and then they also begin to believe that about other people. So when you're global about other people, it shuts,

Lynn Lyons:  Off. Right. Well, that group of people could never like me. Or that group of people is this or that group of people, is that So, the opposite of global and we know that global thinking huge risk factor for anxiety and depression. When we're confronted with that, or when we notice that we're doing with doing that, we want to back up from it and say, Okay, so I just heard myself using that global language, right? I just heard myself say, Oh, I'll never get this done. Oh, there it was right now. Why am I saying that? Well, I'm feeling a little overwhelmed. It does look like a big project in front of me. Maybe it is a big project in front of me. So now I'm gonna break it down and I'm gonna recognize there's the beginning and a middle and an end, there's a sequence, right? And that moves us out of that big global way of thinking that's just absolutely paralyzing. Yeah.

Kimberley Quinlan: Mmm. Yeah, I love that. Okay. How anxieties fear of judgment isolates, and disconnects us from the from people, right? And I, I will, if you could speak to where you also touched on the disconnection, happens on the inside. You won't share a little about that.

Lynn Lyons: Yeah. So so interestingly when when when people are lonely It can be in two categories, one is that it's situational. So you've just moved to a new city. You don't know anybody. You're starting college and you're there by yourself or it can be more of a pattern of the way you interact with the world. And again the conclusions that you come to, so you look at the way that the world is connecting and interacting and you conclude that one is that everybody does it better than you,…

Kimberley Quinlan: If?

Lynn Lyons: right? That it's easy for everybody that it comes naturally to everybody and that it's not gonna work for you.

Lynn Lyons:  And you go inside and I always say, You know, you have a meeting with your anxiety inside you're having meeting and and during the meeting, you say, You know that. Well there's this is, this is terrible. I don't have the skills. Nobody wants to connect with me and also you fear the judgment of other people. So one of the mistakes that we often make with somebody who's feeling this way who's feeling isolated, who doesn't feel like they can connect is we try and talk them out of it.

00:15:00

Lynn Lyons:  By saying things like, Well people don't judge or, um, you know, nobody's paying attention to you or, Oh, people aren't thinking that, right? That's just not true. People do judge, they judge all the time, and we notice people. And if I'm, if I'm on an airplane and somebody has this really crazy hairdo, I'm gonna be like, Wow, look at that hairdo. Or if I, you know, got an airplane and somebody has this really funky tattoo on their face, I'm gonna say, like, well I wonder how they decided to put that tattoo on their face. We do it all the time. And so what we have to develop is the ability to tolerate being vulnerable and we can do it in small steps, you know, you don't have to, you know, you don't want to share your life story with the person you met two minutes ago.

Lynn Lyons: But recognizing that when our anxiety shows up and says, I can't take a risk, I can't be vulnerable, everybody can connect, but me, you go inside and you convince yourself, not based on what's happening on the outside, but what's happening on the inside that you aren't capable of connecting? And then boy,…

Kimberley Quinlan: Right. Right?

Lynn Lyons: it just snowballs

Kimberley Quinlan: I love it and so true of the pandemic and where we're at in the World,…

Lynn Lyons:  You yeah, yeah.

Kimberley Quinlan: Right? Yeah. Okay. The next two chapters were my favorite. okay, and…

Lynn Lyons:  Yeah.

Kimberley Quinlan: so I wanted to talk about this a little bit, you talked about how being busy and over scheduled, Which like I raised my hand to ads and…

Lynn Lyons: Mm-hmm. Awesome.

Kimberley Quinlan: masquerades anxiety and stress.

Lynn Lyons:  Yeah, so the interesting thing about busy and I raise my hand too. I'm you know so I get it. Um, We love the idea of being busy it because it's, it's this currency now, right? We can't, we can't really brag about how money, how much money we make. We can't say to, you know, if you ran into a friend on the street you and they said, Oh, how are you doing? Kimberley you and say, like, Oh, I'm doing great. I am making so much money this year, it's fabulous because they say, Oh my gosh, that's so tasteless. Why is she saying that? But you can say, Oh I am so busy. My life is so crazy. That's become sort of our currency of importance.

Lynn Lyons: Of how busy we are. So the more busy we are the more we feel like we're worthy and the more busy we are the more we don't have time to feel things that we're going to feel so we keep ourselves busy as a way to just keep that that brain of ours in motion and we have difficulties sort of settling back in but it is interesting. It you know, when I was doing the research for this chapter it a few things were really we're really kind of amusing to me and true you read this. They say of course of course is it a life of leisure that used to be something to brag about right back in the old days…

Kimberley Quinlan: Yeah.

Lynn Lyons: because the farmers and the labors and the coal miners, right? But if you, if you could sit back and and relax and drink a mint julep, right? That meant you had social status, well, sort of flip. Now, we don't really admire people that sit back and…

Kimberley Quinlan: Yeah.

Lynn Lyons: don't work. So, that's an interesting thing I found and then the other

Lynn Lyons: Interesting thing I found is that people who brag a lot and sometimes it's that humble brag, right? Oh I wish I weren't so busy. Oh my gosh. Yeah. Um people who brag a lot about how much they work are very inaccurate about the hours that they work and the more hours that you say you work oftentimes the more you're off. So people say Oh I work a hundred hour week and I always think to myself No you don't right? Because Even if you worked 12 hours a day, seven days a week, that's not even a hundred hours a week.

Kimberley Quinlan: Right.

Lynn Lyons: And so what what they found is those people who say Oh I work 70 hours a week really are working about 40 But it's just it's just indicative of how much we want to keep ourselves busy.

Lynn Lyons: And how how often times it's it sounds kind of backwards in paradoxical but it's true that we really like that feeling of chaos that we create because it means that we don't have to sit back and sort of look at how things are really going. And we do it.

Kimberley Quinlan: Right.

Lynn Lyons: We do it with our kids, for sure. And a lot of kids right now, believe that the way that life is supposed to be in the way that we measure our success is, how busy we are.

Kimberley Quinlan: Yeah, I always think of like I I remember moments where I in early in my own anxiety recovery where I could feel and I've talked about this on the podcast like feel myself, typing really fast and it's funny when you're so focused on what you're doing. You do tend to have less anxiety so it feels like a relief. Almost it's a compulsion, right? It's a relief to your anxiety.

00:20:00

Lynn Lyons: It is, yeah. Yeah. Well.

Kimberley Quinlan: Like I don't have to be up here if I'm typing like crazy or I'm focusing.

Lynn Lyons:  That's right.

Kimberley Quinlan: And I think that that you use the word masquerade down, anxiety, and stress. I think that, that is right on the money, right, that where we are. Busying as an avoidant compulsion.

Lynn Lyons: Mmm. That's right.

Kimberley Quinlan: Do you agree with that?

Lynn Lyons: Yeah. Well because if you're, you know, if you're if you're if you've got a lot going on in your head, And maybe your thoughts are saying, You know, you're not good enough, you're not busy enough, you should be doing this right? You're shooting on yourself, you're doing all this stuff and if you can keep your brain in your body busy and occupied, And almost as if like, you can't keep up and you've got, you've got this little feeling of of urgency or emergency. Oh, I've got to do this, I've got to do this, it really distracts and sort of satisfies. Those thoughts in your head of, I, you know, what's gonna happen next. And it allows you to not really experience the worry and the anxiety because you're just busy, busy, busy busy. Well yeah,…

Kimberley Quinlan: Right.

Lynn Lyons: one of the things it's interesting. We did a podcast episode on this a little while ago, this this term high functioning anxiety.

Kimberley Quinlan:  Yeah.

Lynn Lyons: Which is sort of amusing to me, right? Because it's the city right, everybody wants to have these new categories, right? It's not this. It's this high functioning anxiety and they had this list of The list of symptoms this checklist, I saw in this article which was just silly like you know you chew your lip or you chew gum or you don't make eye contact, you know it's just silly but but when we look at it, high functioning anxiety is no different than any other kind of anxiety. It's just that you're getting the job done and…

Kimberley Quinlan: Yeah.

Lynn Lyons: then people are giving you a lot of positive feedback for that,…

Kimberley Quinlan: Yeah. Right.

Lynn Lyons: right? So yeah.

Kimberley Quinlan: Right. A busyness is another form of like, avoidance of the fear, right? Yeah. Yeah.

Lynn Lyons: That's right, that's right. And it because of the way our culture works It, it feels good in the moment and you get the payoff of somebody saying,…

Kimberley Quinlan:  Yeah.

Lynn Lyons: Oh my gosh, you are so busy. How do you do all that you do? Oh gosh, I've never met anybody. You know what? If we want a job done, we got to give it to Kimberley, she's gonna get it done and…

Kimberley Quinlan:  Right. Right.

Lynn Lyons: all of that feels so good, but it totally burns you out, if you, if you keep it up for sure.

Kimberley Quinlan: They'd like No, I'm just over here doing a bunch of avoidant compulsions.

Lynn Lyons: Yeah, right.

Kimberley Quinlan: That's why Right.

Lynn Lyons: We don't say that. Right? Oh my gosh. You're doing so much Kimberley. Oh no, I'm just avoiding compulsing. Yeah, no. We don't say that. Yeah. Yeah, they would. They would they be like, Oh okay. So maybe we won't give her that next assignment then. Yeah.

Kimberley Quinlan: Right. Well, and that brings me to the next part of this which again these were my two favorite pots and concepts mainly, I think because it's I still like, ooh, there's some truth there. I need to be listening. And I think it links so well together with the last one about being over scheduled and busy talking about irritability, right? Because And you had said here and I'll use your your terms exactly how irritability likes to blame others but can be a red flag for you. Do you want to share that? Because I feel like they go hand in hand with that over scheduling.

Lynn Lyons: Yes. Yeah.

Kimberley Quinlan: Do you tell me your thoughts?

Lynn Lyons: No, I agree. And in fact, like all of these patterns, sort of overlap, don't they?

Kimberley Quinlan:  You know.

Lynn Lyons: Because we can be catastrophic and over scheduled at the same time. Yeah, irritability is, is a red flag. So irritability. I talk about all these patterns and irritability is a sign that perhaps you're really not addressing what you need to address. One of the, the definitions of irritability that I talk about in the book is that it's described as blocked goal attainment. Okay, so that's it. A research term is that you can't get…

Kimberley Quinlan:  Yeah.

Lynn Lyons: what you want and something is in the way the other term that I read, and it's in the book, is they defined irritability as feeling angry and the ability to sustain that anger?

Kimberley Quinlan:  and,

Lynn Lyons: So it's this constant sense of not getting what you want, not being able to feel satisfied. And what happens is you start looking outside to find out why you're so irritable. It must be because my kids aren't doing what I told them to do. It must be because my partner is not fulfilling the agreement that we made. It must be because my boss is such a jerk, it must be because of the traffic, it must be because of the weather, it must be because of this and what we really want to step back and look at is How is this constant level of irritability?

Kimberley Quinlan: You.

00:25:00

Lynn Lyons: How are you sustaining it? What are you doing? Is it your perfectionism is it the fact that you want to compuls and people are getting in the way of your compulsing because you're in your mind if I can only compulsa and I'll feel better but people aren't letting you do what you want to do.

Lynn Lyons:  Is it because inside there is a constant conversation with you about how you're not meeting your own expectations. How are you creating this level of Sort of low-grade simmering this low-grade dissatisfaction that is just eating away both at you and and your your relationships. It's hard to hang out with somebody who's irritable all the time.

Kimberley Quinlan: And what would you suggest somebody do? If they've caught this red flag of irritability, how would you encourage them to navigate that?

Lynn Lyons: So, the first thing you want to do, and I think I say this about a lot of the patterns in the book. Is you just want to talk about it? Openly with the people you live with, because one of the things that's enormously helpful is for you to own your own stuff, right? So if you know that you're struggling with irritability or even just on a busy day you come home and you're feeling particularly irritable to say to the people that you love the people who are in your orbit. Hey you know what, I had a rough day. I'm feeling irritable, it is not you, it's me it's not your fault. So you're really gonna pay attention to that blaming and you can even say to the people around. You give me a few moments, right? I've got to go for a walk or I'm gonna listen to some music or man. I just need to eat a peanut butter and jelly sandwich.

Lynn Lyons: And then give yourself permission and, and more than permissions, sort of give yourself a little kick in the hello. That says, I'm gonna, I'm gonna work on releasing this irritability without going after other people. And that diffuses it very quickly and…

Kimberley Quinlan: Mmm.

Lynn Lyons: then if you're a parent, you're modeling that for your kids, which is a wonderful thing and…

Kimberley Quinlan:  Yeah.

Lynn Lyons: then you really have to look and see if it's a chronic thing. What do you keep doing over and over and over again? That's making you irritable.

Lynn Lyons:  How are you going to recognize that and accept that? Because a lot of times people say, Well I don't know why I'm so irritable and then we talk about it. And it's pretty obvious why they're so irritable. Now that means you have to adjust or adapt and it might be your schedule. Maybe you're not getting enough sleep. Maybe you're saying yes, too often. When you want to say, no, maybe you are ruminating in your head about how other people have, let you down all the time, maybe you're catastrophizing. So those horrible stories about what the world is going to look like are really making you irritable. So it's it's a way for you to to step back and say What am I doing? That's resulting in this state that I'm in. Yeah.

Kimberley Quinlan: And yeah, yeah. And I'll just for being transparent. I have found as soon as I'm irritable, it's because I'm refusing to feel some feeling like that is for me. I'm like, I don't want to feel this feeling.

Lynn Lyons: You.

Kimberley Quinlan: So I'm gonna be like Real shop and all edgy around everything. So I think that's just such a great point. It's like, I don't want to feel the anxiety. I'm feeling so I'm just like,…

Lynn Lyons:  Yeah.

Kimberley Quinlan: frightened reactionary. So I think that that is such a common. I see it a lot with my patients as well. Just a deep sense of frustration of like you said, they won't let me compuls and…

Lynn Lyons:  and,

Kimberley Quinlan: that. Okay, that's means that you're gonna have to feel some anxiety,…

Lynn Lyons:  Right. Right. Now.

Kimberley Quinlan: right? So I you're on the money there. I love. Okay. This was an interesting one and the last point how self-care is hijacked and becomes not self-care at all.

Lynn Lyons:  If well, and I think that you you sort of teed this up for me very well because oftentimes what we call self-care is really means of avoidance. Right trying to eliminate. So I'm trying to get rid of some feeling. I'm trying to avoid something that I need to address. I don't want to feel this way. We, I talk a lot about our elimination culture and how we're really focused on trying to get rid of things like feelings or discomfort or right. So we take on these practices that we call self care, that are really about getting rid of something or avoiding something and so that can be

Lynn Lyons: Anything from drinking or using other substances to spending money, you don't have to binging on Netflix and not getting the sleep. You need, because you feel like you want to escape, what's going on? When you are doing something that in the moment you're saying, you know what? This is really for me. And then the next day you feel regret about it, probably not self care. Right self-care.

Kimberley Quinlan: Mmm.

Lynn Lyons: If you do it consistently. After after I do something that is truly, you know, one of my good self-care things. I don't say to myself. Oh, I can't believe I did. I can't believe I got eight hours of sleep last night like, Oh, what a loser. I can't believe I went for a walk with my friend. Oh, right. But if I

00:30:00

Lynn Lyons: Spend too much money, or if I stay up too late, or if I skip my exercise, that helps me so much, or if I eat half the chocolate cake. The next day, I'm probably gonna say, Oh honey, like do that, You know,…

Kimberley Quinlan: Mmm.

Lynn Lyons: I should. So that's one of the easy ways to sort of determine for yourself whether or not you're engaged in self-care or self medication, but self care isn't a one hit wonder, right? It's not, it's not a quick fix. It's a consistent pattern. Moving.

Kimberley Quinlan: Right. Right. Yeah, I talk I wrote a book about self compassion and I talk about the same thing as people say. Well this is the self compassionate thing to do to not face my fear or…

Lynn Lyons:  You.

Kimberley Quinlan: to not, you know, to not get out of bed and yes, I understand some days we have to be gentle but I think we also rely on self compassion. Sometimes as a, as a way to avoid our feelings and…

Lynn Lyons:  That's right.

Kimberley Quinlan: wade fear as well. I think that really, you know, is so true. You did talk about self-medicating, and then you would said that, When you're able to identify these seven points, that's a form of self-care.

Lynn Lyons: That's right.

Lynn Lyons: That's right.

Kimberley Quinlan: Right. Do you want to share a little about that and…

Kimberley Quinlan: what that looks like?

Lynn Lyons:  Well, so if you are reading this book, or if you're listening to me now and you're beginning to recognize that you have a few of these patterns that really take over and then and you begin to own them. Just like I was talking about with irritability and you begin to see the pattern. It takes courage to change the pattern. It takes courage to say, Oh gosh, I look catastrophizer or boy, do I get caught up in a ruminating about things, as a way to solve problems? Or you know what? I have been saying that my two or three glasses of wine. Every night is self-care and I'm really noticing that I feel worse the next day, or I don't sleep very well. So once you begin to own them and once you begin to, you know, you can talk about them openly with the people you care about.

Lynn Lyons:  Things start to shift the biggest thing and I'm sure you see this with your patients as well. Kimberley The biggest roadblock that I run up to run up against is when people deny that they're doing the things that I know are causing them to stress. and then, when they blame other people, You know, I I say this all the time, I have this client, The daughter was struggling with OCD, Dad had OCD, he was highly perfectionistic. Things had to be perfect in the house. He would miss his kids, recitals, or their soccer games, because he had to come home after work. And make sure that everything in the house was perfect. And I was trying to explain this to him, this rigidity and his OCD. And he said to me, What's wrong with a neat and tidy house.

Lynn Lyons:  Now nothing except that, that's not what was going on here. But his denial of his patterns and his inability to own them and to talk to his family about them because you can imagine what his daughter did when he said that, right? She like threw herself back on the couch and rolled her eyes got in the way of him, being able to move forward. so, When you know people talk about it, say you say, you're phobic of something, we talk about the courage to face your fears, right? So if you're afraid of bridges, you have to have the courage to go across the bridge. Or if you're afraid of germs, you have to have the courage to touch germs. I feel like the courage is much more, the courage on the inside.

Lynn Lyons:  To acknowledge what's going on and then to work to do the opposite and to really be to really be honest. And vulnerable with yourself. The courage comes not on the bridge or with the germs, but the courage comes from saying, I'm really struggling with this pattern, with this issue with this compulsion, and it feels scary. I'm gonna face what's going on inside of me. And that's gonna help me face. What's going on outside of me?

Lynn Lyons:  Yeah. Yeah.

Lynn Lyons:  Mmm. Yeah.

Kimberley Quinlan: Awareness is the first step but that accountability. That's a hard one. Like it's it,…

Lynn Lyons:  It is a hard one. Yeah.

Kimberley Quinlan: it's a good one, but I had one and I think Do you have like I know where we're close to being finished? I want to be respectful of your time. But do you have any thoughts on how to work towards that accountability, particularly if you're someone who's rigid and doesn't like that,

Lynn Lyons: Well, I mean, one of the, one of the things that I think is really helpful is for people to recognize that these patterns and OCD and anxiety is really common, and people don't talk about it. But gosh,…

00:35:00

Kimberley Quinlan:  If?

Lynn Lyons: how many people have OCD in this world? How many people struggle with the things that we talk about on a daily basis? So I'm I say to people, you know, you're not unique. Your problem isn't special. It's it's, it feels big to you because it's your problem, but there are really a lot of things that we can do to help this. We know a lot about it, it's not mysterious the content of what your worried about or the content of your OCD is meaningless. This is a process. This is a thought process issue and let's just get over this idea that it's so special and that you're unique and that there's nothing anybody can do because you're worse than everybody else, right? So that's one of the things I do.

Lynn Lyons:  And then also really helping people. Learn about Other People's Stories. I think there are some wonderful books and resources where you read about other people's struggles. And you begin to realize gosh, This is so much of what I've experienced it is. It's a matter of being vulnerable in a matter of moving away from this idea that the perfect world that other people are presenting is not so perfect, after all. Yeah,

Kimberley Quinlan: Yeah, so true. So true. Lynn, I have loved getting all your wisdom. Thank you so much. Do you want to tell us where people can learn about you and about your book and all the things?

Lynn Lyons: Sure, sure. So my website is just Lynn Lyons.com. I'm on Instagram at Lynn Lyons anxiety. I'm fairly new to Instagram. My younger son is my is my Instagram helper, and then I'm on Facebook. If you go on Lynn Lyons, and just put in anxiety or psychotherapist, we've got the podcast fluster clocks with an X that comes out every Friday. Um, By the time, this comes out, by the time that people are hearing this, the audible book for the anxiety audit. Hopefully we'll be released because they told me it will be out in January. I just recorded it right before our Thanksgiving in November. So I'm excited to welcome that into the world. So yeah there's there's you know, all sorts of videos and things on my website and resources and things you can check out.

Kimberley Quinlan: Fantastic and I'll link all those in the show notes. Thank you so much for coming on.

Lynn Lyons:  Thank you.

Kimberley Quinlan: It's a delight to me meet with you.

Lynn Lyons:  Thank you for having me and thank you for all of your wonderful questions you made it so easy, which is nice.

Kimberley Quinlan:  Wonderful, thank you.

Lynn Lyons:  All right. Yeah, that was great. You are you are super easy to talk to so thank you. Yeah.

Kimberley Quinlan: Oh, I'm so glad I didn't tell you. I beforehand, you've written a book with Read Wilson.

Lynn Lyons: Yeah. He is.

Kimberley Quinlan: He's a very dear friend of mine. Yeah. Yeah,…

Lynn Lyons: Yeah. All right.

Kimberley Quinlan: so I'm

Lynn Lyons: Well, I'll tell you say hello. Yeah. We wrote two books together, I am.

Kimberley Quinlan:  yeah.

Lynn Lyons: I was just talking to him the other day. Yeah, that's how did you, how did you meet him just through working on OCD stuff.

Kimberley Quinlan: Yeah, through ICD. He's been on the show a bunch of times and…

Lynn Lyons:  Oh, that's awesome.

Kimberley Quinlan: and I consider him such a, I know a helpful resource and and support. So I just wanted, I want to mention that at the end.

Lynn Lyons: Oh yeah,…

Kimberley Quinlan: Yeah. Yeah,…

Lynn Lyons: that's awesome.

Kimberley Quinlan: I don't often usually we don't take guess…

Lynn Lyons: That's awesome.

Kimberley Quinlan: unless I'm sort of developed a relationship but your name went underneath the,…

Lynn Lyons:  Yeah.

Kimberley Quinlan: the read seal of approval.

Lynn Lyons: If? Well,…

Kimberley Quinlan: I was so glad to meet with you. And have you on the show? Yeah, you guys trained together.

Lynn Lyons: thank you. Thanks for having me.

Kimberley Quinlan: Is that what it was?

Lynn Lyons: Oh no, he we wrote the books together so I'd never I'd never met him before and we were presenting it. I was we were both presenting at a brief therapy conference. I think when was it like Like, 15 years ago, maybe. And so he just,…

Kimberley Quinlan:  Yeah.

Lynn Lyons: he just popped in and listened to my talk and then he emailed me a little while later and said, I want to write a book on kids, but I don't work with kids, and I need a co-author,…

Kimberley Quinlan:  Sure.

Lynn Lyons: would you want to write a book with me? So I was like, Yeah. So so we wrote the two books together. It was a period of four and a half years of writing. And, you know, the two books and I think God. I mean, I talked to him every day. Probably for, you know, three and a half years. So yeah, we've become, we've become good friends. Yeah, he is a good guy. Super helpful to me,…

Kimberley Quinlan: Yeah.

Lynn Lyons: too. I just, I just love what he's offered me. Yeah.

Kimberley Quinlan: Yeah, and and my clients and…

Lynn Lyons:  Mmm.

Kimberley Quinlan: my stuff to be honest. Like so often when I'm consulting with my staff, they'll like bring up a read Wilson comment.

Lynn Lyons:  Yeah, yeah, and his new OCD program is just amazing. Yeah.

Kimberley Quinlan: And it's really wonderful. Yeah.

Kimberley Quinlan: Amazing. Yeah. Really amazing. That the six the six-part plan is so cool. Yeah. I love the work that you're both doing.

Lynn Lyons:  Yeah.

00:40:00

Kimberley Quinlan: Thank you for all your work. I'm like a learner of your work, right? I'm yeah,…

Lynn Lyons:  Oh thanks. Thanks thanks. Yeah.

Kimberley Quinlan: it's really wonderful. Yeah, yeah, well, thank you so much. I it will be out on the 24th of February,…

Lynn Lyons:  Okay.

Kimberley Quinlan: and we usually link to Instagram. I'm really active on Instagram and…

Lynn Lyons:  Okay.

Kimberley Quinlan: it comes out on Friday, as well. I'll probably please come out and Friday. And so, if you want to have your assistant or a publisher, I'm not sure email me. All of the links to anything you want me to add in the show notes. That's usually an easy way to make sure I get it correct.

Lynn Lyons: Okay, okay.

Kimberley Quinlan: And I think that's it. Yeah.

Lynn Lyons:  All right. Great. Shoot. Me an email. Just to remind me before it comes out, so I can start to promote it on my stuff too. Okay.

Kimberley Quinlan:  Yeah, wonderful. Yeah, and it's really great to meet with you and chat. Alright. Take a have a good day.Lynn Lyons:  Okay, thank you very much. Bye.

This is Your Anxiety Toolkit - Episode 318, and welcome 2023. 

Welcome back, guys. Happy 2023. Happy New Year. I want you to imagine you and I are sitting down at a table and we both have the most wonderful, warm tea or coffee or water or whatever it is that you enjoy, and we are going to have a talk. You’re not getting a talking too, I’m not saying that. But I want you to imagine that I’m standing in front of you or sitting in front of you and we’ve got eyes locked, and I am dead serious in what I’m talking to you about because I believe it to be the most important thing you need for 2023. I really, really do. 

So, let’s talk. Okay, you’ve got your tea. I’ve got my tea. Let’s do this. Okay.

So, I want you to imagine that you have a suffering in your life. We all have suffering. It’s a part of being a human. Life is 50/50. It’s 50% easy and 50% hard. We all are going to have suffering this year. But I want you to imagine this scenario. It could be something that’s hard for you that you’re already going through or could be imagined. And I want you to think about that there’s a circumstance or a situation that happened that is out of your control and it’s causing you suffering. Maybe it’s a thought that’s intrusive, maybe it’s anxiety, maybe it’s depression. Maybe you have a hole in your tire, maybe you-- if you hear some people walking, it’s because my whole family are upstairs playing. But maybe you have some financial stresses, relationship stresses. Maybe you feel very alone. Whatever you’re suffering is, I want you to acknowledge that you’re having this suffering. And then I want you to think about, who could I call to help me manage this pain in my life? Is it someone who could support me and nurture me during that suffering? Is it someone who has the solution to that problem? Is it somebody who’s been through it before and they can guide you on what to do? 

So what we do when we have suffering is we gather hopefully a list of people who we can help and we reach out to them. That’s good coping, right? But what I want you to do differently, or maybe you’re already doing this and I want you to do more of in 2023, is I want you to move you to the top of that list. I want you to be the first person you call to offer yourself the support and wisdom and guidance, right? 

I’m not here to say there’s anything wrong with calling the other people. In fact, I am a huge believer in gathering your peeps when things are hard, calling your speed-dial people, right? That’s cool. I want you to be doing that. But I want for this year for you to move yourself to the top of the list and ask yourself, what is it that you need while you suffer? How can I support you while you suffer? What do you need to hear as you suffer? How can I tend to this suffering in a kind, compassionate, non-abandoning way? How can we be that for ourselves? We have to be at the top of the list. And I don’t mean that in any preachy way. I mean it because let’s look at the problems when we’re not, when we don’t show up at the top of the list.

We build this belief that we need other people and we don’t have what it takes to get through it, right? When we put ourselves at the top of the list, we develop and grow muscles in our brain that have us start to see that we can cope really well by ourselves. That we have everything that we need, right? That is so, so beautiful. 

And the reason I’m sharing this with you in this hopefully not preachy way is I was journaling the other day and I was really asking myself like, what is it that I want to talk about? What is it that I’m so passionate about? What is it that lights a fire inside me? And while, yes, I love talking about anxiety and yes, I love talking about OCD and I love talking about mental health and all the things, this one thing I believe is the biggest game changer above and beyond all the tools that I give you in my toolkit. 

Oh, PS, I have to tell you, I was looking for-- I was doing a Google search on Your Anxiety Toolkit because I just had to pull up something and it’s easier for me just to Google it. And when I wrote it in, this teeny tiny wooden kids toolkit showed up, like this little toolbox. And I couldn’t help myself, but I had to buy it because I was like, that’s exactly it, right? This is all about me giving you an array of tools and tools that are super effective and tools that you know when to use them. Because imagine if you had a saw but you were using it for the wrong thing, that would be very ineffective. So, that’s the whole premise of this podcast. But I was thinking about, of all the tools in the toolkit, this might be the most important one, which is the one that teaches you how strong you are. That you are the most unconditional friend for yourself, the most unconditional friend. You are there non-stop, no matter what. No matter what happens, you have the capacity to sit with yourself in compassion while you suffer. 

So, that’s it, you guys. That’s all I have to say. That’s the goal I have for you this year. And I would love to hear and to know what outcomes you get from that. So, as you practice it, don’t be afraid to, if you signed up for our newsletter, reply and let me know. How’s that going for you? How’s that helping? 

Again, I want to really be clear here. We are not showing up for ourselves first because we don’t deserve other people’s help. We’re still going to ask for their help, but we are moving ourselves to the front of the line. We’re moving ourselves to the first person we speed dial, right? And we’re showing up for ourselves as much as possible so that if the person that’s second in line doesn’t have the capacity for us today, that’s all right because we already know that the first-speed dial person, which is us, is there ready to pick up whatever is left over. Okay? 

So that is my hope for 2023. That is my hope for you for the rest of the decade as well. And this is something I feel again so incredibly strong about. Sorry, that didn’t make sense. It’s something I feel so deeply about. Okay? 

All right. I am sending you the biggest love. I have got some super exciting, big things happening in the new year. Big for me, hopefully, helpful for you. Hopefully, that will, again, give you more tools, more effective tools, make you more clear on which ones to use and when. It will mean that the structure of the podcast will change just a little but hopefully for the better. Okay? 

All right. I’ll see you guys next week and we will go from there. 

Have a wonderful day and it is a beautiful day to move yourself to the top of the list. Have a good one, everyone.

Welcome back, everybody. I am thrilled, thrilled, thrilled to have you here again, finishing out the year so strong. In this episode, we planned perfectly for this week because my guess is that you’re starting to make New Year’s resolutions or make New Year’s goals, and we wanted to talk, myself and the amazing guests that we have this week, about how you can change your habits in the most compassionate and effective way.. 

We have back this week with us Monica Packer. She’s been on the show before. To be honest, she’s like a warm hug to me. I just feel like it’s just sitting down and having a chat with a dear long friend, like an old friend. I love speaking with Monica. She’s just got such deep wisdom to her. And so, today, we got together and talked about how to change your habits compassionately and effectively. Because when people set resolutions or New Year’s goals, they’re just talking about creating new habits, like how can I create new habits in my life? How can I make a change in my life? And sometimes, we tend to do that in a very aggressive, critical way. And so, we wanted to sit down and talk about how we can do that in a compassionate, effective way.

Kimberley: Okay. Welcome, Monica. I’m so happy to have you here. 

Monica: Oh, it really is a joy. I just love everything you do and who you are, more importantly. So, I’m excited to be here again.

HOW TO CHANGE YOUR HABITS 

Kimberley: Thank you. Thank you. Okay, so you and I were chatting, and I love this idea of preparing for the hard day, but particularly emphasizing how to change your habits that prepare you for your dark day or your hard day. Tell me a little about why that is so important to you or even how you’ve implemented this in your life.

Monica: When I think back on my history with habit formation, it was clouded for a long time with these all-or-nothing models that taught me to have good habits, they needed to look this way, and it needed to be formed in this way. It needed to be consistent in this way. And a big part of that was not only were we supposed to have an ideal, we were supposed to start with the ideal. You just decide what the habit is and then you do it for 28 days, or whatever number we all have in our heads. You get to that magical number and it’s a habit. And that never worked for me. And so, for a really long time-- well, it worked for me when I was the type A, very overachieving perfectionist. But that came at a big cost in my life. And we talked about that I think in our past interview we did together. And that cost was not one I was willing to make for a long time. I wasn’t willing to sacrifice my mental and physical and spiritual health and my relationships anymore to be so performing. 

And so, because of that, I thought that was the only way to, one, progress in your life and have goals, but also trickle down to habits. I just thought I can do the habits that are required of me for my work and for my family, home management kind of things. But for myself, that was a different story because I thought, no, these are the habits I want, and they’re so beautiful and amazing and would be so helpful in my life. But in order to get there, I can’t do what that requires. I can’t, so I just didn’t. 

But then when I got back into habit formation a few years ago, which was not a plan of mine, but it just happened naturally as I was really working on identity and fulfillment in my life, I realized those two areas had to be supported with habits to just even give me the time and the energy to carve out what I needed to for those two areas of my life. And as part of that, I had to figure out habits in a new way. 

I know this is a really long answer to your question, but the nutshell version of this is that a lot of us, if not all of us, are set up to fail with habit formation in the way that we’ve been taught since we were little kids. I mean, even that number thing I said alone, like how many days does it take to form a habit – we all have a number because we’ve been taught a number. But that number is not realistic for most people, especially if you’re in a caretaking role or in any kind of position or season of life where you have to be more reactive in nature to your responsibilities. Every day is different. Every season is different too. There’s that kind of flexibility that makes it so you have to do habits differently. 

And so, what I’ve learned over the past few years is that, instead of starting with an ideal version of a habit, and that being “This is my habit,” those are only ideal. Those are only possible for those best of days kind of days. When you get really good sleep, your routine is really set. It’s more predictable. And that didn’t work for me, didn’t work for most of the women I work with. I work with primarily women. So, instead, what we want to do is both start with what I call a baseline habit and always have that be the foundational habit we come back to on our worst of days. 

The baseline habit to me is, the ideal is the highline. We definitely want to have the ideal in mind, like this is what I want ultimately. But the baseline is your foundational way to get there. It’s the form of the habit that you can do on your worst of day, when you’re really tired, when you’re going through a depressive episode, when a kid feels really sick during the night, whatever it is. And having that baseline version isn’t you lazying or-- what’s the word? It’s not you being lazy, it’s not yourself saying, “Oh, I’m just going to get my permission to not do the habit.” It’s no. This is my best-of-day version today on this worst-of-day. This is the best I can do on this day. And because I have this version of it, not only am I able to create a habit faster, like I don’t have to wait for a perfect 28 days, I also have something to always fall back onto on those days where I’m not having an ideal day. And that gives me the consistency I need to not only have that habit and what it’s going to provide for me, but also have the foundation to build on, so it gets higher and higher. And boy, I don’t even know how long I just talked

HOW SOCIETY IMPACT OUR HABIT FORMATION 

Kimberley: No, no, no, no. I have lots of questions. So, what does this look like? I love this idea – the baseline habit first. Let’s go way back. So, I think you’re referring to-- and let’s talk about what society tells us habits should look like. Now, I don’t actually have this correct, I think, but I think there’s a really famous book about habits that’s like one of the top Amazon selling that says, is it 60 days? What is the book actually saying?

Monica: Well, I’ve read every book and habit formation, so I’m trying to think of which one it is. They probably say 21, 28, or 100 days. Sometimes they say more than that. But yes.

Kimberley: Okay. So, listeners have probably read one or more of those as well, which is cool. So, let’s just acknowledge that that’s being said as the standard, but would you agree that that’s the standard for maybe people who don’t have a mental illness or people who have a kid who’s suffering? Would we agree that that’s for those incredibly lucky people or privileged people, or what would we say?

Monica: That was exactly the word I was going to use. It is a great standard and it’s a privileged standard. And it doesn’t even have to be about demographics. We can look at privileges that way in terms of gender, socioeconomic and race, and all of that. Those are all factors of course. But I would just even think about, if you’ve read those books and you learned so much like I did years ago, and then you tried to implement them and then you failed, whether it’s sooner or later, then you qualify. You qualify as, that doesn’t work for me

Now, consistency does still matter and we can talk about that, but it’s also not in the way we’ve been taught. So, there are seeds of truth that can apply to everyone in these methods that we’ve learned from and that have been so popular the past few years, but not so broadly prescribed to the general population. It’s not fair. It’s just, that’s the biggest place I actually start when I talk about habit formation, is helping people understand you’re not bad at habit formation, you’re not broken, these methods are broken for you.

Kimberley: Okay. So, that’s really helpful. And I’ll tell a story about that. I actually want to hear examples for you. I like this. I’m a pretty highly functioning person personally, but I think what’s-- but I also have a chronic illness. And by default, I think I’m actually doing what you’re talking about, but you can actually correct me maybe. I’m actually here to learn here. I’m definitely loving it. So, I have the things I want to get done on the days I don’t feel well and that looks a whole lot different to the things that I expect myself to get done on the days where I do feel well. The base, you called it a baseline habit. It’s more about expectations, I think maybe. My expectations on when the days I don’t feel well are like the basics. Is that what you talk about? Is that what you’re meaning when you say baseline?

HABITS SHOULD BE SUPPORTIVE 

Monica: So, let’s break this down just a little bit. One, starting with the idea that habits should be supportive. That’s their purpose. They’re not balls and chains to our lives. They shouldn’t be about the prescriptions.

Kimberley: It’s not a checklist.

Monica: The checklist, no. That’s the shift I can see you’ve already made, is these habits are there to support me. They’re to support me on my best of days and my worst of days. So, with that first breakdown, then baselines come in to any to-me supportive habit, personally supportive habit, whether that’s exercise, meditation, journaling, even getting up early, deep breathing, stretching, whatever those are to you. These grounding stabilizing habits, having those baseline versions is what helps you have the consistency you need to show up on those days where your expectations need to match your reality better.

Kimberley: Right. Well, that’s the point, isn’t it? Okay, so let’s talk about they have to be attached to the reality. So, what does that look like? Okay. We’ll call them-- well, how will we say it? “Hard days” and “easy days” or how will we--

Monica: I always say “best of days” and “worst of days,” but that’s really extreme language and I always preach against extremes, so maybe I shouldn’t be using that. But whatever you’re comfortable with.

Kimberley: Hard days and not hard days. Let’s do that. 

Monica: That sounds great. Because it doesn’t have to be like, you can only do the baseline if it’s the worst day ever. It’s just less-than-ideal day. 

Kimberley: Okay. So, what does that look like? 

Monica: Okay. So, let me give you a real-life example of a seasonal shift where my reality shifted, had to shift my expectations and the way I was showing up to the supportive habits. And this is more of a personal example. This summer, I was really sick with morning sickness, like really, really, really sick. And it went on for four months straight. And I’m still sick, but I’m better, way better. But during that time, I was still able to keep up my supportive habits, my most important ones, of exercise, of meditation, of journaling for my children, and of reading. But those supportive habits looked way different than my spring version of them before I got pregnant and my fall version now where I’m feeling better. I’ll take one of those examples. 

My exercise was I used to go for an hour-long walk and then do a strength training exercise video or something like that. It just turned into-- my baseline version of that was 20 minutes of slowly walking around my block. I didn’t even go far in case I needed to go home sooner. But that still was supportive enough for me to have the time alone that I needed to be able to show up to other things. 

Another example of this is, journaling for me typically looks like I have this journal for my kids that takes just a few minutes, and then I have a journal for myself that also just usually takes about five minutes. I decided journaling for myself could wait. So, I only had the two-minute version of journaling. And that still meant I would journal throughout all that time. And now what’s great about having those baselines is once the fall came around and I began to feel better, I was able to pick up my habits more in ways that match my reality. 

So, baselines, like I said, they are our less of ideal, less than ideal versions of the habits that can-- they give you the flexibility you need day to day, but season to season. So, as part of that, an important thing for women and men who are listening to know-- sorry, I’m used to talking to women, so I apologize for that. But an important thing to know is that your baselines can grow. 

Now my baselines even are different than the summer. They’re just a little bit more time intense or energy intensive than they were. Your highs get higher and your lows get higher too. Your baselines even grow. So, the less-than-ideal versions can grow too, and they have.

Kimberley: That’s awesome. And it’s funny as you’re talking about that I’m thinking of my patients. If we can keep the black-and-white view of it, like you either do it perfectly or you don’t do it, there’s often this shift. It’s like, “Oh no, Kimberley, I did really great. I did all my exposures this week,” or “I didn’t do any of my exposures this week. It’s been a ‘hard week.’” But then there can be a shift to, “Oh, I had such a hard day, so instead of doing all my exposures, I just did six minutes.” And I think that’s what you’re saying in terms of it being a baseline habit of like, they gave themselves permission for it to not be perfect so that even on their “worst day,” they were still able to get in that treatment that they know is going to help them for that supportive work. Is that what you would think of it as?

Monica: Mm-hmm. And I have a daughter who has generalized anxiety disorder. She’s on the spectrum as well. So, we have a lot of different things we need to keep up on in order for her to feel supported in her life. And even for her, we have baseline versions of these things. So, that way, in a day where she’s really struggling, we still have a way for her to feel supported without that all-or-nothing model, just taking off the table altogether.

Kimberley: Right. So, what kind of shifts would one have to make to create a baseline habit plan? Would we call it a “baseline habit plan”? 

Monica: Oh, yes.

Kimberley: Is this an intentional plan? Tell me.

SMALL, INTENTIONAL HABIT CHANGES

Monica: So, first, you need to start with some small, internal habit changes, and that’s something we alluded to. Just pay attention to what your own habit story is. How did you grow up thinking habits should be formed? How do you currently think they should be formed? How do you view your capacity to form habits? And how are all of those things actually connected to you being taught habits in ways that actually are not right for you and that’s okay? Having that internal shift to one own, “Oh, I’ve been following the wrong model. So, I’m not broken and I’m capable of forming habits.” And also, the second shift there is just the supportive one. That’s the shift. It’s not about the shoulds and prescriptions. 

Now the external shifts is, I mean, that’s where we could break down. I could talk to you for an hour and a half about that, but you mentioned a plan, and that is what I help people do, is you do need a plan. And what that looks like is actually way simpler than maybe Pinterest would show you about a habit plan. You start with casting a vision of an ideal habit that matches a need you have. So, you can think more generally first like, what’s the supportive habit I need? I need to wind down at night, so what does that look like for me? And you cast a vision of what could that entail. And then what you do is you take that version and you make sure, one, it’s supportive. So, it’s not about a should. You make sure it’s really small. So, it needs to be-- well, we talked about the baseline version of that, but small is like broken down. So, not a full routine yet. We’re just starting with the first step. Simple is your baseline version. That’s like, what is the simplest version of even the small habit that I can start with? 

MEDITATION HABITS 

For an example, meditation habits, maybe you have a whole nighttime routine ideally that you would like and you know what that looks like. But you’re going to start small with just the habit of meditation at night. And then from there, you’re going to start by making it simple, and that means what’s the baseline version of that? The easiest version of this habit is one deep breath. That’s my baseline for meditation. And that actually was one of my habits during the summer. I still meditated all summer, but it was usually just a deep breath or 10 at night as I was falling asleep and just trying to clear my mind. 

So, we have supportive, small, simple. And the last thing here is specific, and specific means you don’t just say, “I’m going to have this new habit and I’m starting it tomorrow.” That’s not specific. You need to have it tied to an already existing habit and form what I call a when-then pairing. So, get clear about, okay, what already happens at nighttime that I can attach this new habit to? And they might be things-- actually, not even might. Most of the time, the existing habits are things you don’t know are habits because they are habits.

Kimberley: Like brushing your teeth. 

Monica: Yes. Dress in the bathroom, brushing your teeth, getting ready for bed. Or mine at night, honestly, a lot is just starting the dishwasher. Who knew? Oh, that’s a habit. I do that every night. So, it’s something like identifying what’s an existing habit around that time and attaching that supportive, small, simple habit to. That’s your habit plan.

Kimberley: Interesting. So, for those who-- let’s say, I’m going to offer the listeners. Let’s say, most of the people who listen, their goal is to face a fear. That’s my crowd. That’s my people. We face our fears. 

Monica: Love it. 

Kimberley: So, let’s say we’re trying to increase our ability to face a fear every day. So, what you’re saying is, find a habit you already do and attach it to the time in which you do that. So, let’s say if your goal is to do an exposure – that’s often the biggest form of facing fear – in order to get it to be a daily thing that you’re consistent with, you would find a time of the day that you would be already doing something. Often I’ll say, as you drive to work, you could do it while you’re driving to work. Is that what you’re saying?

Monica: Yeah. You’re nailing this. Exactly.

Kimberley: Okay. What if you don’t want to do the habit, but you know you should because it’s supportive?

Monica: So, this is going to-- you just did the biggest disclaimer there. If you truly love the result and the result is what you need in your life, shoulds can still be chosen. We don’t have to totally take shoulds off the table. And there’s a lot of that kind of talk, I think, out in the personal development world like, “No shoulds.” But honestly, I don’t feel like doing a lot of the things I need to do most days responsibility-wise. They are shoulds. But they are chosen because of the results or because of the benefit or what I know my responsibilities need me to do. 

Shoulds can be chosen. So, if you’ve deeply truly chosen the should, which is the first step, then you have to get clear about your baseline. And ask yourself, is this actually a baseline? Because it needs to be so small and simple that you can do it even when you don’t want to. That’s how small and simple it needs to be. And once you do that, you get the momentum, which is a whole other topic. And you might organically be like, “Oh, I can do another deep breath, or I can spend another minute on this exposure,” and ride that wave if you feel like it.

Kimberley: Right. And so, what I would offer to people if I’m going off of your example is, on your baseline day, on your hottest day, you could purposely have a thought you don’t want to have, and that’s it. That could be your baseline. Or another would be, let’s say there’s something you avoid. You could just do it for one minute, be around that thing you avoid for one minute. Is that what we’re looking for? Like one minute? 

Monica: Exactly. 

Kimberley: Good. Baby steps.

Monica: Yes. And don’t underestimate the power of these baselines. One of the biggest powers is momentum that I mentioned, but the other biggest one that honestly to me might even be more weighty than the momentum is the confidence. It’s the identity shift and how you view your capacity to form habits, and your capacity to follow through with the things you say you’re going to do for yourself.

Kimberley: Right. Isn’t that such a big piece of it? Like how many times have I-- let’s say a client has panic disorder and getting on the elevator is so painful because they’re so afraid of having a panic attack on an elevator, for example. And they’re standing at the doors and they’re saying, “I can’t. I just can’t do it.” That’s that confidence piece, right? Because we know we can. We could actually argue like, “No, you just take one foot and you put your foot on the elevator and then you put the other foot on the elevator and you’re in the elevator.” I think that that’s an interesting piece. And I talk a lot about motivation, but what you are bringing to the table, and correct me if I’m wrong, is there are many ways in which we could get motivation and momentum and confidence, but habits is another way.

Monica: Yes. And for me, these baseline versions are, go to a bigger picture concept that I teach in my community of creating momentum instead of waiting for motivation. And it’s just physics. It really is just using physics here. But like you said, it’s the confidence piece. It’s the identity piece of being someone who can face fears, of someone who can show up for themselves, even on the hard days, on all these levels that we’ve talked about. It really helps. The identity piece too is really important.

CHANGING HABITS WITH CHRONIC ILLNESS 

Kimberley: Right. Okay. So, you’re having a hard day. You originally, when we were chatting, were talking about the dark days. We call them a dark day, a hard day, the worst day and all the things. On the days where that’s the hardest of days, the darkest of days, we usually have a lot of thoughts about our capacity to do hard things on the dark day. I know we touched on this, but what is the mindset shift to allowing yourself to be in a baseline day? I’ll give you a personal example. When I have POTS, when I’ve massively relapsed, the day before I could walk three miles, no problem. And on my relapse days, I am lucky if I can get around the block. Lucky. That is lucky. And so, what needs to happen there to give ourselves permission to-- because I’ve actually been the person who goes, “Nope, I refuse this to be a bad day. I am going for that damn three-mile walk,” and then all hell gets broken. It’s horrible. There’s consequences to be paid for pushing myself. So, is there a piece here about the permission? That’s the main last piece I want to ask.

Monica: Oh yes. This alone takes a tremendous amount of courage. People, they think, “Oh, what? Habit probation takes courage?” Yeah, it does, especially if you’re doing it differently than the way that you’ve been taught. And this is where I would go back to something about proving yourself wrong. Doing something in a different way as a way to bolster your confidence and also your know-how, but to say like, “Maybe I can just try to see, I can just prove my old self wrong here. Does this still help? Is it still a way to show myself I care about myself?” on your really bad days where you’re recovering. Is this stretch still giving to your body? Is it still saying “I see you” and “I love you and I’m trying to help you and I know you’re trying to help me”? Maybe you can’t even do that block, but you can do a sense salutation or sorry, that’s the movement I keep doing over here, like what is she doing? That’s the movement I keep doing. 

What I would help people do who are stuck in that all-or-nothing mindset, it’s so hard to let go of. Believe me, I know. Adopt the mindset of curiosity of what would it look like to try this out? Can I prove myself wrong? And I would also get a little logical and look back on your past and say, “Overall, how has this all-or-nothing model served me? Has it helped me more or hurt me?” For the high majority of people, high majority, it hurts more than helps. 

Pay attention to the price you have paid in the past for the all and just acknowledge it takes real strength to do this. That’s one thing-- I had a client say this years ago. She said it takes the greatest of courage to do the smallest of things. And that’s where I would end. Just dare to have that courage to try the smallest of things and to try them again and again and again and see over time. You’ve got to give yourself that time to see how it can prove yourself wrong overall. And that these small ways we invest in ourselves, not only add up, but they count in the moment too.

CREATING A HABIT PLAN 

Kimberley: Right. So beautiful. I have one more tactical question before I let you go. So, would you have people have a breakdown of all the steps to create a habit plan? Meaning, let’s say the goal is to get-- a lot of people here are working at developing a good exposure plan. Let’s say we’re goaling towards 30 minutes a day. Would you say, “Okay, on the dark hard days, we do two minutes. So, that’s reserved for the dark hard days. And then from there, we’re going to work at two minutes, three minutes, four minutes, five minutes, six minutes. And then by the end of the month, we want to be at nine minutes.”? Would you break it down like that or is that actually the opposite of the plan here that you’re trying to go for in terms of a supportive plan?

Monica: So, the bigger question I believe you’re asking is, how do we build, do it strategically or what does that look like? I would say that depends on what the habit is and the purpose of the habit. So, if this is more of like a therapy-based habit that you’ve been working on with clients, I would say it might be helpful to have that game plan. Perhaps not based on a certain time, but more about how consistently they’re able to perform the baseline version, and from there have the foundation they need to build. 

In general, though, for most habits, it goes two ways. You can either maximize or add. You can do longer amounts of the habit or more intensity, that’s maximizing, or you can add. That means you add another step to the bigger routine you want. And I find that can go two directions. One, strategically, you can think like, okay, this is my game plan. Maybe I don’t have an exact deadline, like in two weeks. It’s more organic feeling. It’s more intuitive. I feel strong enough. I feel like I’m in momentum. I feel like I have the structure I need to add or to maximize. But yeah, it still can be done strategically. But most of the time, it just happens organically. You just are able to-- that baseline rises, like we talked about. And as a baseline rises, that means you tend to have more like normal days in between days where you can do a step or two above naturally and organically. 

So, that depends. But ultimately, I think, have trust in yourself to know what you need for a specific habit. Do I need this to be strategic or am I okay to do this more intuitively and organically? But no matter what, starting with the ideal in mind is what gives you the target that you are headed towards.

Kimberley: Right. And that you can, any day, even if you’re on your way up to the strategic plan, you can rely on your base plan if needed. That’s your backup.

Monica: Always, always. And even over time, as your baselines rise, you still have that under baseline you can always fall back to. If seasons change, your life change, circumstances change, your health changes, those are always there for you.

Kimberley: Right. Love it. All right. Tell us where we can hear more about you.

Monica: Well, I am a podcaster on About Progress. We’re a personal development show. We don’t just talk about habits there. We talk about a lot of things. And I’d love for them to come and listen. And I do have a course on habit formation and it’s for women. I know there are men listening here, but it’s primarily for those who identify as women because of the bigger thing I have to teach about why habits spell in particular for women. So, it’s called the Sticky Habit Method, and they can go check that out at aboutprogress.com/stickyhabitmethod. And it says sticky habit because you form habits that stick.

Kimberley: Nice. I love it. Oh my gosh, it’s so wonderful to have you. Like I said, your episode about perfectionism that we’ve done is a really high-rated episode. If you want to go back and listen to that, that would be cool too. Yeah, absolutely. 

Monica: That’s really the heart of all my work, including habit formation. Who knew I would even get into habits, but we’re here.

Kimberley: I love it. I love it. Thank you so much for coming on. I’ve loved listening. I’ve been the student today as well, so that was awesome. 

Monica: I love that. Thank you.

Kimberley: My pleasure. Thank you so much.

LINKS: 

PODCAST http://aboutprogress.com/podcast
STICKY HABIT METHOD https://www.workinprogressacademy.co/sticky-habit-method
FREE HABIT CLASS FOR WOMEN https://workinprogressacademy.mykajabi.com/women-habits-class

In this podcast:

• Laura Ryan tells her story of overcoming superstitious Obsessions 
• How to manage Whack-a-mole obsessions
• How her family helped to support her as she overcame Superstitious OCD 
• How to get through the hard OCD days
• Perfectionism and Exposure & Response Prevention

Links To Things We Talk About:

• ERP School: https://www.cbtschool.com/erp-school-lp

Episode Sponsor:

This episode of Your Anxiety Toolkit is brought to you by CBTschool.com.  CBTschool.com is a psychoeducation platform that provides courses and other online resources for people with anxiety, OCD, and Body-Focused Repetitive Behaviors.  Go to cbtschool.com to learn more.

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EPISODE TRANSCRIPTION

Kimberley Quinlan: Well, welcome, Laura. I am so excited to hear your story today about Overcoming Superstitious Obsessions. Thank you for coming on the show.

Laura Ryan: Thank you so much for having me. I'm so excited to be here.

Kimberley Quinlan:  Yeah, so it's wonderful. I love the stories when I accidentally meet people online, and then we have this cool story that's together, but we're not like not together at all. So I love hearing your story for the first time today, and I love that. I've been a small small part of that journey for you.  Tell me a little about you and your backstory in, you know, the area of recovery.

Laura Ryan:  Yeah. So I definitely would have had OCD my whole life, but it wasn't until I was about 17 or 18 years old that I just stumbled across something on the Internet where I was like Oh yeah, that sounds like me. I've got OCD, but it didn't. It wasn't stopping me from doing anything at that point. So I just ignored it and went on. I had three Uni degrees under my belt. I was working at a publisher and freelancing as a book editor, and then

Laura Ryan:  my family had some health issues, and my sister as well, had some relationship issues, and I don't think I knew what to do with the stress. Um, and OCD crept up. So gradually, it was undetectable, and then sudd,  I found myself at age 22 with crippling compulsions.

OVERCOMING SUPERSTITIOUS OBSESSIONS AND BREATH-HOLDING COMPULSIONS

Laura Ryan:  It was nothing short of torture. It was horrific. I was so ill with OCD that I would come home from a day at work, and I wouldn't even remember the day because I'd spent the whole day in fight or flight. And I had mental sort of thought replacement and breath-holding compulsions. So it was completely invisible to people around me, but it was able to kind of have control over me for the whole day. Like from the second, I woke up to the second. I went to sleep. When I eventually saw a doctor, the psychiatrist was like, Oh, and how often are you affected by these thoughts? And I just didn't understand the question because I was like, Well, every few seconds, I guess.

Laura Ryan:  Yeah, so they were weird. Compulsions, like a lot of Shame around them as well because they were all kind of magical thinking superstitious. Like there was no logical link. They were all like, I'm holding my breath because I think I will magically give someone a disease if I breathe out while looking at them, or Yeah, just weird. We had rules that made absolutely no sense.

Laura Ryan:  which, Also. yeah, it impacted my self-esteem because I've always thought of myself as a Logical person, but these just made no sense.

Laura Ryan:  yeah, I also became stick thin because if I, and it wasn't even anything to do with the food, it was just if you eat this food, the intrusive thought will come true. And I, it just wasn't worth their Stress of eating. and then, there was a point where

Laura Ryan:  I would have conflicting compulsions, so OCD would kind of be like if you do this thing or if you don't do this thing, the intrusive thought will come true, and then I would just stand there paralyzed Like unable to do anything. I don't like to think how long I've spent just standing still, like the pervasive slowness, I think it's called was just Yes, stopped me from. Doing anything? Some nights it would have taken more than an hour to get to bed. It was just I had to touch wood or Rearrange things for so long before I was able to get to sleep. yeah, so I'd been a really

00:05:00

Laura Ryan:  Pleasant child and teenager big people pleaser perfectionist type person, and then all of a sudden I was this irritable, distracted young adult, and I didn't like who I was, and no one in my family knew what was going on with me. Um, and yeah, I was eventually unable to work, and I quit my job. And I was too anxious to Google things. So I looked up OCD on my podcast app, and that was when I found you were a guest on the mental illness happy hour, I think, and you played this game of one-up together, and it was like, It was incredible. It was like it was. Yeah, it was the first time I had

Laura Ryan:  heard of ERP and OCD.

Laura Ryan: Yeah. Sorry, it was the first time I'd heard of ERP and Anxiety treatment that wasn't just meditation or gratitude, which are helpful. But sometimes, when you're in that dark place, the only thing that can get to you. It is something dark itself but also brings that humor as well. I think it is just the most powerful tool you can have when you're there. Then I started looking up Absolutely everything Kimberley Quinlan. I was absolutely your number one fan. You say you had a small part in my story. You had a huge, huge part in my story. Because I was way too unwell to drive. There was no way I would go to my GP and get a mental health care referral. I was not going anywhere near Medical Center. And barely making it out of the house. So, when I found your ERP school to do online, it was nothing short of life-saving. I was able to get enough to go to the GP then and get a referral to see a psychologist.

Laura Ryan:  Yeah.

Kimberley Quinlan: It makes me want to cry, it does. And when can I ask a couple of questions about that when you said There's no way you would have gone to the GP because of the obsessions that held you back or just the shame of it? What was there? Another reason that that was such a huge step for you?

SUPERSTITIOUS OBSESSIONS & SYMPTOMS

Laura Ryan:  It was mainly the superstitious obsessions. If I go there, I'll contract a disease or give someone a disease. Not even in a contaminated way. Just like a magical way. Yeah.

Kimberley Quinlan: Mmm, yeah, yeah, it's funny. I don't know when I'm helping people because you just don't know what you know. Just for those who are listening, the Mental illness happy hour is an amazing podcast, and then the host had no idea what OCD was. And so, we did play a game of one up, which is where we kind of, he said something scary. And then I went up. It was something even scarier and even more gruesome and horrible. Was that something that you started practicing on your own just from that episode? Or did you take up his school to follow the whole process?

Laura Ryan: A bit of both. I kind of took the one up and…

Kimberley Quinlan:  Inflecting.

Laura Ryan: I ran because I think it just helped me. so much immediately, and then ERP school was able to lead me through in a more systematic way. Yeah.

Kimberley Quinlan: Okay. Amazing. Oh, I'm so happy that I could be there. It's not so cool.

Laura Ryan: Yeah, absolutely.

Kimberley Quinlan: It's so cool.

Kimberley Quinlan: Especially you're my Aussie friend too. That just brings me so much joy. So as you and I emailed in preparation for this,  you beautifully and eloquently shared some of the pieces. I would love to hear from you if you spoke briefly about how your OCD evolved. Would you be willing to share a little bit about what that looked like for you?

Laura Ryan: Yeah. Yeah.

Laura Ryan: I had every kind of OCD, so as soon as I started doing ERP, OCD came back with a vengeance with some new topic and…

00:10:00

Laura Ryan: as I think a lot of OCD sufferers know, it can be especially difficult, when a new topic shows up because you don't know what's happening you are unfamiliar with. the sorts of thoughts it's going to throw you, and you don't know how to fight back yet. I remember when it initially switched from this sort of magical thinking superstition to moral OCD. 

Laura Ryan: Hit and run OCD, and I've heard stories about OCD sufferers turning themselves in for crimes they didn't commit, and that was absolutely the kind of thing I felt like doing at that point. I was like

Laura Ryan:   Although usually, I would panic when I was driving, I would constantly be checking in my rearview mirror, recycling, back driving around, again and again, to make sure I hadn't hidden anyone and then,

Laura Ryan:  Yeah, I think it just Really. OCD will fight back.

Laura Ryan:  Yeah, absolutely.

MANAGING WHACK-A-MOLE OBSESSIONS

Kimberley Quinlan: that must have been pretty terrifying for you, though, or demoralizing for you for it to be sort of wack-a-moleing. Whack-a-mole obsessions are when your obsessions are changing from one obsession to another.  Your obsessions will be one up and one down. Switching between obsessions each day or even hour. How did you handle that?

Laura Ryan:  um,

Laura Ryan:  I think, just I think the main thing was staying in touch with the online community and because Every thought you've had, no matter how crazy it is. Someone else has had it, and someone else has probably done a compulsion. That's Like as, or more embarrassing, is something you've done.

Laura Ryan:  Yeah, I always think when I have a thought I met someone else's had this, and then I'll go on like OCD Reddit and find that they have.

Kimberley Quinlan:  Right. Absolutely. So so, that's how it evolved. Wait, you shared. Also, Where are you now? Like what does life look like for you now? Having gone through and know, you'd said You'd moved on to getting treatment. What's life like for you Now? What does recovery look like for you?

Laura Ryan: So, yeah, I spent the better part of two years just really taking the time to get better. I was doing bits of freelance work, but it shouldn't have been because it was taking me way too long. I wish I'd just given myself permission to rest properly. and I don't know whether this was a part of moral OCD or whether I like to think it's just part of who I am. Still, I didn't want to go back into publishing because I Um felt like I wanted to do a job helping other people, and I especially wanted to give back to the healthcare world.

Kimberley Quinlan: It.

Laura Ryan: That helped me so much. When I went, I went to the hospital to do an inpatient OCD program. And the people working in the program were obviously psychologists, psychiatrists, and occupational therapists. And so, I wanted to do a course in OT. But

Laura Ryan:  Then I saw speech-language, pathology, and I've been doing that course for the last two years, and I'm just about to graduate. So, Yeah.

Kimberley Quinlan:  Wow, that's so cool. Does OCD have something to say about you returning to school for that? Like, how did it How did your OCD handle that decision?

Laura Ryan: Oh my gosh, it was so. mad at me for picking something that I needed to do hospital placements to complete. Especially being speech-language. I think they called in America speech-language therapists, in hospitals, at least in Australia, there, they see the people with the Like worst neurodegenerative or the scariest diseases, or they've just had a stroke. Like, really, the most triggering things I could have thought of at the start of my journey. And yeah, and like, you have to like to touch them and would never ever have thought that I could have done this a couple of years ago.

Kimberley Quinlan: Yeah. In ERP school, we talk about your hierarchy, right? Like it would have been a 10 out of 10. I'm guessing you're like doing 10 out of 10…

Laura Ryan: Yeah.

Kimberley Quinlan: it's incredible of all the careers; you picked like your 10 out of 10. That's incredible. Right. Yeah. So was that like a decision? Like I'm doing it as an exposure, or is it just like your values led you there to get to that place?

Laura Ryan:  It was definitely my values and took me. And my therapist, a lot of coaching to get me through. Yeah.

Kimberley Quinlan:  Wow, it's so cool. It's so cool. It's like perfect, right? Because it's so often, I hear of people who have the career that they wanted, and their OCB gets in the way, right? You know, there he'll have health anxiety in there, and us or they have their teacher, but they have thoughts of, or pedophilia obsessions and impacts their work. Like you, you went the other direction where you moved into the career after your treatment which is just so cool. I love that you did that. So one thing you shared, Was what you find hard, and I love that you included that piece in what you find hard. So, would you be willing to share, What do you find hard? We talk about It's a beautiful day to do hard things, but What is it? It's okay that things are still hard. What do you find still hard?

Laura Ryan: Yeah, I find it now that I have so much functionality back compared to where I was not leaving the house to pretty much do everything that I want and need to, I find it hard to find the motivation to do ERP to kick those last mental compulsions, and those things that kind of still follow me around all day. Yeah, I think. I think now it's less about functionality and now more about doing it to get back that quality of life.

Laura Ryan:  which, yeah, I think I often find really hard to  it's much easier to. When you're doing ERP to reason with yourself, oh, I deserve to be able to leave the house and go to the shops. And so that's why I'm doing this thing that feels so awful. But when you're just saying, “Oh, I'm doing this now just because I want to be happy.” It's a lot harder to reason with myself

Kimberley Quinlan: Yeah, it's like you said at the beginning and I've heard that many times that if it's not impeding in your functioning, it is easier to sweep it under the rug and cope and not address the problem. And I've heard that many times. So I think that's a really valid point of, you know, a lot of people will say like there's a really strong. Why are they doing the exposures? There's not a strong why it's hard to do it. How are you learning or starting to practice tools to manage what's worked for you? And what hasn't

Laura Ryan:  'm getting a lot better at being less of a people pleaser and getting better at not putting everyone else before myself filling up my own cup so that I have some to give to everyone else. Yeah, I'm it is hard, but I'm definitely getting better at doing things because

Laura Ryan:  Yeah, if I give myself that, Quality of life. I can be. Even at least I can be if not for me, I can be there better for my family and friends.

Kimberley Quinlan: Yeah. Yeah. Is there you know, if you were to work? I mean, I'm assuming people listening are having similar struggles. Can you walk me through moment to moment how you muster up motivation? Or maybe it's a different experience to get yourself to do. Those exposures? Like, what do their steps involve? Or how do you get to that place?

MOTIVATION FOR ERP

00:20:00

Laura Ryan: Yeah, one of my favorite tools is just before I do anything. So if I'm if I've just driven in the car to go somewhere, I will take one minute before I get out of the car, I will take one minute. and just Kind of have a word with myself and OCD, and I'll be like, right, what's OCD? You're going to throw at me. It's going to say this, and then what will I do? I'm going to do this, and then how's OCD going to push back? And then what am I going to do? Like just having a game plan before you do.

Kimberley Quinlan: If?

Laura Ryan: Functional things for those mental compulsions.

Laura Ryan:  I find it's a really

Laura Ryan:  it's really helpful for me because I don't have to kind of set aside time and find that motivation to do it. I can just kind of plan and make ERP tasks out of, going to the shops or seeing a friend or  things like that.

Kimberley Quinlan: Yeah, that's cool. It's, I think of it, like Olympians or, you know, high-performance athletes as they, they do that same thing. They're high performing, you know, the high performers there, they're rehearsing. You know the strategy to get through that really hard moment. It sounds like you're doing something similar there, which is really cool. I'm fascinated by that, sports psychology piece of it, right? I think that's so cool. All right, you had mentioned, which I thought was fascinating, what OCD gave you. Now, this is sort of a controversial topic…

Kimberley Quinlan:  Okay. So one of the things that you wrote as we were emailing was what OCD gave you right, which I thought was so fascinating because usually, we hear stories are like, I hate OCD, and it's the worst thing ever. And I hate everything about it, and we even know there's some controversy of some people who have sort of misused OCD. I loved what you had to say. So, would you share it? What were your thoughts regarding what OCD gave you?

Laura Ryan:  Yeah, I definitely don't get me wrong. I think OCD is a very unique form of torture, I don't think it's. Yeah, it's horrible. It's absolutely. Yeah, I think. When you said it was one of their Top 10 Most debilitating disorders, you can have either physical or mental. Absolutely. I think it's just Awful. But I think going through treatment gave me this really, really,

Laura Ryan:  I was able to see these incredible sides to my family and friends. they were just so, Incredible at every turn and so accepting of something that's really hard to understand.

Laura Ryan:  and, Yeah, it's also just constant reminders to follow my values. Like if, if you're having a hard day with OCD, the only thing you can use is to get yourself out of that. is to be like, okay, well, What am I doing? What am I valuing? And the treatment is kind of mindfulness and coming back to

Laura Ryan:  What's important? So yeah, I think I'm I'm quite lucky to have those. those treatment principles kind of under my belt because, I think everyone can use them because they're just

00:25:00

Laura Ryan:  Yeah, that's how you have a better life. Yeah.

Kimberley Quinlan: Yeah, that's true. It's so true. And you, you talked about your you had sort of a shift in motivation to sort of take care of your health. Was there a shift in that for you? Once you started going through OCD treatment? That was when further beyond just your mental health,

Laura Ryan:  yeah, it was it kind of turned into adding in. Meditation moving my body a lot.

Laura Ryan:  Yeah, I I remember going down this because I had access to my uni like academic journal database, and I am early on. I went into a lot of obvious research about ERP and OCD. But also SSRIs and exercise.

Laura Ryan:  and I think people found Or some people. And at least for me, I find Like, I'm staying on the SSRIs, but exercise is. As effective for me as those. So if I Do them both. It's like supercharges it so good. Yeah.

Kimberley Quinlan: Yeah. Yeah, absolutely. The research backs that doesn't it? So that's so good.

Laura Ryan:  Yeah.

HOW TO GET THROUGH THE HARD OCD DAYS

Kimberley Quinlan: That's so good. All right, the last thing I question I have for you it's just makes me giggle and smile and feel all good. Inside is tell me a little bit about what gets you through the hard things because that's what this is all about, right? That's what our whole message is. What are some of the things that get you through the hard things and the hard days?

Laura Ryan:  And definitely remembering my sense of humor. And Kind of encouraging the people around you. Because I'm not as. I'm not super comfortable yet telling my family and friends to You know, help me with exposure tasks, but if you can tell them, they help me laugh about these things. They'll They can people can do that, people know how to, and they want to, and it's really good.

Kimberley Quinlan:  Yeah.

Laura Ryan:  Yeah, also, if you go on the go on Reddit and look up Reddit OCD memes,  it's the best. It's so good. It's like and John Hershfield's means they're so good, and they

Laura Ryan: Again they like they get into these really dark awful themes but then we're laughing at them and I think that's just the fastest way to get power over OCD.

Kimberley Quinlan:  Yeah.

Laura Ryan: um, Yeah,…

Kimberley Quinlan: Yeah. Changes the game.

Laura Ryan: it's really cool. Definitely.

Kimberley Quinlan: Doesn't it right when you find? Yeah, it really really does. And you did talk about the game plan Already.

Laura Ryan:  Yeah.

Kimberley Quinlan: You mentioned something called a panic inventory. Do you want to share a little bit about what that is?

Laura Ryan:  Yeah, so I hope it's not a kind of reassurance knowing that I can go back and check it, but I never do. And so when I have an intrusive thought, I just write it down in the notes of my phone and it's stops me from doing things like, checking the police news or asking for reassurance, or like, if I have the thought written down, and it's there, and I can think Laura, you can come back to it like it's there. It's not going anywhere. You can come back to it tomorrow or next week, or even just if you can hold off on doing this compulsion for an hour, the thought will still be there. You can still

Laura Ryan:  Address it. If it still feels urgent, then and yeah, some of them only last a few minutes, some of them last a few days. But I've never come back to a thought a week later still panicking.

Kimberley Quinlan: Mmm, that's cool. It's funny, it makes me think about as With young children, when we're treating young children with OCD, we talk about their OCD box, and they imagine putting their thought up in the box and they leave the box there, not to kind of make the thoughts go away. But just like it's there, you can bring it with you. The box is always with you and…

Laura Ryan: Yeah.

Kimberley Quinlan: we're just not going to let it be there, and we're gonna go about our lives. Anyway, so does it sound like that for you? Is that kind of mindset there? yeah, so that I love that…

00:30:00

Laura Ryan:  Yeah, absolutely.

Kimberley Quinlan: because what you're really doing is you're saying I'm willing to let the thought come with me. And I'm gonna be uncertain about it and sort of staying very present. Like, we'll worry about it later, kind of like not that you're planning to worry about it later but she'll deal with it when it needs to be dealt with which is sounds like never Really okay.

Laura Ryan: Yeah.

Kimberley Quinlan: I love that. I love that. Yeah, okay, cool.

Kimberley Quinlan:  Anything else that you found to be helpful in getting you to where you are today in this really cool story?

PERFECTIONISM AND EXPOSURE & RESPONSE PREVENTION (ERP)

Laura Ryan: Yeah, definitely. I think the Perfectionistic side of me thought that every ERP exposure had to be. 10 out of 10. Full-blown panic attack level, but it's At least for me it's only gonna work for insofar as I'm willing to actually feel what it brings up. So

Laura Ryan: I think they the best exposures for me are the ones that just feel mildly uncomfortable and even to the point where I'm sitting there and I'm like, Oh, am I, Even bothered by this. Like, it's sometimes I feel like I'm lying or…

Kimberley Quinlan:  Mmm.

Laura Ryan: Or I don't have OCD or yeah, I think those tiny. Yeah. Like a hundred. Many exposures are way way better than one, one giant one, at least for me.

Kimberley Quinlan: Wow. That's cool. I'm so glad you brought that up, and because that is actually, interestingly, I'll share with you when I'm supervising my staff. That's probably one of the biggest questions that my staff come with of like, my client seems to be wanting to do these crazy high hard explosions and it feels like it's sort of compulsive in that they're doing these exposures.

Laura Ryan:  Yeah.

Kimberley Quinlan: And I think you're speaking to this really important topic, which is the exposure should Simulate the fear and the uncertainty And so you're saying, I think. But correct me if I'm wrong Doing a small exposure actually simulates in brings on other obsessions and fears along the way. So that's how you're doing your exposures. That's so cool. Is that correct?

Laura Ryan: Yeah. Yeah, absolutely.

Kimberley Quinlan:  Yeah, wow. And we say Any happy school. We talk about doing a b minus effort, right? Like not doing it perfectly and sometimes perfect. You know, purposely making an exposure imperfect has, was that a trigger for you? As you went through this process of trying to make the exposures perfect? Yeah.

Laura Ryan: Yeah. Absolutely. I remember, I came to my first session with my psychologists, like, with a printed out, hierarchy of like this. Yeah. Everything was scored perfectly and I was ready to work from. Yeah. Number one, to number 10 in and cool. According to the research, we should be done in 12 weeks and then I'll say See you later. That was really…

Kimberley Quinlan: You like my schedule,…

Laura Ryan: no, it works.

Kimberley Quinlan: It says right here. This is how dispersed to go. Right, right. Okay. And it didn't work out that way. No, no that would have been hard to take.

Laura Ryan:  Yeah. Yeah.

Kimberley Quinlan: Yeah. Yeah, I have loved hearing your story. I'm so grateful that we got to meet in person and connect. You know, it's sort of a full circle moment for me and I hope you know that you should be so proud of the work you've done and how far you've come.

Laura Ryan: Thank you so much. Yeah, I can't believe I'm talking to you.

Kimberley Quinlan: Yeah. I know,…

Laura Ryan: Yeah, it's awesome.

Kimberley Quinlan: I'm so happy to have you on the show, I really? And that's again, I say it all the time, like it just to know that. That. People can make small but very mighty steps on their own. Is the whole mission here,…

Laura Ryan:  Yeah.

Kimberley Quinlan: right? Is that just even if it's the first step, I'm so happy if that's the step that people take. So I'm so grateful for you for sharing your story.Laura Ryan:  Thank you so much for having me.

SUMMARY: 

• How to include family members in ocd treatment
• Supporting siblings during ocd treatment 
• How to apply the “be seen” model
• Ocd family therapy: including siblings as “assistant coaches” 
• Developing empathy during ocd treatment

Links To Things I Talk About:

• ERP School

• https://peaceofmind.com/for-siblings/

• OCD Stories (with Jessica Serber)

• https://theocdstories.com/episode/dr-michelle-witkin-siblings-and-ocd/

• https://www.amazon.com/When-Family-Member-Has-Obsessive-Compulsive/dp/1626252467

• When a Family Member has OCD

• https://www.anxioustoddlers.com/psp-050-explaining-ocd/#.Y2Lc2S1h2Tc

• Krista’s webpage

• Instagram: @anxiouslybalanced

Episode Sponsor:This episode of Your Anxiety Toolkit is brought to you by CBTschool.com.  CBTschool.com is a psychoeducation platform that provides courses and other online resources for people with anxiety, OCD, and Body-Focused Repetitive Behaviors.  Go to cbtschool.com to learn more.

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EPISODE TRANSCRIPTION

Kimberley Quinlan: Well, welcome Krista Reid. I am so excited to number one connect with you, but to talk about a topic that I don't talk a lot about which is something that I'm excited to really talk about with you today.

A Peaceful Balance Wichita: Yes, thank you so much for having me.

Kimberley Quinlan: So welcome.

A Peaceful Balance Wichita: I'm excited.

Kimberley Quinlan:  Yeah. Look at you. You're all the people who don't see, you're like everything's bright and it's so happy. It makes me so joyful just to see you.

A Peaceful Balance Wichita: Thank you, anybody. That has met me. Will get it. I'm a very colorful person. Thank you.

Kimberley Quinlan: I love that that we need more of you in the world.

Kimberley Quinlan: I really feel Yeah, good thing. I made children that sort of created more of me, right? That's the best I can do.

A Peaceful Balance Wichita: I we need more of you.

A Peaceful Balance Wichita:  You go. There you go.

Kimberley Quinlan: All right, let's talk about supportive siblings. Let's talk about…

A Peaceful Balance Wichita:  Yeah.

SIBLINGS AND OCD

Kimberley Quinlan: how the family can play a role in recovery. I kind of want you to take the lead here and tell me everything, you know. So tell me a little bit about why this subject is important to you and how you used it in clinical and in the field of OCD.

A Peaceful Balance Wichita: Yeah, absolutely. And so I'll give you just a little bit of background. I always have been interested in sibling dynamics, and in fact, when I was in grad school completing my thesis, I even consulted the director of the program. I said, Are there any theories about siblings? And he's like, well, you know, there's the one by Alf or Alfred Adler on birth order. But really outside of that, no and that has just always been so entirely profound. Because when we think about family work, if you're looking at family theories, if you're looking at different types of family interventions and models, a lot of them really focus on parent child. And when you're dealing specifically with a child who has an, I'll go into the physical medical side as well, because I don't think this is exclusively just OCD or just mental illness.

Kimberley Quinlan: Mmm.

A Peaceful Balance Wichita: when we're seeing that a lot of times, the model is fixated on the child with the medical issue and the parent And what I was finding was that siblings. They kind of get othered In this. It's full process and the definition of other. It is essentially, you know, being excluded from meetings being excluded from family sessions being excluded in some way, shape or form. Now I could see how potential listeners will say, Well, isn't it that child with the OCD the child with the medical issues othered Yes, I'm not debating that at all, I'm saying, primarily within the family unit, that the sibling themselves can get very other and siblings struggle when their sibling has a disorder. You…

Kimberley Quinlan: Mmm.

A Peaceful Balance Wichita: they can struggle emotionally, they can struggle behaviorally. You know, just looking at the construct of OCD, they could struggle with the with the grief. Of their sibling having OCD, the moods that may come with the disorder. And oftentimes, this can lead to resentment within the sibling relationship, or even guilt or shame. And I I have siblings, and I think this potentially might be even where a lot of my work is very important because I am very close to my siblings. I am super close. Like I I feel like I'm very fortunate. I have, I have amazing relationships with my siblings and so it absolutely breaks my heart when you see a child.

A Peaceful Balance Wichita:  Who who has this? Some type of distance within their sibling relationship either because they themselves have the disorder or their sibling has the disorder. And so, I started finding different ways to incorporate siblings and to the therapeutic model. I'm really big into family work. I don't understand how special when you're working pediatrics pediatrics. And that's primarily what I'm going to focus on today is a pediatric work. I don't understand how when you're working with pediatrics? How you you can't have the family involved? To me, that doesn't make any sense because we're seeing, especially in the outpatient world, we're seeing these kids an hour a week, so tops four hours a month. Pretty sure there with their families, a lot more than just four hours a month. and then thinking about,

A Peaceful Balance Wichita:  The siblings. What can we do to make them feel like they're not being other? How can they also not be parentified? Because that's sometimes happens within the disorder. World is the siblings may feel that they have to have some type of responsibility for their siblings medical issues. And that is Absolutely. I don't want any sibling to have that. I want them to have a childhood. I want them to be kids, but how can we incorporate them without parentifying them and without othering them and also bringing in the family as a whole and tackling this beast together whether that's OCD or whatever? That beast might be.

00:05:00

Kimberley Quinlan: That's so interesting because as someone who treats OCD but also treats eating disorders, I have found that, you know, you'll treat the one child who has the primary disorder. We get them better. And then a year or two later, the other kid that didn't have the the diagnosis starts to suffer and all this emotion comes out and they start to really acknowledge how painful it was for them and and it all comes out later.

A Peaceful Balance Wichita: Okay.

Kimberley Quinlan: But I know that there are other cases where it comes out during and you've got multiple things happening at once. So, that is why I think this is so important is

Kimberley Quinlan: In my early days of treating you would be like, no, that the siblings. Fine. Look at how well they're doing. They're they're doing well in school and it's quite a miracle,…

A Peaceful Balance Wichita:  Yeah.

INCLUDING THE WHOLE FAMILY IN OCD TREATMENT

Kimberley Quinlan: isn't it? But then Yeah, it all comes out, right? It all comes out. So I love that you're talking about this, right? So you you And number number one, before we move on. Is this true of not just siblings, Would we say? This is true of partners of OCD or eating disorders or depression as well. Like Does this spread to that or…

A Peaceful Balance Wichita: Yeah. I I agree a hundred percent,…

Kimberley Quinlan: What are your thoughts?

A Peaceful Balance Wichita: you know, this, I hate to call it curriculum because that makes it sound so sterile.

A Peaceful Balance Wichita: Process I guess I'll call it and I feel that this process is and as as you know aforementioned it's not just about OCD. I can see this being across the board for any medical issue. Absolutely. It could be for Let's a roommate. Let's not even like let's let's take out the family part.

Kimberley Quinlan: um, And here.

A Peaceful Balance Wichita: You know what, working with a college. I college student, who has a roommate that, maybe they're pretty close with. Absolutely. I if they're willing to bring that person in, How can we incorporate them? Because doesn't that client win? That's what we're wanting…

Kimberley Quinlan:  Yeah.

A Peaceful Balance Wichita: because we know that no matter what your medical diagnosis might be relationships, struggle, and…

Kimberley Quinlan:  Mm-hmm.

A Peaceful Balance Wichita: that absolute last thing I would wish upon anybody.

Kimberley Quinlan: yeah, I'm even thinking of me as someone with a chronic illness On how I think it even like you said it stretches to medical to like that. You know, I know I look back until tell a quick story. I look back to when I was really sick and really sick. And I even remember seeing my children, Starting to play a parental role on me. Like, What do you need today? Mom, instead of like, No, I'm supposed to be asking you that Hun. Like, I think that it's,…

A Peaceful Balance Wichita: Yeah.

Kimberley Quinlan: it can spread. So I I think that this is that's again why? I think this is so important. So I'm gonna skip to my main sort of questions here. Now, it's like you talk about what is called a coach Like an OCD coach. I know I've watched one of your presentations like Do you want to share with us What this model may look like?

BE SEEN MODEL

A Peaceful Balance Wichita: Yeah. Absolutely. So before I even talk about the OCD coach, because that's not like, I'm not reinventing the wheel, this isn't something that I think a lot of your listeners are going to say, Oh like that's that's a new thing. No, it's not a new thing especially when working pediatrics. That's a pretty common term because that's what we really want these parents, or caretakers to be of these kids. As we want them, to be able to learn how to do what we are doing with their kids. So they don't have to be in therapy forever. So, I developed this process and I call it BE SEEN  seen as an acronym, because why not us medical professionals. We love our acronyms. So let's make another acronym. And also it's really easy to just to remember

Kimberley Quinlan:  Right.

A Peaceful Balance Wichita:  And I chose this specific, acronym one. It fits the letters, really nicely of what I was hoping to explain throughout this process but also for a couple different reasons. One I have OCD and I struggled as a child and adolescent and one of the primary factors in my own recovery, that was so A profound was I realized I did not want to be seen. I did not want people to note because I felt I felt bad, You know that shame just smothers you like a blanket and it just it it was embarrassing. And then I was thinking about it from the other side of siblings.

00:10:00

A Peaceful Balance Wichita: When you have a child who has a chronic illness, you think about how often, are they going into doctors appointments? How often are they going into whatever type of treatment facility? They may they may be utilizing. The sibling is often and they can get hidden. They can get hidden. And if I in fact, I think it was Chris Baer who did unstuck who actually called the sibling, the forgotten child. and I,…

Kimberley Quinlan: Such a crisp, man.

A Peaceful Balance Wichita: I absolutely, I'm gonna, I'm gonna get to how that whole thing. Actually, kind of birthed this idea here in a bit.

A Peaceful Balance Wichita: But thinking about just how profound it could be for the sibling to be seen. And as I mentioned before,…

Kimberley Quinlan:  Hmm.

SUPPORTING SIBLINGS DURING OCD TREATMENT 

A Peaceful Balance Wichita: I don't want them to be responsible for their siblings treatment. That is so incredibly inappropriate. And I want them to have a childhood, but I also want them to participate and have a relationship with their sibling. So when I think of an OCD coach essentially, how I define an OCD coach, is going to be that's going to be the adult figure. So that is going to be the person that is going to take the the child to therapy to treatments. That's going to be the main one, utilizing, exposure and response prevention therapy. They're going to be kind of the one overhead and I like using the word coach.

A Peaceful Balance Wichita:  Because one, I really like sports and I just think that there's something kind of neat about a coach because a coach is going to be, they're gonna be tough. They're gonna be fair. And at the end of the day, all they want is for you to win. I just think that's such a cool concept and when you tell that to a parent, a parent, a lot of times can say, Okay, so I get that because I could say, I want you to be the parent to the kid but also think about a coach because when you have your child on a team,

OCD FAMILY THERAPY: INCLUDING SIBLINGS AS “ASSISTANT COACHES” 

A Peaceful Balance Wichita:  In OCD Family Therapy, that coach is going to be tough. And I'm not trying to take the emotions out at all because we know coaches can be incredibly empathetic. The coaches are probably going to push your child a little bit more than you would put child. And so putting yourself into that role and thinking about this is for a win, I know my child might be hurting, I know my child because they're doing the exposures because you're not allowing them to have the OCD accommodated, you're pushing them to grow. So, Putting yourself into the coaches role versus only solely. The parents' role can be such a powerful metaphor for parents and I just really, really love that. So when I'm looking at the siblings, I call those the assistant coaches, those are the ones that can assist and help out. The players.

A Peaceful Balance Wichita:  So the child that is in OCD  therapy or in treatment or whatever necessarily it might be and so be seen. So each letter of scene represents something s is supportive. How can you support the child? And I've actually created Worksheets, that are age appropriate for the sibling and the child with OCD, which again, it really could be any kind of medical thing because the acronym really doesn't exclusively cover OCD. They can do this together and so s is supportive finding different ways to support and

A Peaceful Balance Wichita:  With the worksheets that I've developed with ages five to 10. I just love this. It's it's an art activity and the kids together get to draw them slaying. I mean I'm using quotation marks slaying the OCD monster or making a can of like OCD away spray and so it's just a really, really cute. A activity to do and again because it's ages five to ten, that's such a level of mastery and explorative and, you know, they, they like to draw in color and play at that time. So, even if their sibling with OCD, it's a lot older. Think about what an amazing bonding experience that could be, you have a five year old sibling, and a 12 year old with OCD, that's a pretty cool, a situation able to put those two together to talk about it.

A Peaceful Balance Wichita: Because then that five year old. I mean, how empowering and beautiful that is is like, okay, so you know, sibling older sibling, I'm going to draw a can of a way spray, and this is what it's going to do, and it's gonna get it's gonna help get rid of this and this. And we know that children think so highly a metaphors. That, that could be such a really cool way for them to interpret that. And to be able to understand that because we also don't want little kids to well, it's not, we don't want to, it's they just simply don't have the cognitive abilities to understand OCD comprehensively So let's find age appropriate manners to be able to do that.

00:15:00

Kimberley Quinlan: Yeah.

DEVELOPING EMPATHY DURING OCD TREATMENT

A Peaceful Balance Wichita: And then the next one is developing empathy during OCD treatment. I'm not gonna lie doing an empathy exercise with kids can be a little bit challenging and I think I think that because the Emotions are so complex. In situations are so complex. And so I was trying to find a way to be able to put this in a manner that A five-year-old is going to comprehend and yet also like a 15 year old is not going to think is to babyish.

Kimberley Quinlan:  Yeah.

A Peaceful Balance Wichita: Per se. So it's a it's another worksheet because they're all worksheets it's another worksheet where the siblings can work alongside each other and it really can go either way. It usually works better if the child with OCD goes first. And so the child with OCD can share a so, for instance, I feel disgusted. When I'm around a bad food, I'm just gonna say something super blanketed and then the child the sibling with who does not have OCD could say, Okay? So let's talk about disgust. When do you feel disgusted? And they might say I feel disgusted when my parents make me eat broccoli. And so that's just a really cool and simple way for them to see that this is, you know, we can we can relate on emotions.

A Peaceful Balance Wichita: And we don't have to agree on your, on your emotional reaction, but we can all we can realize that we all have these emotions and this is how we can bond. And for a young young child,…

Kimberley Quinlan:  Hmm.

A Peaceful Balance Wichita: This could also be a really cool lesson in emotional intelligence, because they may not necessarily understand or comprehend. All these different kinds of emotions I'm not gonna lie. I think this might be my favorite one because I think this really encompasses a lot of different things. I love empathy exercises, I'm sure you like being big.

Kimberley Quinlan: Well, I think it builds on that common humanity, doesn't it?

A Peaceful Balance Wichita: But it really does. And that's the whole point is, you know, going back to what I mentioned about being seen, we're all humans and we're flawed and we don't want anybody to feel like they have to be perfect in this process and we don't want anybody to feel like they have to be all knowing, because there's such a beautiful way to which is actually Um, I was gonna go back to support. I've already talked about supportive, but it's a really cool way to support each other. and also not feel like you have to be an expert or Creating them per say,…

Kimberley Quinlan:  Yeah. Yeah. Yeah.

A Peaceful Balance Wichita: all right. So then the next one. The next E is encourage this one and the worksheets is make a sign. So like if you were at because again, these are assistant coaches and I'm kind of using the metaphor of sports or games or like, if you're running along a marathon, what sign would you hold for your sibling? And so, then they get to make a sign for older kids. It could be a Post-it notes, have Post-it notes, and then put it like in your siblings lunch or on the bathroom mirror, draw a picture of them, make a card for them, You know, finding different ways to encourage your sibling with out feeding and to the OCD. That could be a really big part of it. Because let's say, for instance, you have a sibling.

A Peaceful Balance Wichita: Who their OCD attaches on to the color? Black black is death. Black is some. Well, you know what, we're just not going to draw with the color black because it's not the siblings responsibility to do the exposures. Unless that is something that has been discussed actually in the therapy session, because, again, I can't say it enough that I do not want the sibling, to ever be in charge of treatment, or exposures or anything along the lines of that, of course, without actually working with a therapist beforehand.

Kimberley Quinlan: Right, right? Can I ask you a question really quite just to clarify Tim?

A Peaceful Balance Wichita: And yeah. Absolutely.

Kimberley Quinlan: So that parent is the coach. Right? And…

A Peaceful Balance Wichita:  Yes. Yes.

Kimberley Quinlan: then the child is the assistant coach, you mentioned. Do they get assigned that or…

A Peaceful Balance Wichita:  Correct.

Kimberley Quinlan: Do we just call them that? Do they know they're the coach? Do we use those words? Do we assign them? That? What are your thoughts?

A Peaceful Balance Wichita: I think that could really be up to a parent. Those are just terms that I've used you.

00:20:00

Kimberley Quinlan: They're like,…

Kimberley Quinlan: conceptualizations. Okay.

A Peaceful Balance Wichita: Exactly it…

A Peaceful Balance Wichita: because children work, so highly with metaphors and they can use whatever, I had a child. Once say, a lot of want to be a coach, I want to be a cheerleader. Cool. Then you could cheerlead we really kind of whatever it's like…

Kimberley Quinlan:  Okay.

Kimberley Quinlan:  Right.

A Peaceful Balance Wichita: if they want to be the waterboy, I mean I don't care as long as they whatever they can conceptualize it as and we can still kind of follow this supportive method fine.

Kimberley Quinlan: Yeah. Okay, thank…

Kimberley Quinlan: I just want to clarify that. So okay,…

A Peaceful Balance Wichita: Yep. Right.

Kimberley Quinlan: we're up to we're up to N.

A Peaceful Balance Wichita: That's just great. I say in is non-judgment. And this is the part that we really, really, really like to push that OCD is not your siblings fault. Absolutely did not ask to have OCD. They're not doing this on purpose to despise you or for whatever reason. And also realizing that as the sibling, the way the sibling with OCD behaves is not the siblings fault. This can be a part where you have some psycho education and learning more about what OCD is and what OCD is not. And finding different ways to be able to talk about that. Because that itself can be very difficult and…

Kimberley Quinlan: Mmm. Right.

A Peaceful Balance Wichita: I have, I do a lot of OCD psychoeducation when I work with families. And this is where I was going to bring unstuck back. I think that even before going through this process with families unstuck in my opinion I I'm sure other professionals you know, have their own ways of doing it but I find it to be one of the most profound psycho education methods to use for families. Because, and I'm, I do you work with kids as well. Okay, I'm sure you can, you can relate that when you're having that Psychoed session with a kid, it gets lost. They're done. They're bored. They're just like, well can I just do something else? When you have a which I love that, it's like 20 minutes, it was so made for kids the unstuck documentaries. It was beautiful. And kids talking about OCD to kids.

A Peaceful Balance Wichita: I mean I I don't know how it it is more impactful than that. Because a long treatment, it's funny enough, my clients will actually refer to the kids in the movie. Like oh, okay. Well, that one boy. Um, he was able to wear Hulk mask or that one, that one girl was able to hug a tree. Oh, that one. She ripped out pages of the Bible and they'll actually refer to that and they see that as being incredibly empowering. what that also does is it lets the parents know that here are some kids…

Kimberley Quinlan: You.

A Peaceful Balance Wichita: who I mean, you hear their stories, you know that those were pretty severe cases These are kids who came out the other side and are in recovery. and they're talking about these challenges, they're talking about How difficult it was for them. And so when parents are learning about ERP for the first time, it's it's very scary, it's very and so I think it's not only powerful for the children with OCD and their siblings but also their parents to be able to see this documentary, I can't speak highly enough about it, but that's not why we're here. Kim, we're not here to talk about this documentary.

Kimberley Quinlan: No, but I think I mean that's the beauty of the community, right? Is we all bring little pieces to what's so important. As you're talking, I'm thinking like

A Peaceful Balance Wichita: That.

Kimberley Quinlan: He sees that movie because that's the impact it's having. I mean I've seen it and I loved it it's so it's when we can't miss the siblings, right? Like that's some important piece. So I love that you're talking about that and I do think you're right. Question totally off topic.

A Peaceful Balance Wichita:  Yeah.

Kimberley Quinlan: But on topic is, when you're with a client, do you? Encourage them to watch on stock. Do you bring the family in and do this training with them? What kind how do you apply these concepts in session or Are you know, for someone who doesn't have therapy, what might they do?

A Peaceful Balance Wichita: Oh, okay, I'm gonna answer that. Someone who doesn't have therapy. Might what they do. I'll go. The therapeutic route to begin with, of course, after you solidify the diagnosis? Which again, for kids can be boy, that can be a challenge that can be such a challenge. So, this is after diagnosis, This is just part of the therapy. I do I, I will say, Okay, so bring in the family and I would say, I would love to have siblings here and they'll say, Well, the sibling is five or six, is that? Okay, absolutely, because you will be surprised at how aware the young sibling is going to be their older sibling.

00:25:00

A Peaceful Balance Wichita: And all time, you will also be surprised at how much accommodation the young child might be doing because they might see that as being. Well, that's just my older sibling. My only can't cut food.

Kimberley Quinlan: Yeah, right.

A Peaceful Balance Wichita: My older sibling doesn't walk down this one hallway. That's just how they are. Well, we also want to teach them that, you know, this is this, This has a name and here's some ways that you can be encouraging for your sibling. And so I have an entire session where I invite the entire family in and we watch the movie and then we process it together. and from there,…

Kimberley Quinlan:  Right.

A Peaceful Balance Wichita: We go on to.

A Peaceful Balance Wichita: Week, We go on to just write right away going on into the bc model and figuring out different ways how the sibling can be involved. Not other not excluded and then we'll go into more of kind of like, the clinical stuff, the Y box, exposure, higher and…

Kimberley Quinlan:  Yeah.

A Peaceful Balance Wichita: and so forth. But you ask, how can people that don't have therapy being able to utilize this. Honestly, it's on silly. I I'm probably the. Okay, there's two ways. I'm very competitive but I'm not competitive. When it comes to This this work, I post these worksheets for free on my website because this is something that I'm not here to make a profit off of it. I'm not here to, I'm not even gonna copyright it because at the end of the day, if we can help one sibling feel heard, Cool. That's it. That's that's amazing. No, no amount of money or…

Kimberley Quinlan:  Right. And

A Peaceful Balance Wichita: anything could ever be better than that?

Kimberley Quinlan: We can link the links to these worksheets in the show notes. You're comfortable with that. That would be amazing. Yeah. Okay,…

A Peaceful Balance Wichita:  Absolutely.

Kimberley Quinlan: that is so cool and so people can kind of work through them on their own. Okay.

A Peaceful Balance Wichita:  Mm-hmm. And in fact, there there was a family that I worked with whose younger sibling had had some special needs. And what I did with the parents, is I just kind of briefly explained this to them and because they know their kid better than, I know, their child and they know How how their child is going to be able to kind of understand process. This, they were able to take the information they did and that they needed to be able to help out the sibling who now helps out. That the sibling with OCD.

Kimberley Quinlan:  Yeah, yeah. Okay. So a couple of quick questions that I want to ask is so and it's a sort of going off of some past cases that I had. So what about the the sibling, Who's just really angry.

Kimberley Quinlan: the situation at how the, you know OCD has made their family, very For treatment before they were getting resources. Do, do they There's those children who have a lot of resistance to this idea of being a coach. You work with that. Is it through the empathy? Do you have any thoughts?

A Peaceful Balance Wichita: Door. And that's a fantastic question. Because we can't, we can't force. We can't force anybody to do anything. And I kind of view it like the child with OCD, If the child with OCD does not want to do the treatment. Well, then my job as a clinician is to meet that child while they're at and…

Kimberley Quinlan: Yeah.

A Peaceful Balance Wichita: that very much with the sibling, you know, of the child with Ocds, I'm gonna have to meet that sibling where they're at, if they don't want anything to do with this, if they want nothing to do with any of this process at all. I'll do one of a couple things one. I, I might refer the sibling on to a therapist who doesn't necessarily like they don't necessarily have to treat OCD but they can understand OCD comprehend OCD. Well enough to be able to have a conversation. And sometimes the sibling is like, Well, I'm not the one with the problem. I don't need to go into therapy, so I'll do my best. I can to coach the parents and help them to support that sibling as well.

Kimberley Quinlan: Right. Right, so. Okay and just conceptually. So the parents are using the parent. Coaches are using the bc model the children.

A Peaceful Balance Wichita:  Yeah.

Kimberley Quinlan: If they're ready and willing, they're using the bc model. And the person with the disorder or the medical condition is also using the bc model. Be seen model for the sibling and the family correct.

A Peaceful Balance Wichita:  Yeah, I mean this this doesn't have to just be with OCD, In fact, you know, as as I'm looking at just the the acronym of seeing, I don't know if you just has to just reach the medical stuff. Because at the end of the day, don't we generally want to be supportive and empathetic and encouraging and non-judgmental humans. I think just kind of a neat model just to teach our children in general.

00:30:00

Kimberley Quinlan: Mmm. Yeah.

Kimberley Quinlan:  That's what I was thinking. business sort of, like, 101 Training to be a nice. and like,

A Peaceful Balance Wichita: It really is it really? Like I said, I'm not reinventing the wheel, you know, I was able to use some different strategies that I've learned with. So originally as a therapist, I was on the way to becoming a play therapist. And a lot and also dealing with Dr. Bruce Perry's neurossequential model of. Oh My Gosh. Oh my gosh. Why can't I think what it is? It's his nurse sequential model for trauma. That's what it is. Oh wow. And then just just pulling different plate therapy, text me techniques. And I kind of just establish this thick this and…

Kimberley Quinlan: Yeah.

A Peaceful Balance Wichita: you're right. This is basically just Yeah, I like how you said 101. Be a nice person.

Kimberley Quinlan: Yeah, but the truth is and that's why I think it's so important is we all are nice people. We all want to be but when we get hit by a disorder, It's easy to go into reactivity as a parent. I know for myself or as I've seen, you know, siblings it's easy to go reactive. So these are sort of basic tools to come back to the basics and and recalibrate,…

A Peaceful Balance Wichita:  Exact.

Kimberley Quinlan: which is why I love it. Okay. So no,…

A Peaceful Balance Wichita:  Ly. Yeah.

Kimberley Quinlan: I love this so much is before we finish up. Is there anything that we haven't touched on that? You want to make sure we address here and we're talking about Supporting the siblings, but supporting the person with the disorder, any I've missed.

A Peaceful Balance Wichita: Um, can I list some resources? Oh, okay.

Kimberley Quinlan:  And please.

A Peaceful Balance Wichita: There's really not a ton of information out there about how can the sibling be involved with any medical treatment to be honest with you and I'll focus specifically on the OCD portion. Of course, John Hirschfield's amazing book in regards to family at the,…

Kimberley Quinlan: On a family,…

A Peaceful Balance Wichita: Yes at the very tail,…

Kimberley Quinlan: I see.

A Peaceful Balance Wichita: and he talks about different ways, family members can can be helpful. Natasha Daniels on her YouTube channel, she's so great. They're all great everybody. I'm listing is like All Stars. She specifically has a video about how to talk about OCD with young children and I think there's actually even more specific video about how to talk with siblings. Dr. Areeen Wagner on the Peace of Mind Foundation website. There is a whole slew of stuff about how to talk with siblings and I think the Bear Family is even involved in some of those presentations as well. And then this is gonna sound silly because I'm gonna shout out another podcast. Is that okay?

A Peaceful Balance Wichita: Okay, there's a couple on the OCD stories that they talk about siblings. Jessica, Surber rested.

Kimberley Quinlan:  Yes.

A Peaceful Balance Wichita: One about her own experiences being a sibling. And then, this is an older one. Maybe two, three years ago. Dr. Michelle Witkins. She does a lot of advocacy for siblings and so she has an amazing podcast on there where she talks about that work.

Kimberley Quinlan: Right? No, I will link to Eyes and you know I'm a massive stew fan so don't wait. Don't worry about it. No, I he's been on our show. I've been on his show a bunch of times. We are very much in Communic.

A Peaceful Balance Wichita:  I figured, I don't think there was a feud going on.

Kimberley Quinlan: Around food at all. No, that's that's so good that you have those and I will list those in the show notes for All as resources to use. I love. Thank you so much for sharing all those and we will have links to your sheets as well.

A Peaceful Balance Wichita: ah,

Kimberley Quinlan: You can An excellent resources.

A Peaceful Balance Wichita:  oh, you're sweet. Thank you.

Kimberley Quinlan:  Well, I am so grateful for you to come on and talk about this. I think it's really, really important that we talk about siblings, you know, address the whole family because it is a family condition, right? Thank you. I'm so just overjoyed to have you on the show.

A Peaceful Balance Wichita:  Well, thank you. I'm overjoyed to be here.

Kimberley Quinlan: Where can people hear from you or get information about you?

A Peaceful Balance Wichita: So my website, so my practice name is a peaceful balance, Wichita Kansas, and my website is a PB wichita.com. and really, to be honest with you, probably the easiest way to To contact me is on Instagram. I'm probably on their way more often than I'd like to admit and…

Kimberley Quinlan:  Yeah.

00:35:00

A Peaceful Balance Wichita: my handle is at anxiously balanced.

Kimberley Quinlan: Love it and you put some amazing exposure lists and movies. It's so good. You but no it's so it's such a huge resource.

A Peaceful Balance Wichita: I think I have way too much fun with those.

Kimberley Quinlan: If you're looking for specific movies, documentaries songs, I think you do a great job of listing exposures.

A Peaceful Balance Wichita:  Thank you.Kimberley Quinlan: Thank you so much.