OCD and Anxiety Disorders with Kimberley Quinlan
01:05:36 Share

Hello and welcome to Being Well, I'm Forrest Hansen. If you're new to the podcast, thanks for joining us today. And if you've listened before, welcome back. Today we're going to be talking about working with anxiety and particularly a pretty common form that significant anxiety takes, obsessive compulsive disorder.

To help me do that, I'm joined by an expert on generalized anxiety and OCD, therapist Kimberly Quinlan. So Kimberly, thanks for joining me today. How are you doing? Oh, thank you for having me. I'm so happy to be here. I am really happy to have you. We had a whole adventure with scheduling. I reschedule you multiple times. You were just a gem throughout the whole process. So a little bit more about Kimberly. She's the host of Your Anxiety Toolkit. It's a fantastic podcast that has, I think, over 400 episodes.

She's also got a YouTube channel by the same name. It's really, really good stuff. I was very happy when I first bumped into it. How long have you been a therapist for, Kimberly?

Oh, over, let's see, about 12 years now. So part of why I wanted to talk with you is that you're bringing this great blend of personal experience and professional experience. You've been open about your own experiences with generalized anxiety and eating disorders, and you've spent years helping other people work with them. And then you were diagnosed fairly recently with OCD. So what was it like to be diagnosed with something that you are incredibly knowledgeable about as a clinician?

I have to admit it was not my favorite day only because, you know, it's such a whirlwind of a time and it was mostly bizarre because this is a condition that I had been treating and public that I did not have.

A lot of people always ask, do you have OCD? And I would always say, no, I have generalized anxiety. And I always had had some OCD-like traits. But then about maybe a year and a half ago, I got hit with a massive wave of PTSD, actually. And the OCD immediately followed afterwards. And so at the beginning, I really couldn't.

Couldn't even as a clinician, knowing the condition, knowing the symptoms, I actually didn't even catch it myself until one of my best friends, who is an OCD therapist as well. Of course, we stick together, basically said like, hon, I think we need to like get you assessed. Yeah.

And so that was a, it was not my favorite day. It did not feel so great on the ego that day because I thought I would have been able to catch it, but I didn't. How has having that personal experience changed how you think about it, how you approach it with the people that you work with? Was it like a light bulb moment? Did it really change how you thought about some things?

I mean, no, I think that the beauty of knowing about these anxiety conditions and knowing a lot about mental health and having a lot of resources and connections allowed me to quickly

move into really helpful solutions. Whereas people without OCD and don't know about the condition, resources and research says that it takes them about seven to 14 years to get a correct diagnosis and the correct treatment. So for me,

Even though it's not a fun condition and it's very, very painful, I was very, very lucky in that it was a very quick move into solutions for me. So I was thankful for that. Maybe we should back up a little bit here for people. What's OCD and how does it work? Sure. So OCD is a mental health condition. It's also, again, a brain disorder that involves obsessions and compulsions.

So unlike what social media might say an obsession, you know, it can mean something you love, like I'm obsessed with Lego or I'm obsessed with this brand, right? But that is not what we're talking about when it comes to OCD. OCD is an intrusive, repetitive, unwanted thought, feeling, sensation, urge, or image. Usually it comes in the form of thoughts, but not always.

And then the person with OCD will also have compulsions. And a compulsion is a behavior that we do either physical or mental to reduce or remove the anxiety or discomfort or uncertainty that they feel. And it ends up sort of

trickling into every corner of their life and can really take somebody's functioning. So again, I think a lot of people, again, from social media misunderstand OCD as this fun quirk that I just like lining up my cookies in my cookie jar. And that can be a behavior for sure that has with OCD, but people with OCD do not want these behaviors. They do not want these thoughts. It's incredibly painful.

Could you give some examples of maybe a common anxiety that somebody might have linked to what you're describing, a sort of repetitive thought and an associated compulsion? So OCD can attack any area of your life.

Let's talk like a quick 101 on anxiety disorders. So social anxiety is like the fear of being judged in social settings or the fear of being embarrassed. Phobias are the fear of one specific thing and you avoid it. Health anxiety is the fear of, you know, you getting sick and dying. With OCD, it can move to anything.

It's not specific to one area. So you might have more like what we call Hollywood types of OCD that Hollywood has portrayed a lot, hand washing, crack jumping, ordering of things. That's OCD and that's incredibly painful, but that's very, very small percentage of people have that type of OCD. There's also harm OCD, which is the fear that you might harm a loved one. Again, intrusive thoughts or images about harming a loved one.

But you don't want to. Usually they're the sweetest, kindest people, but they have these intrusive thoughts. Another one might be religious obsessions. So the fear that maybe you've sinned, maybe that you're not praying right, maybe that you've prayed to the wrong, instead of God, you're praying to the devil or something like that.

It could affect your relationship. So maybe you're having obsessive, intrusive thoughts that maybe you've picked the wrong partner and you can't sort of get unstuck from it. It might also move to sexuality and trying to get really certain on, but what if I'm not this sexuality? What if I've made a mistake? Maybe I'll hurt my loved ones. So it can seep into so many areas of somebody's life.

Normally when I do these interviews or conversations with people, Kimberly, I feel like I have a strong basis of knowledge in whatever it is that we're talking about. This is something that I truly know very little about. I'm behind on my anxiety disorder knowledge in general and OCD in particular. Do we know why people develop OCD?

Well, no, we don't. Unfortunately, we don't have enough research yet. But what we do know is there is a strong genetic component. We also know that environment plays a role.

So depending on society, rules that were put up as a child, sometimes it's also like, were you exposed to a trauma in the past? There doesn't have to be trauma, but that sometimes can be. And sometimes we're getting more information now also about some more biological causes. We have some impact on terms of certain, like Lyme disease may cause the sudden onset of these conditions.

But generally speaking, it's a lot of genetics and a lot of environment. You mentioned that you had had a significant experience related to PTSD and maybe the OCD kind of emerged out of that. Or do you feel like OCD is something you've always had? Were these unrelated? Do you think they were related?

I didn't always have it because I've always been very aware of the fact that I've always had anxiety. When I had an eating disorder, one of the reasons I love treating OCD is I always felt like my eating disorder felt more like OCD than it did a traditional eating disorder.

I did a lot of compulsive exercise, a compulsive calculating of foods and numbers and things like that, and did a lot of restricting in very compulsive ways. So I really always felt a deep sort of understanding of people and folks with OCD. However, when I was in college, and I talk about this on my own podcast, when I was in college, my roommate died of suicide. And I

I shoved that down so deep to the point that I actually thought it didn't bother me. I really, I see clients who have suicidal ideation. I educate on suicide. It's, I really, really genuinely thought that,

I was fine about it. But then for reasons I don't understand, out of nowhere, I started to have these really strong waves of PTSD symptoms about that event. And I don't know, maybe it was hormonal. I mean, perimenopause, it could have been because of that. I was also at the very back end of getting over a pretty severe medical condition. So I don't know why all of a sudden why it popped up.

But as soon as it popped up, I started to have all these fears that I would be responsible for somebody else's death. And then that's when it became more OCD. I was having a lot of obsessions and doing a lot of compulsions about preventing death and preventing harm to people. So I feel like for me, and this is common for some people, the PTSD erupted and quickly in swooped OCD down.

I think as a coping mechanism, right? Trying to prevent it from ever happening. But I did a lot of assessment with some really well-known clinicians to differentiate what here is your OCD and what here is the PTSD and how can we treat those at the same time, but make sure we're treating them effectively in their separate little zones that they're in. So what did you start doing for this?

Well, I cried for about a weekend. That's a good place to start probably. Yeah, because I was embarrassed. I was humiliated. This is a condition that I treat. I was embarrassed I didn't catch it myself because in my mind, these were real threats, not irrational. In my mind, it felt very real, which is true for people with PTSD and OCD.

Once I gave myself time to grieve, then I went to work. As I've said in where I shared in my own podcast, I was so blessed that I'd already seen the treatments work with my own clients. I knew what to do. I knew the research. I didn't have to spend time mulling over this research and asking my doctor and asking a psychiatrist. I knew what to do. So I reached out to a...

Number one, it's hard if you're a clinician to find somebody who will treat you because usually you have a working relationship. And I found an amazing therapist and

I went to work. I just basically the treatment that they used for me was prolonged exposure for the PTSD and exposure and response prevention for the OCD. So we talk about exposure pretty regularly on the podcast, but neither Rick nor me are experts on it. So I would love to talk with you a little bit about doing exposure while exposure sometimes can get kind of a bad rap from people.

So you mentioned ERP, exposure and response prevention. People often focus on the exposure part of that phrase, not so much the response prevention part of that phrase, but that's kind of where the actual magic is. So would you mind giving like an example of this and explaining how it works? Exposure and response prevention is a beautiful treatment that allows people with any kind of fear to practice therapy.

And exposing, and there's the word, exposing themselves to the experience that scares them, whether that be exposing them to the thoughts they have, the place they've avoided, the emotions they might experience, the people they're

And then that's, again, that's only a portion of it. The real magic is when they do that, they practice what we call response prevention, which is to reduce and remove the compulsive safety behaviors that you would usually do when in contact with that fear.

So here we'll use an example of health anxiety. So let's say you have a very, very intrusive, repetitive fear about that you might die, that you might have a brain aneurysm or you might get cancer. And you wake up on a Tuesday and you have a migraine or a headache.

So the intrusive thought is going to say, this is the first symptom of a brain aneurysm. It's only a matter of time until you die. You have to go and make sure that this isn't cancer. It's not a brain aneurysm. You're not dying. So

Go and, you know, remove all your uncertainty by what I want you to do is I want, this is sort of pretend your brain or your OCD talking or your health anxiety talking as like, I want you to Google every symptom of a brain aneurysm and see if you have those symptoms. I want you to call the doctor and get an appointment right away and get into an MRI immediately. Now, for some people, if you have, let's say you're experiencing a heart attack or some severe symptoms,

that would be maybe the appropriate behavior. But for people with health anxiety, they usually get stuck in this repeat cycle

And so with exposure and response prevention, we would identify, okay, you've got a headache. The exposure is in this case sort of already there. How can we, the response prevention would be, can you wait or can you withhold from Googling? Can you reduce any mental compulsions that you're doing? And can you maybe, okay,

take, what would a normal, someone you trust, what would they do? They'd maybe take a ibuprofen, have a glass of water, maybe take a nap and wait for the headache to rise and fall on their own without running to get an MRI. So exposure would be exposing someone to their fear and then also practice reducing those safety behaviors. So how do you pick a good exposure for somebody?

Yeah. Well, I think the first thing is we want to do a functional analysis of the symptom. Again, what is a compulsion for one person isn't a compulsion for another. So treatment must be, and this is why I think sometimes ERP has gotten a bad rap because it hasn't been employed very well. It hasn't been used very well. Exposure and response prevention is a highly researched treatment and

all of the meta-analyses, I always get that word wrong, all agree that it is the gold standard treatment for these conditions, but they must be done very thoughtfully. And then we must do a functional assessment to start to identify what are your fears? What are the behaviors you're doing to reduce or remove those fears? We also want to get an understanding of like culturally,

Do these behaviors make sense? So here is an example. For some cultures, you might have certain rituals that you do around food, around praying, around preparation of food. That could be just a part of your culture and your religion for some.

For other people, it might be a compulsion. They're doing it because they've had an intrusive thought and they're trying to make it go away or they're trying to neutralize that thought. So we want to first identify what is the function behind the behavior.

And then if we both agree that this is OCD or a mental health condition, then we can both agree on what would be a good exposure. Now, I say to every one of my clients when we start, I'll never have you do anything I wouldn't do myself. I'll never have you do anything I don't want to do. And what we're actually working towards is just getting you back to living a life according to your values, not according to your fear.

This may or may not make sense, Kimberly, so work with me on it a little bit and see if you could follow kind of where I'm going here. I'm wondering if there are big differences between doing something like ERP at the clinical level, particularly when it's around an anxiety, something the person is avoiding, whatever it is.

versus the much more mild and everyday forms of exposure that people do when they want to build a new strength or work with some kind of relatively mild fear. A person with mild social anxiety, they want to stretch a little bit, they want to try on being more extroverted. You wouldn't necessarily think of that as trying to work with somebody's OCD or something like that, but the person wants to develop in a way. And so they're kind of trying on a new way of doing something. That's typically the way that we talk about it on the podcast.

Are there significant differences between how you think about those two things? Or is it just a matter of severity up the scale or the intensity with which you're doing it? Generally, it just depends on the intensity. I always say, if your fear is here, try to meet it here and a little above.

If your fear is up here, still try and meet it here and a little above, right? Like you always want, you don't want fear to win. We always want to show fear that we're in charge, kind of like training a dog. You kind of have to be the alpha, otherwise it'll take over. And fear will very easily take over because it's a part of our DNA to run away from danger. And if our brain is telling us mistakenly we're in danger, sometimes we think that's the appropriate thing to do to run away or avoid. Right.

However, there are some nuances that we want to take a look at when it depends on the kind of fear. So a great example is, okay, simply put, if you're afraid of dogs, gradual exposure to dogs is brilliant.

right? And again, that's why I think sometimes ERP gets a bad rap. Gradual exposure is ideally the best way to do this, especially if you're new to it. You don't want to go from zero to 100. It's going to shock you. It's okay if you do, but ideally we're going to start small and work our way up and get some mastery and get some confidence and feel like, okay, I can do this. I got this.

So with phobias, yes, that might be the case. Whereas let's say you have panic disorder. Generally, people with panic do a lot of avoidant compulsions. They avoid the places that they are afraid they will panic. And so the treatment will be exposing them to those places. But the place technically isn't the thing they're afraid of. The panic is. Panic disorder is the fear of panic.

right, the unwillingness to have a panic attack. So in that case, we would do a special kind of exposure called interoceptive exposures.

Interoceptive exposures is exposing you to the specific sensations that you don't feel confident feeling. So let's say someone has panic disorder and I'll say to them like, okay, pretend I'm an alien from out of the different galaxy and I came down to this earth and I said to you like, what is a panic attack? Tell me what that's like. Like I want to know exactly what that feels like for you. And they'll say, okay, I get a really tight chest.

Or I get really dizzy and I'll say, okay. So then once we've identified this specific experience, then I will expose them to those sensations. Maybe I will spin them in a chair and practice exposing them to dizziness.

Without doing those avoidant behaviors, again, we want to do response prevention. But what happens with that is the more they practice just spinning in the chair, not excessively, we don't want them to feel ill, but they start to build a mastery with, oh, I can tolerate that feeling. So that next time they feel a panic attack coming on, they've built a sense of confidence around those sensations, which makes them more likely to stay and not run away.

There are also people who have fears of things that we don't expose to. Like, let's say if you're afraid, like use me as an example, my fear is that I would be responsible for someone's death.

Yeah. How can you do an exposure around that? An exposure is I'm not going to send my clients off to go, okay, don't hold your kid's hand as they cross the street because that's healthy, really effective behavior. So this other kind of exposure we might practice is what we call imaginals, which is instead of doing the exposure, we write a story about the fear happening and we read it over and over again. And that's more of like a prolonged exposure kind of style. Am I right about that?

Well, prolonged exposure is a specific kind of exposure for PTSD. Imaginals is a kind of exposure we use for OCD. They're very similar. Again, there's some tweaks we need to make to make sure that they're effective. And we also have to make sure we're doing that response prevention as well. We'll be back to the show in just a minute, but first a word from our sponsors.

That cha-ching sound? That's the sound of another sale. Online, in-store, or maybe even through social media. Because with Shopify, selling doesn't just happen in one place anymore. It happens everywhere. Shopify is more than just an online store. It's your all-in-one command center for running a modern retail business.

Whether you've got one location or a thousand, their point of sale system brings everything together so you can sell in person, online, through TikTok, Instagram, email, wherever your customers already are. It lets you track every sale, manage inventory in real time, and offer your customers exactly what they want. Whether it's buying online and picking up in store, browsing endless aisle options, or

or having something shipped directly to their door. So if you're building something meaningful and want to take your retail game to the next level without adding too much complexity, Shopify is where you start. Want more? Check out at shopify.com slash beingwell, all lowercase, and learn how to create the best retail experiences without complexity. Shopify.com slash beingwell.

Little moment of honesty here. How many times have you meant to book that doctor's appointment, but just didn't? Maybe you told yourself that you were too busy, or that it would just get better on its own, or that you didn't know which doctor to go to in the first place. I've been there. It

It took me way too long to find a primary care physician. Sometimes the idea of navigating the healthcare system feels more stressful than whatever issue it is that you're trying to fix. But our sponsor ZocDoc makes that process so much easier. ZocDoc is a free app and website where you can search for and compare high-quality in-network doctors and instantly book an appointment.

And we're not just talking about primary care. You can find more than 100,000 doctors across every specialty from mental health to urgent care to dental, dermatology, and more. If I needed to find a doctor, I'd use ZocDoc.

Stop putting off those doctor's appointments and go to ZocDoc.com slash being to find and instantly book a top-rated doctor today. That's Z-O-C-D-O-C.com slash being. ZocDoc.com slash being. Now, back to the show. Maybe I'm just getting too in the weeds here because I'm curious about this. What's the difference between these two things? How do you finesse that?

Well, prolonged exposure involves telling the story specifically of what happened to you in the trauma you experienced. So it's not imagination. It's the real thing that actually happened. It's an account of what happened, what you remember feeling, what you remember seeing, every part about that, and really working at experiencing the emotions that you refuse to experience.

So then imaginals aren't that much different, except with PTSD, the work is on the past event. With OCD, it's working on the feared event that hasn't happened that you're afraid of the consequences of, or you're afraid of

of the identity that would be attached to you if it did happen. So there's some tweaks there that we would make. Gotcha. So there are two pieces of this that one is a common question that we get that I'll ask in a second. But the first piece of it is that in part because of the Hollywoodization of OCD,

If you watch the TV show Monk or something like that, there's a lot of stereotyping around it. It can be quite difficult, I think, for people to really understand how intense the felt experience is for somebody who is dealing with this because you see it from the outside and you go,

you know, what do you mean that this thing scares you? Or like, why do you need to-- again, to use the very stereotyped example, like, why do you need to wash your hands six times after touching the doorknob or something like that? Like, we have a very, very hard time kind of grasping it. But for somebody who is having that experience, it is

I've had very, very mild versions of this where I kind of know something intellectually about something that somebody might be dealing with. And then you have like one moment where it just becomes clarified by your own experience of it a little bit. And it's like, whoa, it is very overwhelming. For the person who is going through that,

are there things that you do with them to either resource them so they're more comfortable taking that first step or that you're working with the fear so that it's possible for you to do the initial exposures that the person is doing? Not typically because, well, let's sort of walk through the treatment. So first we're going to do a heavy assessment again to identify the functions of the behaviors and identify the specific obsessions.

Then we're going to actually do quite a lot of psychoeducation to help them understand what is OCD and what it isn't, how it keeps you stuck, why avoiding it and trying to get away from it, doing compulsions, how that actually is reinforcing the condition. Because often we feel like compulsions are the solution.

Even though they're painful to do, they can give you some short-term relief. So we want to do a lot of education around that. And then we also want to educate them about the benefits of this new strategy, this new way of seeing the condition, this new way of conceptualizing how we're going to overcome that. Once we've done that, people tend to be more on board.

And then what we will do is we'll let them decide to what degree they're willing to do exposure. Some are like, let's go. I want to get this condition over and done with. Whereas others are really stuck in like, again, because different people have different insight too.

their intrusive thoughts. So we will help them to decide. But again, we'll be doing a lot of education to help them understand that a part of the condition is to make it feel very, very real. We actually have brain imaging to show the areas of the brain where there is extravagance.

extra activity that can cause that experience of it being so real. That's why I missed it, if I'm going to be completely honest. Here I am, I would say I'm at the top of very, very skilled in my field, but yet in my mind, because it felt so real, because it felt like such an imminent,

threat, like danger is here and I need to take it seriously. I didn't catch it either. It was another clinician who was outside of me going, Kimberly, hon, it sounds like you're going above and beyond to keep your family safe. Is that how you feel you, is that what you feel you need to do? And that was a big piece of it for me.

The second question, which we get all the time from people is, well, what if I do it and it goes poorly? The exposure? Yeah. So basically, the example of this often that people give is more focused on forms of social anxiety where they're working on becoming, again, this is probably more like low level, not necessarily a formal OCD diagnosis or something like that.

But a person is in a group of people, they're working on speaking up more, contributing more, feeling less overwhelmed, whatever it is. They make a small bit inside of the group, they feel like it goes really poorly, their fear is essentially reinforced by what they perceive as their experience.

Yes. We get a lot of questions about that in part because Rick has a process that he calls taking in the good, which is basically a form of exposure where you're trying on something new and hey, if it goes well, you really reinforce, wow, that actually went well, I could do that. And then the natural question is like, well, what if it doesn't go well? Right. There's a mindset shift that happens in this work. And you see a big grin on my face because this is my favorite part of the work.

So if a client comes to me and says, Kimberly, you'd be so proud of me. I haven't panicked all week. I'd be like, boo. Yeah, we haven't been pushing the edge of it. I would say that's wonderful because I want you to be well. I don't want you to suffer. I want nothing but peace and joy for you. But when people have the goal being to not have discomfort, right?

they usually will continue and maintain that condition. If their goal is to have no anxiety, what we resist persists is the common saying.

However, if their goal is I was uncomfortable for two and a half hours this week and I did it and I didn't leave, that's when I get the party hats out and we celebrate like crazy. Again, not because I want them to suffer, but because I want them to build a sense of mastery over what is a very human experience.

which is an emotion, fear, humiliation, embarrassment, sadness, guilt, shame. These are such painful emotions. I don't blame you. It's so uncomfortable. And when you have these conditions, they're so intense. I mean, sometimes it's more than one emotion. It's like five of them or all of them.

But what we want to do is, again, we want to build mastery so that you know there is no emotion you're not willing to feel. There is nothing that you aren't able to handle. Now, again, that doesn't mean we go and do a 10 out of 10 exposure right away. We want to be thoughtful. We want to be kind. But what I would say specifically to that question is,

No one tries out to win the Olympics or tries out to get on the Olympic team once and then drops out and says, fine. Usually it takes them many, many fails and we fail forward to achieve these amazing goals.

I will say, I wish we would teach this to little kids in school to practice being uncomfortable and to do it compassionately because that's when kids actually get self-esteem. That's how you build self-esteem is by hurdles, challenges, getting through them, but on repeat, on repeat. I always say to clients, go and do your reps.

We want reps of this. So I would say to someone, if you tried one time and it failed, I am in such awe of your courage. I am so excited that you did that. You learned that you can.

But you also learned that it wasn't easy and that things didn't go well. What can we tweak this time to go and do it again towards the goal that you're looking for? But the goal shouldn't be to not have anxiety. It should be that you didn't leave and that you showed up authentically. So you just mentioned self-compassion there. That does seem like a huge part of this process, particularly when a person has an inevitable stumbles throughout it. Yes. If you're going to...

make those many bids. You have to be able to tolerate a little bit of backsliding along the way. Are there things that you have found help people develop a little bit more of that compassion toward their own struggle with regards to anxiety and OCD specifically?

Yes. So believe it or not, one of the first parts that I do in treatment is to identify where they're beating themselves up. We call it self-punishment or self-criticism. A lot of people with mental struggles have the mental struggle and they beat themselves up, which is now one problem turned into two.

So we always want the fastest way to reduce our suffering is to catch that self-criticism and judgment and punishment and work to reduce that. And then we want to inquire in how we might comfortably change that to a voice that is kind, encouraging, always has your best interests at heart, knows your strengths, but also knows your weaknesses and doesn't use it against you.

And that, I call it the kind coach voice you can use throughout the state, the stages of exposure and response prevention. We have researched that by using that kind, encouraging voice, we actually reduce procrastination, increase people's willingness to face fears and

increase people's willingness to be more courageous and ultimately stay committed to things. There's so much research around self-compassion now that helps benefit those with an anxiety disorder. And so I always try to weave it in. In fact, I wrote a book for OCD called The Self-Compassion Workbook for OCD, which the whole goal of that was

How can we use this gold standard treatment, which is so good, but marry it with another form of coping that is gentle and kind? As you're going through this process with somebody, is there a point at which you're starting to consider medication? There's often a bit of a stigma related to medication for people still. How do you think about it and when do you start to consider it?

Believe it or not, a combination of exposure and response prevention with a medication is actually the top level treatment. So I'm very pro-med. For me personally, I never put pressure on my clients to take medication unless they want to. But I always sort of think of it like a little bit of an assist. It just is like a little leg up. It helps you. Again, if I anywhere in my life that I can take the help, I try to take the help. And so for me, I

I'm very confident and comfortable selling people that I take medication myself.

There is so much stigma and it's a very personal decision. I always tell my patients, and I'd still say this to this day, my most difficult case I've ever treated in my whole career, never took a medication and they recovered. So you can do it. It's not to say that if you don't take medication and you don't want to for personal reasons that you won't recover because you can. It just might mean

You're going to have to wade through some maybe louder thoughts and feelings that feel more real. And that instinct to run away might be a little stronger, but it's still very doable. So I think that there's opportunities for those who choose to and opportunities who choose not to.

Is it typically an SSRI for people with more anxiety-based disorders? Yes. So just a disclaimer, I'm not a medical professional. So please do speak to your doctor because it's different for every person. But technically, yes. And generally, an SSRI is going to be the first line of treatment for OCD and has very good results.

However, the dosage is different than those who are on a dosage for depression, let's say. So often clients will come to me in an assessment and they will say, I'm on an SSRI. You don't need to worry about me. I'm already set up and I'll inquire about the dose. And they're at a depressive dose.

an OCD dose can be higher to get the benefits. Not that you are sicker or more mentally unwell, it's just that different doses benefit different conditions. So,

So do speak with your psychiatrist about that. Yeah, and brains are very complicated in terms of how it responds to these chemicals. Yeah, so it's very natural to look at, "Okay, one person is taking 10 of this. I'm taking 20 of this. I must be twice as bad."

It's a lot more complicated than that in terms of just how we respond to these things. And we don't have a science about it yet either. I mean, I will disclose I tried multiple meds before I found one that made me feel good without the side effects that I could tolerate. So absolutely talk with your doctor. It'll depend on genetics, medications you're on, your weight, your height.

your gender, it's important to make sure it's a very personalized process. So you mentioned the thoughts aspect of it. You might be dealing with some louder thoughts or some more intrusive thoughts.

That is a piece of it that I think is another one that's quite difficult for people who have never really experienced a true intrusive thought with the kind of severity that is often associated with OCD. It's kind of difficult to wrap your mind around. Are there particular families of therapy or schools of thought that you use around unhooking from thoughts? Are you more of an act person, like some mindfulness-based CBT? What's your approach of choice here?

So I love this question. So it's very personalized and it depends on each person.

I love acceptance and commitment therapy. I love mindfulness. I love introducing dialectical behavioral therapy, depending on whether they're regulating emotions well. Sometimes even cognitive forms of therapy are beneficial as well. But again, it depends on the person and where they're stuck, where they're hooked.

If somebody is struggling with, I mean, act and mindfulness have many of the similar, they're just different ways of framing a practice. But again, if someone's really getting hooked on those thoughts, we'll always go to act and mindfulness, which is the practice of observing a thought and

And being able to diffuse from it instead of making a lot of meaning from it and treating it like it's a fact, even though it's a thought because thoughts aren't facts. It's allowing ourselves to identify where we're giving it meaning about ourselves. And so these concepts act, mindfulness can help us identify.

have a different relationship with thoughts instead of responding to them as if they are true we can start to respond to them sort of like spam in the in the spam that show up in your email when you see a spam email you don't open it up and spend hours reading it and treating it important we just put it in the spam folder and we kind of want to be able to do that with intrusive thoughts as well we'll be right back to the show in just a moment

Have you ever picked up a snack labeled "natural" or "heart healthy" and felt like you were making a good choice, only to later look at the nutritional information and go, "wait a second, this is just not what I thought it was"? That's exactly the kind of marketing spin the Zoe Health app is designed to cut through. Zoe is the company behind the world's most listened to nutrition podcast.

Zoe Science and Nutrition. And their new Zoe Health AI Food Scanner app gives you real answers about so-called healthy foods based on science. You can download it for free on the Apple Store or Google Play. This is truly such a cool app. You can just snap a photo of your meals and snacks, learn about what's in it, and then find healthier options.

Their app instantly reveals how healthy or processed your food really is, and with a single photo, Zoe's app gives you evidence-based nutrition feedback in seconds, powered by their unique food database. Zoe shows what the label won't. Download the new Zoe Health app for free. Search for Zoe Health in your phone's app store today. That's Z-O-E and the word health.

I remember when my email inbox was an absolute source of dread, when random newsletters and spam pitches crowded out the real important conversations that I meant to reply to three days ago. So when Notion, which I use all the time and am a very big fan of in general, reached out with their new Notion Mail tool, I was very interested. Notion Mail is smart, flexible, and designed to help you get through your inbox without losing your mind.

It integrates seamlessly with my Gmail account and automatically organizes my inbox based on what I actually care about. And because it's made by Notion, there's great integration there as well. So I can reply to somebody about a project and have the relevant notes or an outline right there in the same space, which is very convenient for me. If you're somebody who works online, communicates a lot, or just wants to spend less time managing email, this is really worth checking out.

Get Notion Mail for free right now at notion.com slash beingwell and try the inbox that thinks like you. That's all lowercase letters, notion.com slash beingwell to get Notion Mail for free right now. When you use our link, you're supporting our show. Notion.com slash beingwell. Now, back to the show.

There are two really important moments, at least it seems to me, in that kind of process. The first is the moment where a person has a moment of realization where they go, "Oh, this is an intrusive thought," essentially. Or like, "Oh, this thought might not be real." Or like, "Look at that, how weird." So that's a really important moment, that kind of moment of recognition that a person has. Yes. But even once you get past that moment,

you can still have a lot of stuff, a lot of content flying through your mind that's quite unpleasant to be with, even if you recognize it as not rational, exaggerated. Just sort of the diffusion act doesn't necessarily end the thoughts themselves. And I think that sometimes people have this wish that that'll just solve the problem, that stepping back will be enough.

For starters, just what do you think about that? And how do you help people work with still the ongoing presence of these things that are distressing for them? Yeah, such a beautiful question. So being able to observe and identify a thought is the skill of awareness, being aware of your present experience. And that's gold, right? That's so important.

Once we've done that, you might observe it and go straight into behaviors that reinforce it. And so what we would do with exposure and ACT and DBT, depending on what's going on, is we lean toward behaviors that line up with their values.

We lean towards actions that are effective. And it might mean that we have to do a little bit of a functional analysis of like what would be helpful, what wouldn't.

Now, let's say you have an intrusive thought that you may harm somebody. Harm OCD is a common subtype of OCD. So you've had this intrusive thought, like, what if I want to kill my grandmother? As you can imagine, they don't want to have this thought. It's incredibly terrifying. It doesn't line up with their values. They literally would not kill a fly. Really distorts self-image. Yeah, totally. Am I a bad person? Yeah.

Yeah, yeah. So this is attacking their whole experience of being who they are. Observing, okay, this is an intrusive thought. I observe it there. That's the first step. But you love your grandmother. You love your child. It's still very distressing to be experiencing this. Absolutely. So we're going to be practicing a lot of acceptance of whatever physical sensations and discomfort you experience. Yeah.

We're going to then identify while, and I key on the word while, while you have those thoughts, not instead of, but while you have those thoughts, what action can you choose to do while you're accepting their presence, while you're allowing the heart to race and the head to sway?

race and your stomach to hurt or whatever, you might feel shaky. While you feel all those sensations, what actions are you willing to engage in? Now, some might say, okay, I'm just going to keep chopping the apple, right?

Because let's say they had this thought was triggered by the fact that they are holding this sharp knife and Nana's right over there. Right. So we might choose to keep chopping, but there's a committed action there. There's a commitment to staying in the presence of it while your brain is screaming at you. You might stab Nana. Yeah.

So you're holding space for multiple different emotional experiences, which can be very overwhelming. But it's the practice of really making space for that experience and still staying in alignment with your values. You mightn't be able to do that right away. Maybe you put the knife down, but you stay in the room. And maybe that's a huge win for you because you didn't leave the room, right? Maybe you...

Keep using the knife, but you sort of chop once, put it down, give yourself a break, sort of get yourself together, use your skills and come back to it. So there's no perfect way again, but ultimately it's about this willingness to be uncomfortable. In some ways, a bring it on, like, let's go bring it on fear. Give me your best thought. I'm okay that you're here. I'm going to let you be here. Say whatever you want, but

but I am going to keep chopping this apple. Is there an amount of time typically that it takes a person to get to a place where either those thoughts are a lot less frequent or when they appear, they're significantly less unpleasant? Or is it just totally person to person? Who knows? Can't really tell you here.

I'm always really reluctant to give timelines because I think people with anxiety are usually very intelligent and they're problem solvers. And so if I said, let's say I said, a course of treatment is 24 sessions average. They're going to be anxious about- Tracking this closely. Yeah, totally. This-

progress. So I, as a gift to people with anxiety, I usually don't like to say. And the other thing is our brains are pretty clever. Your fear finds new ways to trick us. And a part of treatment is for us to be savvy and catch its new ways of tricking us and troubleshoot those as we go. The other piece is a lot of folks with

Anxiety has multiple conditions. They might have OCD and social anxiety, or they might have health anxiety and generalized anxiety, or they might have health anxiety and PTSD, or they might have depression. They might have life stresses that are

slowing down what would be the normal flow of treatment. So every client is different. But I will say if you show up to therapy, you're willing to do the work, you do your homework because it's a homework-based treatment, your outcomes will most likely be very good. Were there particular things, to kind of go back to the very beginning, that you took from your wide range of knowledge here?

into your own personal toolkit as you were working through your OCD? Yes. So number one was

was when I first found out, well, I first realized that I had these conditions and that they had sprung up out of nowhere. My instinct was like, I'm just going to pretend nothing happened and hopefully this all goes away and I won't have to admit that this is really happening. I didn't even tell my husband to begin with because I was just like, he probably, he knew something was wrong.

But the thing that was so beautiful for me is, and people who don't have my experience don't get this gift, but I hope to give it to other people, is I'd already seen this work before.

Yeah.

But I'd already seen it work, which meant that I could dive in and give it my full trust. I didn't have to do the psychoeducation. I didn't have to do trust building. I didn't have to be educated. I already knew. I was just like, let's go. The other point, and I talk about this a lot, is

I used to take what I called OCD walks, which was when I knew I was going to start doing a lot of compulsions. When I was triggered, I would take my small dog and I put him on a leash and I would just slowly walk around the neighborhood. And I'd be like, there's a leaf and there's a tree. And I smell the flowers and I can hear the bees buzzing or whatever. And I would give myself a pep talk of how can I make this my bravest day ever?

And that would shift me away from like, how can I make this all go away? Because this is so hard to, and there's nothing wrong with that, by the way. I've been there many times. You've all been there. I've been there. Yeah. Yeah. I mean, I'm a master at mental tantrums. Like I throw them in my head, but I would go, okay, Kimberly, this day is either going to go okay or,

if you're willing to be courageous and make this your bravest day yet, or you're going to reinforce your disorder and make it harder to climb out tomorrow. So what choice are you going to make here? And I was like, okay, what can I do to make this my bravest day? And that shifted things for me to, no, I'm going to face my fear. Like,

I won't explode. I won't implode. My head's not going to fall off. My heart's not going to stop. I'm just going to have to lean in here. And that was really helpful. That phrase, like, what can I do to make this my bravest day? I think it's a really beautiful way to put it. Yeah. Yeah. Yeah. Just a great piece of it. So as we kind of come toward the end here, Kimberly, and I just thought that was such a great note to kind of wrap some of this on. Are there things that we haven't talked about yet?

that as a very experienced clinician with all of this, and somebody who talks about these subjects a lot, where you're kind of going to yourself, oh, I want to mention this thing, or, oh, I think it would be really helpful if somebody who's asking themselves, like, wow, is this me? If they heard this. There's a few things. So number one, and this is the most important, is you are not your thoughts.

If you have OCD, you're going to have some pretty gnarly thoughts, but they are not a reflection of who you are and your value. Please do not allow yourself to decrease your sense of worth because of the presence of these really grueling thoughts and these compulsions.

Number two is you deserve kindness and warmth. So often people with these conditions treat themselves poorly or accept being treated poorly because they don't feel like they are worthy or they deserve to be treated well because of the presence of their thoughts or because they have this mental condition. And I always say to clients,

The clients I see are the most creative, intelligent, most hilarious people I have ever met. They are lovely human beings. But OCD and these depression, anxiety, they can make us feel like a monster. They can make us feel horrible. And we have to be able to push back against that and know that that isn't true. Yeah.

The last thing is that there is help that you don't have to, while you may have intrusive thoughts, I still have them.

But you can get to the point where they don't matter so much anymore, almost to the point where you laugh, even though they're not funny, but it's kind of like a bit of an eye roll where you're like, wow, OCD, great try, like good try. Like that was a really good one, OCD or, you know, fine, OCD, come along if you want. Like you can start to talk to it and

and not take it as if it's, again, it's not in charge, it's not in the driver's seat. So recovery is absolutely possible. It's just a matter of taking some brave steps. This just made me think of something when you said toward the end there, the self-devaluing aspect of it, particularly I would imagine maybe in some cases for people who feel like

it's very obvious what's going on for them. And you have to make kind of a choice about whether or not to talk to other people about it. I think that a lot of people who have a mental health condition are making choices, active or passive, about how much to share, how much to, you know, just like how revealed to be about this whole thing. Have you found working with people that

People who are more revealed tend to do better, less revealed tend to do better. It's totally person to person and it's very hard to draw a broad conclusion about it. What I would say, generally speaking, is that folks who tell their inner circle, the people they trust...

tend to do better because they have support. It's not really about the fact that you told someone, like you could be like, I don't care. I'm going to tell everybody. I'm just going to shout it from the rooftops. But that doesn't mean you are ready to face your fears. It might be just that you, you know, but there are those people who will go to their loved one and say, listen, I'm struggling with this thing. I'm stuck. Okay.

Is there a way you could support me through this? Encourage me, hold me accountable. They do tend to do better just because we are community-minded people. We tend to do better when we have a support system. Now, that being said, I have had clients who let's say are even clinicians who

who still feel so stigmatized by a mental health condition, who chose never to tell anybody. And because they didn't want anyone to know, it really motivated their recovery. And so it's case by case. What I will say, though, is shame grows in the dark. And so often, if you're keeping it a secret because you are so deeply ashamed of yourself,

that might be something you want to work on because you don't have anything to be ashamed of. And trying to avoid that shame is probably going to slow down your treatment as well. Thanks so much for doing this with me today, Kimberly. I've really appreciated it. Loved talking with you. Is there anything you want to let people know about where they can find you? Sure. So I have a podcast called Your Anxiety Toolkit. I have a YouTube called Your Anxiety Toolkit. I have an online educational platform called CBTSchool.com.

So I have a private practice with therapists that work for me in Calabasas, California, but I was getting so many calls from people who could not afford these types of one-on-one care. So cbtschool.com is me showing people in a course on like a pre-recorded course-like platform, showing people exactly how I would do it with a client so that they could do it on their own. Thanks so much for doing this, Kimberly. I totally love talking with you.

I hope it was helpful. Truly, I really hope it gives some people hope. I had a great time today talking with Kimberly Quinlan. She's the host of Your Anxiety Toolkit, which is a great podcast. And she's a licensed therapist working in California. She specializes in anxiety disorders and particularly OCD.

Kimberly was also diagnosed with OCD herself fairly recently, and we talked during the episode about what she applied from her enormous amount of clinical expertise to her own personal experience with OCD.

So to start at the beginning, OCD is a chronic condition that's characterized by a combination of, right there in the name, obsessions and compulsions. Obsessions are intrusive, unwanted thoughts, images, or urges that tend to cause a lot of distress for a person. And then compulsions are the things that we do in response to those thoughts in order to manage the stress that's caused by them.

We gave a number of examples of this during the conversation. The kind of classic Hollywood example is somebody who touches something, who has a fear of contamination, and they feel like they have to wash their hands a bunch of times in order to rid themselves of that fear.

Now, really importantly, these compulsions are not little things. According to the DSM, if you're going to actually get formally diagnosed with OCD, a person needs to spend more than an hour a day doing these compulsions. They are time-consuming, they are frustrating, and they can have a real impact on a person's quality of life.

One of the things that's really difficult about treating anxiety disorders, including OCD, is that they are self-reinforcing. So the typical cycle that a person has is they have some kind of an obsessive thought or an intrusive thought. Something comes into their consciousness that

probably isn't totally rational, but it feels rational to them. They have a real concern about another example that Kimberly gave during the episode about harming somebody else. They're chopping fruit in the kitchen and their grandparent walks in and they go, wait a moment, am I going to hurt my grandparent with this knife that I'm holding right now? Of course, they're not going to hurt their grandparent with the knife, but the thought has appeared and now it is very, very difficult to shake. So they're experiencing a lot of anxiety about this thought.

That anxiety then leads to the compulsion. It leads to the soothing behavior that they do in order to feel more comfortable. For them, maybe that's putting the knife away or engaging in some other kind of behavior that gets them some distance or separation from the person that they're concerned that they're going to hurt.

This then leads to temporary relief. And in a funny way, the temporary relief is kind of the whole problem because you convince yourself that it was the behavior that you did, the putting the knife down, that kept the other person safe.

And this just reinforces the underlying anxiety or the underlying OCD. Your compulsions might reduce the anxiety temporarily, but you're strengthening the overall pattern over time. So what's the alternative that we have? Well, it's exposure, and particularly the second half of exposure, exposure and response prevention, or ERP.

People tend to misunderstand exposure in part because we just say the word exposure and we leave out the response prevention part of the equation. So what are we really doing in ERP? ERP is the gold standard treatment for OCD, and it has two parts. First, you've got the exposure piece, which is about facing the feared stimuli. But the second part is you're resisting the desire to move into the compulsion that helps make that anxiety manageable.

So in the case of the person with the knife in the kitchen, they're resisting the urge to put the knife down. They're holding on to the knife. They're keeping on chopping the fruit. Maybe they're slowing down. Maybe they're moving more carefully. Maybe they have to move it away for a moment, but then they can pick it back up.

Whatever it is that's reasonable for that person. And that's what safe exposure is all about. It's not something called flooding, which is where we just try to blow somebody out of the water by exposing them to a whole bunch of some difficult thing all at once. It's well managed. You've level set appropriately. You've picked a target that makes sense for that person.

And those are all things that you would do if you were working with a clinician, but we can also just take aspects of that advice into our daily lives as well for any kind of fear that we're working with. Don't cannonball into the deep end of the pool if you don't know how to swim. Build up some resources first, pick a challenge that's well matched to your current level of ability, and just put yourself in a position to succeed as best you can. But sometimes when we do that, we don't succeed.

Sometimes things go sideways for us. I gave an example to Kimberly of a person who has more social anxiety interacting with a group of people and really feeling like it didn't go well, like other people didn't treat them well, they weren't responding to them in the way that they wanted to. And this is a very common question that we get on the show, particularly about taking in the good. So you tell us to take in the good, but what if there's not a lot of good to take in? Or what if I go to something and I'm trying to have a good experience, but it just goes bad for me anyways?

I thought that Kimberly had a fantastic answer to this. I'm going to remember it for the future. The point is that you're trying. No rational person expects to walk into the gym and bench press 200 pounds the first time that they try. That's just not how we get good at things. We get good at things by failing at them over and over again, and frankly, by learning how to tolerate the difficult emotions that come up when we fail over and over again.

She gave an example of talking to a client who would say something to her like, oh, I didn't feel anxious at all this week. Well, that's nice. I'm glad you didn't feel anxious. But she would be way more excited if a client came in and told her, hey, I did all of these hard things. I didn't like it at all. I experienced a ton of anxiety, but I was able to keep going anyways. I tried again.

I hope you enjoyed today's episode. I had a great time talking with Kimberly. She was such a lovely person to have on the show. I also really enjoy her podcast, Your Anxiety Toolkit. She just has a great voice and fantastic accent as well, but just a really beautiful way of talking about this stuff. And she does it in a way that I find personally very pleasant and easy to just turn on and listen to.

If you've been listening for a while and you've made it to this point and you somehow haven't subscribed to the podcast yet, please subscribe. It really helps us out. If you are listening on a podcast feed, you can also find us on YouTube. It's just search for my name, Forrest Hansen, on YouTube.

If you want to get in touch with the show, you can find us on Patreon. It's patreon.com slash beingwellpodcast. And you can also send us an email, contact at beingwellpodcast.com. I would love to hear from you as well. If you want to leave a comment on Spotify, on YouTube, as a rating and review on the Apple Podcast platform, it's always really helpful to know what people are enjoying about the show, the kinds of people that they would like to hear us talk to in the future, guest suggestions, all of that.

I read pretty much every comment that we get and it really does help me out. So again, thanks for listening and we'll talk to you soon.