What Excites Us!

Episode 61: Understanding OCD & Anxiety - Navigating Intimacy with Sarah Hazelton (Encore)

Transcript:

[00:00:00] Gwyn: This is a show that is adult in nature and themes. If you are not an adult or you are not in a place that you should be listening to adult things. Don't. Just stop listening now. Come back later. This is an Encore episode that I am releasing because mental health day was yesterday. And I have a bunch of stuff that I need to do to take care of my mental health. In the introduction I talk about that it is largely OCD and it is, but we do also touch on anxiety and it is a really valuable episode.

Hello and welcome to What Excites Us, the podcast that discusses sex and sexuality through a lens of acceptance and healing. I'm Gwyn Isaacs, a certified sex coach and educator who wants everyone to know that they and their desires are okay. And as long as you don't harm anyone, including yourself it's even okay to engage in those desires.

This episode is a discussion largely about OCD and how that affects intimacy for folks suffering from it. If you or anyone you know struggles with intrusive thoughts, you can't shake and it feels comfortable for you, please listen. Because we cover how OCD can manifest, how it is treated, how to find a qualified therapist and what to do if you can't.

My guest, Sarah Hazleton, is a licensed, independent clinical social worker specializing in the treatment of OCD and anxiety related disorders. She completed her master's degree at the University of New England in 2007 and spent the early part of her career as a clinician working with children, adolescents, and families experiencing severe and persistent mental health challenges.

Over recent years, Sarah has focused her therapy practice on the treatment of OCD and anxiety disorders using Exposure Response Prevention and Acceptance and Commitment Therapy as primary treatment modalities. Intimacy, gender and sexuality are often interwoven in a client's obsessive and anxious thoughts, yet are often not identified by clients as a treatment issue.

Sarah hopes to improve awareness of some of the unspoken and taboo thoughts and worries that people experience. She is working to decrease the stigma felt by people whose OCD and/ or anxiety are affecting their relationships, intimacy and identity.

Hi Sarah. Thanks for coming to the show.

[00:02:52] Sarah H: Hi Gwyn thanks for having me.

[00:02:54] Gwyn: The article you sent me was amazing.

[00:02:57] Sarah H: It is. Yeah I haven't run across an article yet that it just encapsulates everything and anything that has to do with anxiety and OCD and sex and intimacy.

[00:03:05] Gwyn: Yeah. I read it a few times and had to go look up definitions cuz I am not a licensed therapist. But yeah. Really insightful. Let's just start with definitions. Mm-hmm. What is OCD? What is anxiety?

[00:03:18] Sarah H: Sure. So OCD is obsessive compulsive disorder. There's a few kind of little tangents of it that we'll definitely get into because one of them is very focused on sex and sexuality. But it's essentially people who have OCD have a intrusive thought of some type. Thought can be an urge, a physical sensation. It can be sort of a video that plays in your head. It can be series of still images. Sensations are really common. And whatever it is, it builds and builds.

And I think a good description is like when you have a mosquito bite and. Oh, you really wanna itch it. As it's gonna make it feel better, but it doesn't make it feel better, and you just have to resist the urge to itch it and itch it. And then finally you give in, it's oh my God, that's so much better. But then it starts itching again, not that far after. And so for people with OCD to combat those intrusive thoughts or any of the intrusive sensations or visual images they do what's called a compulsion, which is basically an in the moment emergency rip cord. That's only purpose is to decrease the discomfort that somebody's feeling.

So in a very, very classic sense somebody who has OCD, contamination OCD is one of the more common ones that people are familiar with, especially with Covid and the pandemic. It's not something that just like boom appears. This is something that goes on for a period of time for folks. Months, often years, people experience OCD before they get proper treatment. And so if somebody has contamination fear about perhaps getting covid from a doorknob, over time they avoid touching doorknobs. Maybe they excessively use hand sanitizer.

They learn that if they have to touch a doorknob, they can use the sleeve of their shirt to open it, or they can use a Kleenex to open it. Often after that people need to wash their hands. And so there's this whole series of, you know, a trigger of, okay, I have to touch this doorknob that probably has covid on it. And then they have some type of workaround to not have to completely touch the doorknob or to then afterwards mitigate whatever germs they feel like they've gotten. And so that's the intrusive thought, the obsessive piece. And then the compulsion is the action that they do to decrease that discomfort that comes.

[00:05:37] Gwyn: Is it sort of like anxiety on steroids?

[00:05:40] Sarah H: A little bit. So the difference between anxiety and OCD. OCD in some ways is a little bit better in some ways because the compulsion does decrease the discomfort. It works. People don't do compulsions because they don't work. They do it because doing the compulsion decreases that discomfort. Folks with anxiety, there isn't anything that they can do to decrease that discomfort immediately. So there's the, anxiety, yes. Often with intrusive thoughts, intrusive images. Anxiety is also significantly based in worry. So either worrying about things that are coming or ruminating about things that have already happened in the past. And really just getting stuck in a cycle of, worrying about it, thinking about what the worst case scenario could be.

A lot of folks with anxiety come up with many possibilities of what could happen, most of which are not likely to happen. But, it's kind of the, if you prepare for the worst. Then you'll be ready for the worst. Except folks with anxiety, their worst that they're preparing for is extremely unlikely to happen.

So they're actually preparing for something that is so unlikely that people who don't have anxiety, look at it like, like what are you doing? Like, why are you doing that? Because folks with anxiety have a completely skewed way of evaluating risk and thinking about how to mitigate that risk because the concept of risk is so outta proportion with what risk there actually is.

[00:07:16] Gwyn: So most people have some anxiety.

[00:07:21] Sarah H: Yep. Absolutely.

[00:07:22] Gwyn: Momentarily comes and goes.

[00:07:24] Sarah H: Yep. Absolutely.

[00:07:26] Gwyn: Job interview or, they're gonna get on the subway today or whatever. But what is the difference between that being like a regular normal, in quotes, cuz that's really not a good word. Average I guess between being a regular, average way of being and the people who cross the line into this level of pathology .

[00:07:49] Sarah H: Yep. So you're right. Everybody has anxiety. Anxiety is something we really have to be able to keep ourselves alive. You know, I mean anxiety is what makes us check aspiration dates on food, it's anxiety is what makes us look both ways before we cross the street. Anxiety is really a required part of being a human being especially with evolution. And we've really evolved as a species to be very keyed into anxiety. Anxiety for most people is very functional. It keeps us safe, it keeps us prepared. It keeps us clued into where is potential risk and potential danger. It kinda keeps us on our toes. It also keeps us just moving through our days with some speed with some relative timeliness.

If there was a high school student that legitimately didn't have anxiety, they wouldn't study for tests, they wouldn't do homework. They might not even show up to class because there is no unpleasantness or no negativity if they're not worried about anything. And so anxiety really is part of being a functional human being.

And there's been some books and some research on people that, for specific medical reasons, Don't have a fully functioning amygdala. And it's actually pretty catastrophic. Going through life with, without having, a fully functioning amygdala is a huge problem. And people are basically spending their days like narrowly avoiding death at any given moment.

Where it turns into something that isn't functional is when people start changing what they do or the way that they do things to accommodate their anxiety. COVID is such a perfect example. So during Covid, people stayed at home, wore masks, wore gloves, for the most part, followed CDC recommendations to keep themselves safe.

Most people who have some level of clinical anxiety basically took all of that and then some. So people wouldn't leave the house even when it was, recommended. They're like, okay, no, it's safe. Vaccines are on board. It's safe to start going outside your house. Folks with anxiety wouldn't do that. I've had folks with anxiety around contamination with covid not order food. Have to wash not only all their groceries, but all of the food within their groceries. I've had folks just stop eating certain food products that were challenging in their eyes to be able to sanitize and to be able to definitely get rid of whatever potential germs might be on there.

And so when it goes into a place that it's really at a clinical level, that's when we start seeing things like folks changing their daily routines, changing their daily habits, missing out on things that they would typically be engaging in. Folks with anxiety, especially when you start talking more significant anxiety we're talking some fairly substantial changes to the way that they move through the world.

In addition to that folks with anxiety experience a tremendous amount of physical discomfort. All of the physical symptoms that come with anxiety, headaches, stomach aches, you know, kind of increase of chronic pain. Digestive issues, sweating, nausea, the whole gamut of things that we traditionally think of when we're like stressed out. Folks with anxiety live with that on a constant basis and it starts impacting their general functioning. You know, folks start having to call out of work because they wake up and their stomach's upset. They feel like they're gonna throw up every day.

Relationships start being really impacted because folks are, in social situations with other people, but the level of worry that they have and the level of physical symptoms that they have, make it really unpleasant to just be around other people. Like if you're feeling that much physical intensity you don't wanna be going out and going around other people. Your tendency would be to like go home, curl up under the covers and hide from the universe. And so that's what we start seeing when anxiety gets to be at a really significant clinical level. So it really runs the gamut. I mean, A lot of people who have a clinical level of anxiety externally look totally fine.

You know anxiety is one of those things that people can walk around with every day, all day long, and, unless they're in a situation that's directly poking at their anxiety, they can appear to be fine. But all of that stuff inside, all of those physical sensations they're experiencing, that's very much not fine. And the accumulated effect of that level of stress and that level of physical intensity can be pretty severe.

[00:12:16] Gwyn: You mentioned various types of OCD .

[00:12:20] Sarah H: Yeah.

[00:12:20] Gwyn: Can you just list a few of them? So that we have a sort of a baseline understanding?

[00:12:25] Sarah H: Yeah, absolutely. So what I would consider like standard OCD that would be things like the contamination OCD so fear of getting some type of illness or sickness. An extension of that would be medical OCD. And so really focusing on those physical sensations, but every physical sensation could be something far worse. There's a lot of focus on, do I have cancer, do I have a brain tumor? Do I have all sorts of really terrifying physical ailments.

But I have a brain tumor could come from somebody having a really bad migraine one day and something in their brain clicks and OCD picks up on it and all of a sudden any sort of, any brain or head-based oddity of any kind, even the little most tiny minute things then are tagged as. Oh my God, that could be brain cancer.

Other than that, there's also relationship OCD that's one of the sort of more specific subtypes that, sex and intimacy ends up being really impacted by. There's also a huge category called generically Pure O or Pure OCD. And pure OCD is defined typically as OCD without compulsions. But, most people who have Pure OCD, they still do compulsions. They just look really different. Because they don't fall into that classic, oh, I have to wash my hands again, or, oh, I have to check that the door's closed or that the oven's off.

Stuff that falls into the Pure O category. The compulsions are much more mental as opposed to like actions that you have to take. Within Pure OCD that's generally one of the kind of avenues of OCD that people talk about the least. Because Pure OCD often revolves around things that are either societally inappropriate or morally reprehensible. Again, lots and lots of sex and relationship stuff comes into this. Folks who have Pure OCD, some of the are common ones would be fear of being attracted to somebody of a gender that is not actually the gender that you're attracted to. It could be fear of having a sexuality that you don't actually have.

And when I say fear the majority, actually everybody that I've worked with that has Pure O it isn't a, I disapprove of this. So if somebody has Pure O, and their thing is focused on, a fear of being a lesbian if they're you know, a cis heterosexual identified female with intrusive thoughts or intrusive images about being a lesbian. There's nothing wrong with being a lesbian, like most of the folks that suffer with this if they were, it'd be fine, but they're not. But, the way that the intrusive thoughts work is they come across in a very judgmental way, and they really serve to undercut somebody's sense of who they are and of, the way other people see them and the way that they see themselves.

So imagine if you're a cis, het female who's having intrusive thoughts about being a lesbian. You are quite sure that you're not a lesbian, but you have intrusive thoughts about, one of my favorites is the Yoga Butt. Somebody who's suffering from Pure O and it's focused on am I a lesbian? Am I attracted to women? Do I really actually wanna have sex with this woman? Those, folks that are suffering at that might be walking through the mall or walking down the sidewalk and see, just some random person wearing yoga pants and they notice oh, nice butt. Like it's a great yoga pant butt. For most people who don't have OCD that would just be a complete one-off, oh, nice butt.

For people who have Pure O and that's something that would be a trigger, that starts a cycle of, oh my god, do I wanna touch her butt? Do I wanna have sex with her? Am I sexually attracted to her? Am I turned on right now? They start body scanning for any signs of being sexually aroused. And they go through this entire sort of mental gymnastics of, I'm not, but what if I am? And again it's not that, their fear is that they could actually be attracted to women.

That for most of the folks that I've worked with, like whatever, if they're attracted to women, they're attracted to women. That's not a big deal. But the thing that's so upsetting about it is that core not knowing if you know who you are really. And that questioning of do you actually know who you are? Okay, you're straight. But are you really straight? What if you're not straight? And it skews the entire way that people can move through the world. It can have a huge catastrophic impact on people's intimate relationships with their partners. Or with the way that they attempt to navigate the dating world. So that's a really common example that I've ended up running into a lot.

[00:17:22] Gwyn: That's really interesting. And it makes me wonder if I missed some things with clients. Being unable to really delineate, which makes sense not being a trained therapist, the depth of their concern and confusion as being more than just confusion.

I really wanna hammer home the concept. We all get these mosquito buzz thoughts. Yeah. They happen and then you just swat 'em away and they go away. But It sounds like for folks who are suffering with these things that that they don't go away. No. That they, they just dig in deeper deeper and deeper.

[00:17:56] Sarah H: Yep. And they become more intense and they cause more and more emotional upset. Because you can't make them go away. I had a woman who I worked with who had a lot of intrusive thoughts about whether or not she was a lesbian. And she was in a het relationship. But, when she and her partner would be being intimate, she would have intrusive thoughts about sexual images of women. People without OCD okay, that can go a few different directions. You can really go with it and lean into that fantasy of another person in your head while you're being intimate with your partner.

But for folks with OCD that would start this train for her of oh my God why am I having these thoughts and images while I'm being intimate with my boyfriend? Does that mean that I'm not attracted to him? Does that mean that I don't love him? As we're fooling around, am I turned on because of him? Or am I turned on because of what I'm thinking about in my head? It's really, really difficult. And you know what most folks with OCD find in those kinds of situations is that you can't just turn those thoughts off. The more you try to not think about them, the more you think about them.

Most people, I think I would maybe stretch to say all people when they're being intimate or when they're in a sexual situation, most people have some type of intrusive thoughts. You know, like, Oh, the cat's being weird. Or, oh, I have to remember to do that report tomorrow at work. But then they move on and they come back to being in the moment and being in this situation. Folks with OCD that thought comes in and it just stays and they start perseverating on it and they start being hypervigilant to it.

And the entire sexual encounter changes from, okay, no, me and my boyfriend are having a great time having sex to; okay my boyfriend's having sex with me, but I'm not sure what I'm having sex with or who I'm having sex with. Am I actually so turned on by these images in my head that I don't wanna be turned on by? Does that mean that I actually am attracted to women and not attracted to my boyfriend who I am currently having sex with? And so it turns into this very all-encompassing very, very intrusive thing during sex for folks.

Another angle it can go is, and this is where the compulsion piece kicks in, folks will engage in sexual activity to prove that the thoughts that they're having aren't true. So for somebody who has a lot of intrusive thoughts about, let's say being attracted to a different gender than what they in real life are attracted to. They might, you know, have sex repeatedly more than they typically would to prove to themselves that they're not attracted to what they're afraid that they're attracted to.

All of these experiences, they're very, very physical, sensory focused. And so while all this is going on in people's heads, there's also really strong physical sensation component to it, with a lot of people doing a lot of body scanning. Doing a head to toe assessment of, what am I feeling? What am I noticing? Am I sweaty? Am I not sweaty? People do a lot of focusing on what is happening, what do they expect to happen, sexual response wise. And if what they expect to happen isn't happening or it's happening in a slightly different way, then that's a fear, then they're like, oh my God, am I actually dot dot dot because of the way that my body's responding.

[00:21:24] Gwyn: You've mentioned it coming up during sex. What happens to folks who are struggling with these things during actual intimacy with a partner?

[00:21:35] Sarah H: Yeah. So it's extremely distracting. Extremely distracting. And so without question, it takes away from the in the moment experience both for the person with OCD and often for their partner. A lot of it depends on if their partner's aware that this is happening.

As you can imagine sharing with another human being, even a therapist, that you are afraid that you might not love your boyfriend or, you might not actually be attracted to your husband of 15 years. These are not things that people share. There is a tremendous amount of stigma and shame around OCD period, but especially around any of the OCD styles that impact gender, sex and intimacy.

A lot of people feel like it's almost a dissociative process. And not necessarily in the like clinical dissociative style, but they're so in their head and so wrapped up in what's going on internally that they're really not there for the experience. I've had a lot of folks describe feeling numb, feeling like, okay sex is happening, but I'm not really there, I'm not really in it. It's like my body and my partner or this person that I'm with, but I'm not actually in it with them.

It can bring a tremendous amount of self-consciousness. Self-consciousness about their own participation, their own physical responses a lot of self-consciousness about, your own sexual performance. All of those kinds of things. It can actually very legitimately decrease sexual performance, decrease all of the standard arousal attraction systems. So yeah, so it can have a really significant impact on the actual experience of sex.

If you think about it relating to sex, people can have OCD about it. People being completely and totally consumed with might I get pregnant? Might I get an STD is the protection good enough? Is the condom gonna break? Is my birth control gonna really do what my birth control's supposed to do?

OCD causes people to really focus on that, like one little minute percent. So like women who take birth control if you have O around getting pregnant, these are the folks that are like, okay, that 99.7% success rate with taking oral contraceptive, oh no, I'm gonna be that 0.03%. That's gonna end up getting pregnant. Period. End of story, hands down. And if that's the way that somebody's OCD is playing out, things that they're gonna do are gonna be like, okay, wear are two condoms. I'm gonna be on oral contraceptive and we're gonna use condoms and I'm gonna have a stash of plan B at the ready, just in case.

So really going above and beyond to mitigate the risk that's there, even though the risk is actually quite small. But their OCD and those intrusive thoughts of the "what ifs" simply take over. And somebody's ability to have that judgment of how much risk is risky, how much risk is really not risky? It's completely, totally skewed.

Another section that comes in a lot is contamination OCD. Folks being concerned about contamination with semen, contamination with vaginal discharge. Folks that have to, then take showers immediately afterwards. Or, folks that douche repeatedly to try to ensure that they're not contaminated by somebody else's body product. Yeah, there's lots and lots of different avenues that OCD can pick up on related to sex. And they're really debilitating.

[00:25:03] Gwyn: Yeah, I can imagine it shuts a lot of people down just Yeah. It, nevermind I don't wanna deal with any of that, so we just won't.

[00:25:09] Sarah H: Yep. Exactly. Exactly. Another piece that comes in is called relationship OCD. And so it's basically OCD and intrusive thoughts around whether or not you love your partner and your partner loves you. And so these, folks look for a lot of reassurance. Do you really love me? What if I did this? Would you still love me? What if I did this, would you still love me? There is no right answer that their partner can give. Because OCD will always be there with the Yeah, but what about this? And OCD will always be looking for that one in a million chance that the partner's reassurances might not be correct.

Or might not be good enough. And one of the hardest things when it comes to relationship or any sort of relationship sex, intimacy OCD is, there is almost never anything set in stone. And so no matter what you can come up with OCD wise, there is always a grain of a chance that thing could happen.

When we get into some of the more morally reprehensible sides of OCD and sex it changes from, okay, there's a grain of truth that this could happen. To there's a grain of truth that somebody could find out that this is something that's in my head, and then that will be completely devastating.

Some of the more common ones, and again, these are ones you just don't hear about them that often because they're so shameful and humiliating. Who on earth would wanna talk about them with anybody? But, the rates of folks having intrusive thoughts about pedophilia, intrusive thoughts about being sexual or having sex with individuals or non-human individuals that are completely inappropriate.

The rates of folks who have intrusive thoughts about being sexually active with family members or children or people that basically anybody that would be completely and totally morally reprehensible to be engaged with sexual contact with. Those kinds of things. I wouldn't say it's common, but it's much, much more common than you would think. People just don't talk about it because my God, who would wanna admit to their therapist, let alone any other single soul on the planet, that they sometimes have intrusive images or intrusive thoughts of having sex with their parents.

Nobody would ever want to admit that. Yet. Those are the places that OCD goes. Because OCD picks up on the things that are the most important to you and it goes at those things. So there's a lot of folks that have, intrusive thoughts or intrusive images of, like I said, of pedophilia. Who on earth is gonna talk about that with a loved one? Nobody would! That's not something that you tell your best friend. Oh yeah, I'm having intrusive thoughts of having sex with children. That's a place that OCD goes though.

One of the keys for all of this, and the reason that A, it's so unusual for people to talk about, but when they do they get so much relief when they do talk about it, is because those are the last people in the world that would ever do those because they're so afraid of being that person that they will like go to the ends of the earth to not be that person.

I've worked with a handful of folks all across the age spectrum that had pedophilic, OCD. These are your people like they will literally change the way that they drive to work so that they don't drive by a preschool or an elementary school. Not because they're going to do anything, but because even the availability or even seeing a child puts them into such a state of sheer and total panic over, oh my God, I can't do that. What these thoughts that I'm having but do I wanna do that? And of course, I don't wanna do that.

They're just thoughts. They're just thoughts. And we as human beings have tremendous amount of control over taking action on our thoughts. The reality is they're the last ones to do that. Like period end of story. You know, I'm sure there's folks that take their own lives to avoid the potential of being somebody who could attack a child or who could attack another person. And so the level of avoidance that people go to when they're suffering with this kind of OCD it's catastrophic.

[00:29:44] Gwyn: I feel for them I suddenly have a whole new level of caring for Howard Hughes.

[00:29:50] Sarah H: Yeah. Yeah. The work that I do is hard, but it's earth shatteringly amazing to sit with somebody that has been plagued by thoughts that basically disgusted them and they have so much shame about. And essentially have cast themselves into the role of being a disgusting, horrible person who can do something unforgivable to another human being at any given moment. And that they have to put all of this work and all of this effort into not putting themselves into a situation where maybe potentially maybe they could actually have the chance to do what they are thinking in their head.

To be able to like work with somebody who's been suffering with that. And it, every time first session, one of the things I say is, I know you are never going to do any of these things because you have OCD. And OCD means that you can have the most horrid, reprehensible thoughts in your head that you will never carry out.

And to sit across from somebody who's been suffering with this for years and years, and to tell them like, no, all that stuff in your head. I have no concerns you're gonna do that. I'm not calling CPS. Why on earth would I call, and for them to be telling me these things and, and for my response as a clinician to be why on earth would I tell anybody?

These are just thoughts. You're not gonna do any of these things because you'd rather just lock yourself in your house and like, literally never leave. Then take the risk of maybe doing these things. People don't share this stuff with their therapist because they're afraid they're gonna go to jail.

They worry that their therapist is gonna have to like, turn them in. And one of the first things that I do in sessions with folks who come, who have any kind of OCD is, I give them like my mini lecture of, okay, OCD takes all sorts of shapes and forms. Some people with OCD think this, some people with OCD think this, you know, and I lay out all of the potential pieces of OCD that people don't wanna talk about so that they know, okay, if I have that in my head, I know it's safe to tell her because my therapist is sitting here telling me they're just thoughts.

We have thoughts all the time that we do absolutely nothing about. Even thoughts that stick with us. We do absolutely nothing about them. But the nature of OCD means that people are convinced that if they don't follow a very specific prescribed set of rules that they've come up with for themselves, with their compulsions or their mental reassurance, if they don't follow those paths and if they don't follow their checks and balances and rules, they will do those things.

[00:32:43] Sarah H: It's especially awful for like kids and teenagers. Cause being a teenager with hormones is hellish experience to begin with. But being a teenager with hormones, and also has all of these sexual intrusive thoughts or like violent, sexual intrusive thoughts in their heads. Oh haha. You just feel awful for them. Yeah. Your thoughts and things that are in your head, that doesn't mean you're gonna do them.

How many times have you thought oh my God, I'm gonna throw my history book at my teacher if he doesn't stop blabbing on about this one thing. Have you ever thrown a history book at a teacher? No. Okay. So you can have thoughts that are pretty powerful and pretty specific and you can not act on them. And the exact same thing with sexual OCD and with all of that sexual intrusive OCD. Just because you have the thought doesn't mean that you are going to do the action.

[00:33:30] Gwyn: Yeah. And being a young person, not having any of the benefit of time, everything feels very, has to happen right now. Because there's no yet concept that no, no, life goes on for a really long time.

[00:33:44] Sarah H: Exactly. With the unfortunate easy access of porn on everybody's handheld computers that they have in their backpacks. Unfortunately that has meant that OCD has gotten very creative with how creative it can get. Yeah. No statistics on this, but I have to imagine that over the last 30 to 50 years the sexually intrusive OCD has, okay, maybe not increased in numbers across population, but how can it not have increased in creativity of where those thoughts go.

[00:34:19] Gwyn: Do we have any idea where these imbalances come from?

[00:34:24] Sarah H: No, that's a great question and something that basically every client I've ever had is why do I have OCD? I haven't looked at the most recent research. I know that's something that is being researched. There's been a lot of more recent brain scan type research trying to figure out like what parts of the brain are triggered for folks with OCD. And so some of that information is out there. Generally for my clients there's two answers. Answer number one is for some people there's a really specific event that they can identify as being the thing that kicked off their OCD.

It's typically something that's relatively traumatic. So like if you throw up in second grade in your classroom and you like barf all over your desk and all over yourself, you're gonna be at a slightly higher likelihood of being emetophobic, which is the fear of throwing up. If you got Covid because, you were like, no, I don't wanna wash my hands. I'm not wearing a mask at school. And then you get covid and then you give covid to your entire family, which I have a couple clients that has happened to. Okay yeah, the pumps are primed for OCD to kick in.

And so for some clients they can identify a specific event or series of events that sort of laid the groundwork for OCD to show up. Other folks, nothing. It just simply appeared. Typically quietly and in very gentle small ways. And then it increases and increases over time.

Many people, and these numbers are dramatically improving, especially with the younger population. But it sometimes can take 10, 12 years for somebody to get an accurate OCD diagnosis and appropriate treatment. And a lot of that's just lack of education. And as nice as it is that the language of OCD is becoming more well known.

There's a bazillion memes about it, there's full Instagram pages about it. So yes, people know more about OCD but they don't necessarily know the right stuff about OCD because it's all of that. I can't find my favorite pen. Oh God I'm so OCD! For folks that actually have OCD, that's infuriating because, they'd be like, oh my God, I wish the biggest crisis of my day was that I couldn't find my favorite pen. That would be freaking awesome. Can I please have that kind of OCD?

[00:36:35] Sarah H: So, Yeah, so it typically does take a really long time to get accurate diagnosis. It takes even longer to get accurate treatment for most people. The gold standard of OCD treatment and anxiety treatment is something called Exposure Response Prevention. Shorten to ERP. It's, super, super well researched, very much the established, most appropriate treatment for OCD and anxiety. And Exposure Response Prevention is a twofold system.

Number one, you have to voluntarily expose yourself at a level that's uncomfortable, but not way too uncomfortable. You expose yourself to the thing that you fear. Or the thing that is your trigger. And then your anxiety is going to increase, your discomfort is going to increase, and you tolerate it. You don't do anything about it. You just sit and experience it. Bit by bit over time, you then teach your brain that this thing that is tagged as very dangerous isn't actually dangerous at all.

The thing that you're trying to avoid is actually the discomfort you're experiencing. And so it's giving your anxious brain or your OCD brain a whole bunch of new information that this thing A, is much less dangerous than we think it is. And you can handle it.

And so it's the expose to the thing that causes the anxiety or the discomfort. And then the response prevention is not doing the things that you would typically do to make yourself more comfortable. So exposure response prevention, we're exposed for OCD and for anxiety, equally effectively. It's the best for both. It plays out slightly different for each. For OCD, it's much more about put yourself in this situation that you know you're gonna be triggered. Know what your compulsion might be, and commit to doing that thing without doing your compulsion.

So for instance, with somebody with contamination OCD related to semen. What you might do is okay, not jump to the hundredth percent of have sex with somebody and then have semen on you, but it might be something more like, have your partner ejaculate into little cup or something that you just keep in the fridge.

That in and of itself for a lot of people's contamination, OCD is plenty. Just knowing that there is a Tupperware container in the refrigerator that is completely sealed, not gonna magically explode all over the fridge, but that it's there. And tolerating over the course of time the fact that it's there, not moving it, not touching it, but being aware that it's present. And over time you do get more used to it.

A next step would be to hold the container. And then you graduate up to, okay, taking the container lid off. And you keep on upping it and upping it, maybe putting some on the back of your hand and seeing how long you can just have a little bit of Q-tip semen on the back of your hand until you forget about it.

All of this is done without the compulsion. So the semen on your hand, don't wash it off. You don't make a bargain with your OCD that I'll put it on for 20 minutes, but then I can wash it off and so it'll be okay. No, you don't wash it off, but you pre-plan how that is gonna go. You pre-plan with your therapist. How do I want this exposure to work? And so you basically story out what that anxious experience is gonna be looking like in a very controlled setting, very controlled, pre-planned situation so that you know what's gonna happen. So that everything is like, all right, I know everything and I know how bad this is gonna feel.

And it's really the therapist's job to work with you and figure out how challenging is challenging enough without being too challenging. And then it turning into an extremely unpleasant experience. Cuz that's what we don't want in any type of exposure work. These are voluntary situations that people are entering into that they know are going to be uncomfortable.

On a slightly different angle with a lot of the intrusive thoughts with the pure OCD. You can't just make yourself not have thoughts, that doesn't work ever for anybody. You can't just say, stop thinking about this and you will stop thinking about this. Typically, you will then think about that thing more.

And so instead for folks that have those types of intrusive thoughts or mental intrusions, instead exposure work much more looks like engage in the sexual activity that you are going to engage in with your partner, but plan it out. You script out as best as possible how that sexual encounter is gonna go, what the thoughts are gonna say. Cuz they happen all the time. You know what's coming. And really scripting out how do I wanna respond to those thoughts as they come.

For some clients, saying them out loud to their partner like, oh, okay, now I'm having this visual thing. Oh, now there's this visual thing. Oh, now this one showed up. And just narrating it out loud makes a huge difference. For some folks, they much more need to focus on what's called diffusing the thought.

Diffusing is the, process of taking the emotional connection out of the thought. And so if you're, engaging in sex with your partner and you have a visual intrusive image of, thrusting penises, for instance, and, and this image of thrusting penises just comes in your head over and over again, trying to not think about it, isn't gonna do anything at all.

You can't not think about things , but instead we use diffusion and diffusion separates the emotion from that visual. And this is something that you would have to work on with a therapist. Being able to know that the thrusting penis is going to be there when you're trying to have sex with your partner. Knowing that visual is going to be there and doing the work ahead of time to say that's just a thought, that's just a visual. That doesn't have anything to do with what's happening with my physical body right now in my arousal response.

A lot of the times people can do substitution thoughts. Thinking about something that's sexual related that is a less triggering thought. You can make a joke out of it. So there's all sorts of different, basically different ways to take the emotional intensity out of it. I had a client who you know, who had the intrusive penis image over and over again. Um, and she was in a same sex relationship and she was like, I dunno, the last time I had seen a penis.

So she's like, I dunno where the hell is this coming from? I'm like, oh, it's coming from OCD So there's that does not mean you want to actually have a penis in your bedroom with you, but you know, this is an image that you're suffering with that's causing significant problems for her with her partner. And so she decided she wanted to go the silly route. And. This is where Exposure Response Provision can be really creative and fun sometimes.

So her and her partner made a paper mache penis. That was the same as the ones that she had in her head. They made a paper mache one and they decorated it. And they put it in their bedroom. And it was just there all the time. And the ridiculousness of the two of them together, making this gigantic paper, mache' penis, painting it and modge podging it and decorating it with all sorts of super feminist like pussy pride and, they really went to town with this thing.

It made a huge difference because all of a sudden it wasn't this forbidden, horrible image in her head while she was trying to have sex with her partner. She has this like absurd literal visual penis at the end of her bed. And it became something that they basically just laughed hysterically over. And the thoughts would still be there, but when it would show up you know, she'd be like, oh my God, it's back. And they would both stop having sex and they'd yell at the paper penis get outta here. It was hysterical.

So these are the things, you know, when we talk about doing exposures and we talk about. Especially in a OCD that's really sexual or intimacy based, there's so much terror, so much embarrassment, so much shame, so much stigma around all of it, that sometimes you just need to flip it on its head and think about it an entirely different way and have a different approach with your thoughts.

Have a different relationship with your thoughts where you know, instead of it being something that brings horrible, embarrassment and shame, as soon as it pops into your head, creating a different narrative and a different story around it so that it isn't so serious because it is still just a thought. So my job is also super fun.

[00:45:23] Gwyn: Yeah. That particular story made me think about how vision boards work for folks.

[00:45:28] Sarah H: Yes. Yep.

[00:45:29] Gwyn: And that, you just create this thing that you are, and I, I do this with clients too. Or I'll have them write a phrase and stick it on their bathroom mirror or on their dashboard or someplace where they see it all the time. So that , you're not even aware of it, but it just seeps in.

[00:45:43] Sarah H: Exactly. Yep. Yeah.

[00:45:44] Gwyn: So the idea of the giant paper mache penis as the anti vision board.

[00:45:49] Sarah H: Yes.

[00:45:50] Gwyn: Brilliant. Yep. I love it so much. Really happy. And along the sillier nature of these things, when you were talking about the semen in the fridge, I of course was like, how long is it gonna last? Will it get really nasty like will it explode like a yogurt container? Which I know it's not the point at all, it just felt that I needed to share that.

[00:46:17] Sarah H: Yeah. And I think, overall especially with the sex and intimacy related OCD, so much of it is the therapist's comfort level with all of it. I would be really crappy at my job if somebody came in and they're like, okay, I'm having intrusive images of doing something sexual to my cat, which I've also had people that's a thing. I would be really bad at my job if I was like, oh my God, really?

That's not the response that people need, you know? So it's much more of oh, totally, and what about your dog? And, oh, what about that neighbor's cat? What about the other cats in your life?

[00:46:51] Gwyn: I've worked with a lot of clients who can't speak with their therapists about this.

[00:46:55] Sarah H: Mm-hmm.

[00:46:56] Gwyn: For a lot of therapists, it is a extreme discomfort. And so that's part of what I do. So I'm glad that there are folks who don't feel that way and can tackle these things because they are prevalent and things get stuck in our heads. Even basic things get stuck in our heads. And then, you know, like, I need to carry an umbrella cuz it's gonna rain. And then it doesn't rain and then you're annoyed cuz you carried the umbrella, but that's a mild annoyance

[00:47:23] Sarah H: Yeah.

[00:47:23] Gwyn: Versus the sort of things that can come up when it comes to sex and sexuality and gender.

[00:47:28] Sarah H: Yeah.

[00:47:28] Gwyn: That can just completely shut us down. Not having a safe place to share that is insurmountable.

[00:47:35] Sarah H: Yeah.

[00:47:36] Gwyn: For folks who can't find a therapist right now Exposure Therapy Um, ERP, was that right?

[00:47:42] Sarah H: ERP yep.

[00:47:44] Gwyn: It sounds like if that's something that you're able to do on your own and teeny tiny baby steps that maybe, big maybe you could try that.

[00:47:52] Sarah H: Mm-hmm. So first off, the IOCDF the International Obsessive Compulsive Disorder Foundation they are the top resource in the country. Www.iocdf.org, they've got chapters in many states. Their big focus is outreach and education. Literally just getting people more aware of and more access to appropriate treatment and appropriate services. Because, there is a decent amount of trauma and a decent amount of negative experience that somebody can have with a therapist who is trying to treat OCD but just doesn't have the experience.

The average therapist who is a general practitioner, they are just legitimately are not necessarily going to have appropriate training for the level of OCD that we're talking about here. Those trainings are available, absolutely. But it really does go above and beyond into the range of being a specialist.

So IOCDF is a great resource. They've got a therapist search function. You can search by state and by region for therapists that have gone through some trainings and are vouched for by IOCDF as being able to provide appropriate evidence based therapy for clients.

Telehealth is also a really good way to access. As long as your therapist is licensed in the state that you live in, they can see you. I'm licensed in Maine, New Hampshire and Vermont I can see clients in any of those states, even if I am not in that state. And so that opens up some pretty significant increased access if you don't live near a big metropolitan area with a lot of therapists.

There are definitely a gigantic collection of self-help books available. There's lots of them. I have some that I like better than others. But I would say, for those types of recommendations, IOCDF is the best place to go. A lot of the self-help books that are out are either written in support or written with the support of IOCDF, or they're clinicians that have just been working in the field of O C D and anxiety for a really long time. And a whole bunch of doctoral level folks have put out a lot of self-help books in education books.

There's also a whole bunch of books for family members who have somebody who's experiencing OCD. There's some really good ones there. I would stay away from any of the kind of Instagram style therapists. That line tends to be more glitz and glam look at the pretty. I am on a couple of them and there's lots of adorable pithy comments or quotable things that are cute and touching, but aren't very helpful for somebody who's actually really suffering with OCD.

There's also support groups. All over the country. I lead a once soon to be twice a month support group for junior high to high school aged kids. It's based out of New Hampshire, but it's open to everybody. And I've got some kids from Texas that join it. Um, a couple other from the West coast.

And so there's no regional limitations on that. And you can go on the I O C D F website and you can also search by support groups. There's, I know just a New Hampshire, there's. I think probably four different support groups. There's an adult OCD support group. There's a support group for parents with anxious children. There's the youth support group that I run, and so there's support groups all over the place.

And that's a really good way if you just can't get in with a therapist, at least you can be talking with other people who have OCD. Typically, at least in the ones that I've participated in, there is an OCD clinician that's either there and available or that's doing the facilitation of the support group. And then there's lots and lots of webinars and YouTube videos that, talk about OCD and talk about OCD treatment.

As far as folks setting up their own exposures. It is always better to do that with a therapist so that you can have somebody to pace you and to think three steps ahead of where you're thinking and where your OCD is thinking. But that's just not available for some people. Some people simply are just not going to have access to that. And so if that's the case, then a support group and, a good solid self-help book oh my gosh. It's better than nothing,

[00:52:18] Gwyn: it sounds like baby steps, whatever you think the next step would be. Cut that in half at least.

[00:52:23] Sarah H: Yes.

[00:52:24] Gwyn: would be what is coming across as a recommended tiny little pieces. So that mouse bites as a friend calls it.

[00:52:31] Sarah H: Exactly. Yeah, exactly. Exactly. And I think, especially for folks with OCD, one of the things that I hear over and over again, both from clients that have OCD, from friends of mine who have family members who have OCD and from other clinicians that I collaborate with, a huge part of it is literally just understanding OCD, It's just education.

There's a ton of education and self-education that people can do to really understand how OCD works. To understand some of those things I was talking about. About, okay, you might have the interests of thoughts and it might be absolutely terrifying. And because they're in your own head, you might be completely and totally convinced that you could actually do these horrible things and you won't. And those are the kinds of things that you can learn from a book and just get some of that education around what OCD is and what OCD isn't.

[00:53:27] Gwyn: Now if they're in the place where they can start looking for a therapist, how do they interview that therapist?

[00:53:34] Sarah H: That is an awesome question. So first off, if they're able to find a therapist that's on the IOCDF website most of those therapists have bios that kind of go through the type of experience that they've had with OCD. And so if they're able to find somebody who specifically advertises that, they're an OCD specialist on the IOCDF website. Then it's much more of just interviewing, like you're interviewing any other therapist because you know that therapist has a baseline really solid understanding and education about OCD.

The place that people are much more likely to run into difficulty is Psychology Today. I don't know about any place else in the country, but at least in our region, Psychology Today is the place you find a therapist. Period, end of story. We're all on it. And if you go on Psychology Today and if you do a sub search for therapists that take your insurance and that specialize in OCD, you can get a whole lot of them.

But because of the way that Psychology Today is designed is all just check boxes and so it's each therapist's prerogative to check or not check different boxes. And there is a tendency, because we wanna help people. You don't wanna say, no, I can't help a certain kind of person.

There's absolutely a tendency to just box check. Which, that's literally just out of wanting to help people. But if you have a client who's looking for really intense OCD treatment, the box check therapist isn't gonna have that level of expertise. IOCDF the website does have a list of recommendations for how to find a therapist. So they've got a great list of questions, but yeah, it's questions like do you have experience doing exposure work?

Maybe, giving them a little like, okay, so here's my OCD, these are the things that I'm having a hard time with. What do we do? And just see how the therapist kind of talks about that, you know, how much confidence they have. How easy is it for them to kind of, do some predictions about what the first few sessions will be like.

You know, somebody who's a therapist who's experienced with OCD is gonna be able to ask the right questions, to kind of lead you into other ways that OCD could be playing out. And in general, the thing that I hear from my clients is that it feels like they get you. And that's probably the biggest number one thing that I hear from clients. After we've been working together for a while and we're kind of doing that reflection back on how far you've come. Frequently I hear like you just got it. You just understood. You didn't think I was weird. Your face didn't fall off, out of shock with anything that I said.

And not only that, but you asked the right questions that I was like, yes, that too. Ooh, that too. And so a good OCD therapist is really gonna be able to join with folks in a really collaborative way because Exposure Response Prevention is not something that's therapist tells me what to do when I do my homework and do it.

It's very collaborative. Because it has to be, it can't not be. If a client's not ready to do a particular exposure or a particular challenge, then they shouldn't do it. And the only way that you're gonna be able to be there with them is to have that open communication about what they're comfortable with, what they're not comfortable with, and especially where are they comfortable not being comfortable. Because all of this work involves very intentionally being okay with being uncomfortable.

[00:56:53] Gwyn: Well, This is a really horrible note to end on however, we both have other meetings to get to, and this has been this has been fantastic. Thank you so much for talking with me.

[00:57:06] Sarah H: You're welcome. Absolutely.

[00:57:08] Gwyn: Yeah. I'm really excited to share this with the listeners this is all sorts of illuminating.

[00:57:13] Sarah H: If you want, I can drop you an email with some of those links, like the link to IOCDF and then a couple links to some of those better books that I mentioned.

[00:57:21] Gwyn: Absolutely. I will put those all in the show notes so that people can find them. Awesome. Thank you so much, Sarah. This has been great.

[00:57:28] Sarah H: Thank you, Gwyn.

[00:57:30] Gwyn: If you would like more, please visit patreon.com/whatexcitesus, where you can hear more of the conversation, including some for folks who aren't members. You can also check out the show notes for the article I mentioned at the beginning and all of the recommendations that Sarah had. And as always, if you have more questions about this topic or any other, you can leave those questions for me free and anonymously if you choose at whatexcitesus.com. I will follow up with the guests and record mini episodes for those. If you enjoyed this conversation, please be sure that you are subscribed to the show so you will hear all the other great conversations we have here. Also, I would ask that you have a chat with your friends. Having more of these conversations will help reduce the stigma around these topics, and I believe that will help the world overall.

What excites us is produced, edited, and hosted by me. Gwyn Isaacs. The podcast is hosted by tickle.life. All music is used under the Creative Commons attribution license. The opening song is The Vendetta by Stefan Kartenberg and this is Quando by Julius H. I appreciate you. Thank you so much for listening and be kind to yourself.