Disgusting-ly good news about OCD treatment

Is there such as thing as good news about disgust? Yes! If you suffer from or treat contamination OCD based on disgust, I recently published a new proposed treatment protocol for it that could be useful information for you and your therapist - particularly if traditional exposure-based OCD treatment hasn't helped as much as you would like.

A growing body of research is now showing that contamination OCD based on disgust ("I can't stand feeling gross", "I'll never feel clean enough again") is processed in a different part of the brain than COCD based on fear ("I'll get sick from germs or poisons, or will get others sick"). More importantly, it doesn't respond to traditional exposure therapy the same way. I recently published a proposed treatment protocol for disgust-based OCD based on emerging literature, involving rapidly learning to practice functioning better, as a clinical article in the IOCDF Spring 2023 Newsletter (see page 13).

This article has already generated a great deal of positive feedback from OCD sufferers and clinicians alike, many of whom have shared that it has helped in cases where people previously felt stuck with existing treatment approaches. I have also recently discussed this on several major podcasts in the field, including Kevin Foss' FearCast Podcast, Stuart Ralph's The OCD Stories, and Kristina Orlov's The OCD Whisperer (coming July 2023).

More to come on this - stay tuned!

Theory X, Theory Y and Treatment Motivation

Psychotherapists and corporate executives often have little in common. Unless you’re someone like me, who has done both. 

Because of this, I have come to feel that a core concept of corporate leadership holds the key to effective therapy for anxiety disorders. This concept is known as Theory X versus Theory Y.

I became a psychotherapist later in life, in my mid-50s. Decades earlier, I was director of customer services for a California software startup that is now a major part of a nearly billion-dollar operation. Let's explore how this concept ties in with success in both of these fields. 

First, a little background

Theory X and Theory Y were the brainchild of 20th-century management professor Douglas McGregor – who, in turn, was a student of famed psychologist Abraham Maslow. His ideas have survived remarkably well into the 21st century.

Theory X holds that employees fundamentally lack ambition, avoid responsibility, and need to be pushed. Theory X managers feel unless you “motivate” employees with rules, boundaries and consequences, they will goof off. Theory Y, on the other hand, presumes that people have intrinsic motivation to do a good job when they are shown respect and given agency.

Theory Y management strategies have built some of the most successful businesses of all time, by fostering autonomy and initiative at all levels of the organization. Another surprising place you will find Theory Y is the military, who realized that you don’t want unmotivated slugs sharing a foxhole with you. Many books have documented this trend, from the 1980s classic In Search of Excellence to recent bestsellers like Brené Brown’s Dare to Lead.

My own corporate success was largely fueled by Theory Y principles - for example, team involvement in hiring and policy decisions, cross-functional responsibilities, and championing individual growth and achievement. Everyone felt heard, respected, and had a reason to feel important when they walked in the door each morning, and they in turn delivered. This helped our company grow rapidly and eventually go public. Later, I led another 24-hour call center operation to near-perfect customer satisfaction, near-zero turnover, and a 25% sales increase in the middle of a recession using a similar approach.

So, what does any of this have to do with psychotherapy?

I feel therapy for anxiety disorders has unwittingly made a hard turn towards Theory X over the past several years. Since the 1970s, it has moved from a focus on relaxation and desensitization to a focus on sucking it up and facing your fears. Have a phobia? Go at it head-on. OCD compulsions? Turn the Nike slogan on its head and "just don't do it." Your kid has anxiety? Suck it up, Junior.

As a result of this, too many therapists now see themselves as agents of confrontational change, whose job is to make clients face up to what their symptoms are costing them, and then push them to “do the work” of uncomfortable treatment strategies.

This is more than a change in clinical technique – it is a cultural shift. For the record, I support techniques that involve facing your fears, like exposure therapy, when they are paced appropriately and delivered humanely and collaboratively. But too often, these approaches entail a power dynamic that revolves around pushing the reluctant to do the uncomfortable.

Anxiety therapists who privately treat squeamish clients like disobedient schoolchildren and debate how to “motivate” the non-compliant sound exactly like Theory X managers who try to push their lazy employees to get back to work. And unfortunately, outcome studies show that these clinicians often get similar results as these workplaces do – far from perfect. This is why I feel strongly that the next frontier in anxiety treatment needs to also be a culture change. Now, let’s explore this.

Bringing Theory Y into the therapy room

I hear the same thing over and over again from clients and clinicians alike with lived experience with anxiety disorders. Clinical strategy of course matters – and often matters a lot – but one of the biggest factors in our recovery is often how much a therapist listens to us and collaborates with us. Here are some of the things I’ve heard people describe about their real experiences behind closed doors in treatment:

·        Therapists try to “motivate” people to keep doing things that ultimately aren’t working for them.

·        A manualized treatment protocol takes precedence over the whole person sitting in front of them, including factors such as trauma, life change, health status, neurodiversity, and more.

·        Dr. Wonderful decides how well the client is progressing, what their goals should be, and how hard they should be working.

·        Stuck points in treatment are presumed to be the fault of the client, and they are branded as treatment failures or told to come back when they are “ready.”

All of these spring from the same kind of Theory X "get back to work" mentality I experienced back when I was a bored grocery store clerk in high school. Had these therapists adopted a Theory Y mindset, regardless of the approach they used, I am convinced that they would have had much better outcomes.

Here is how I would compare these mindsets:

Theory X anxiety treatment	Theory Y anxiety treatment
Have clients confront themselves with what their symptoms are costing them.	Explore what a client’s own goals and motivations are.
Enforce accountability for treatment compliance.	Check in with them and help them strategize next steps.
Push them to challenge themselves.	Help them self-motivate by building on achievable victories.
Help clients face their fears.	Help clients function better and expand their boundaries.
Focus on bravery.	Focus on strategy.
Assume that treatment failures are the fault of the client.	Assume that treatment failures are the fault of the approach.
If they remain stuck, dismiss them as a treatment failure	If they are stuck, meet them where they are at. Be patient, flexible, and open to modifying your approach.
Think like a tough-love coach.	Think like a helpful consultant.
Confront clients who aren’t working hard enough to recover.	NEVER EVER shame a client – listen and troubleshoot.

 

In a very real sense, a Theory Y approach could help self-regulate what clinical approaches work best, by giving clients a voice in what is or isn’t working for them – and in the process, build the kind of clinical relationships that give these approaches their very best chance of success. Unfortunately, this subtle but important attitude rarely finds its way into either graduate school training or research studies.

How evidence-based is Theory Y?

Given the amount of confounding factors in most organizations, much of the literature on Theory Y’s effectiveness has taken the form of management case studies. However, an ambitious multi-level analysis performed in 2015 showed that Theory Y did, in fact, have a major impact on organizational performance. McGregor himself saw the need for some of both approaches, but clearly proposed his theory based on the importance of motivation.

As for its impact on psychotherapy, for now you’ll have to trust the observations of one humble executive-turned-therapist in remote upstate New York: in my own experience, clinical and personal, as well as those of my colleagues, it is a huge and often game-changing factor in treatment motivation and therapy outcomes. To be frank, I almost never hear people complain about treatment itself – they complain about clinicians who judge them, shame them, push them, and pigheadedly insist there is only one way – theirs, of course – to get well.

So my advice? Get out of expert mode. Listen to your clients, be open to hearing and trying new ideas, and don’t give up on people. Then watch what happens. Personally, I firmly believe this will be the next frontier in effective anxiety treatment.

(Postscript: I received a very thoughtful comment on this blog, to the effect of "is there no place for urging bravery, or letting people know they aren't helping themselves get well?" And I agree 100%! (I also happen to believe this person is a very wise and humane therapist.)

Here's the difference in my mind, using the framework of Theory X versus Theory Y. Taking a Theory Y approach to leadership doesn't mean you can't ever fire or discipline employees. I've done both in my management career, when it was needed. Likewise, there are many testimonials (look, for example, at many IOCDF conference keynotes from recovered sufferers) where the right kind of tough love was life changing, and perhaps even life saving.

However, there is a big difference between firing an employee who is stealing the toilet paper or creating drama every day, versus a workplace full of rules and punishments where people are terminated constantly. Likewise, in the clinical realm, there is a huge difference between the using right kind of aikido in the treatment room when it is appropriate, versus a toxic and unhealthy power dynamic that doesn't listen to clients and regularly uses shame and confrontation as a treatment tool. I am fine with the former but not the latter.)

Stop Treatment-Shaming Your Clients

Imagine that you fall and break your leg, and the hospital staff point out how clumsy you must have been. Or you visit a dietician who greets you with, “Wow, look at how fat you are.” Or you get prescribed a medication that makes you horribly depressed – but your doctor insists that this is evidence-based medicine and sighs that you aren’t treatment compliant.

Few doctors would ever treat their patients this way. But unfortunately – with the best of intentions – some psychotherapists subtly (or even not-so-subtly) shame their clients in the name of treatment. Especially in recent years, as there has been more of a move to treat things like fears, phobias and PTSD with strategies that involve talking reluctant clients into doing hard things like exposure.

Facing your fears head-on, especially when administered compassionately and at the right dose, can be life-changing for many people. Unfortunately, this has also ushered in a culture change where some therapists feel doing a good job means practicing “tough love” and being agents of confrontational change - and in the process, unwittingly employ shame as part of their treatment strategy.

I sometimes joke that cognitive behavioral therapy, the approach I practice, has evolved over time from relaxation and desensitization to something resembling teaching people to bungee jump off a bridge. Joking aside, some therapists have an almost-gleeful focus on pushing people to do exposures nowadays. I respect that, but in some cases this crosses the line into an unhealthy power dynamic where we stop listening to our clients, minimize their limits, and treat anything that goes wrong as their fault.

A tough-love strategy might make sense if treatment always worked for everyone, but unfortunately it doesn't. While ERP (exposure and response prevention) has become a go-to approach for issues such as OCD and anxiety, a recent meta-analysis of RCTs for ERP shows that it is still far from perfect, and I personally know of several people – including clients, fellow clinicians, and even myself – who have been traumatized by over-eager exposure therapy. (For example, this article describes how Atlantic Magazine editor Scott Stossel went through an exposure for vomiting that went horribly sideways - and how he was shamed into it by his CBT therapist, despite his misgivings.)

This same dynamic has been true throughout the history of psychotherapy. From psychoanalysis to mindfulness, our profession sometimes encourages an unspoken ethic where our dogma is Right and our clients are Wrong. Or worse, brands too many of these clients as treatment-resistant and sends them away. In the process, we can lose sight of how horrible it is to suffer from mental illness, struggle with treatment, and conclude that you are beyond hope and it’s all your fault. 

So how can you be a good evidence-based therapist without shaming your clients? Here are my thoughts:

Normalize everything. Every single time. Are they sharing concerns about their treatment? Nod empathetically and say, “of course.” Do they have severe symptoms? Tell them they have lots of company, and it’s treatable. Did they slip up on their therapy homework? I tell them “Nobody does therapy homework perfectly” – and then get to work with them on next steps.

Don’t confront people with their symptoms. Some therapists promote having clients face up to how much their illness is costing them in the name of “treatment motivation.” I see where they are coming from, but I've also personally seen this backfire badly in the wrong hands. There is a thin line between helping people inventory their recovery goals (a good thing) versus "look at how bad off you are" (a really bad thing), and it can plunge people into hopelessness at a time when their self-esteem is already in the toilet. So at the very least I'd be r-e-a-l-l-y careful.

Stop weaponizing terms like “evidence-based treatment.” It implies that you are right, and when it doesn’t work, they are somehow defective. In my experience, the problem is usually that YOU need to go slower, try a different approach, or suggest another expert.

Never use the phrase “treatment compliant.” Your clients aren’t disobedient schoolchildren who aren’t doing their homework, and shouldn’t be treated that way. They are human beings paying you to get well, and your approach isn’t working for them. Always troubleshoot, never criticize.

I personally have a bias that ERP usually works best at a gradual pace where people experience lots of support and success - and that good evidence-based treatment is a smorgasbord with more than one flavor on the menu. But wherever you plant yourself on the treatment spectrum, there is nothing about evidence-based therapy that precludes being kind, collaborative and focused on discovering what works best for each client. 

And never presume you have all the answers: we've made wrong guesses about treatment ever since the days of Freud, and who knows what we'll learn over the next decade - or from our next client.

One of my clinical colleagues put it well: to use an analogy from behavioral experiments, “the rat is always right.” To which I would add that evidence-based therapy – or any kind of therapy – works best when you stop shaming your clients and listen to them.

(Image by Jenny Friedrichs from Pixabay.)

Tofu and OCD Treatment: The Case for Harm Reduction

A few years ago, I went to a homecoming football game at my alma mater Cornell University - and learned first-hand why OCD treatment fails as often as it does.

Before the game, my old department had a tent party with a spread of food: one tray piled high with ribs, another with hamburgers, and a third with "healthy vegetarian sandwiches."

Guess how that turned out? The ribs were gone in short order, the hamburgers soon after. But even though many people were still complaining about being hungry, the kale-and-tofu-sandwich pile sat there completely untouched. (As for me? The ribs were delicious, and I was glad I came early.)

I know what many public health experts would say: that these people were making bad choices. That evidence shows they would be healthier and live longer eating the tofu sandwiches. That we need to invest in more education about better eating habits.

Here's what I would say: if we want people to eat healthier, we need healthy food that more people actually eat.

As a trained OCD therapist who suffers from it personally, I feel exactly the same way about OCD treatment. Exposure and response prevention (ERP) is currently the gold standard for treatment, with a great deal of literature behind it. It basically involves doing what makes you uncomfortable, without doing any of the behaviors you normally do to soothe this discomfort, until you get used to it. And even with newer models like ACT and inhibitory learning, the focus is still on distress tolerance.

The problem is that many people - and for that matter, many clinicians - like exposure therapy about as much as they like tofu. It often (but not always) helps when people DO it, but the same literature will tell you it fails about half the time because of factors such as treatment refusal, dropout, treatment failure and relapse. Some people simply won't do it - and more importantly, some people bravely do it and it simply doesn't work, or kinda sorta works. Too often our treatment community has nothing to say to this unlucky 50%, and promotes a message that recovery is only for the special brave people.

In fact, current clinical research sometimes seems bent on making treatment more uncomfortable with each passing year. For someone like me in my sixties, I've watched the CBT field evolve from Barcaloungers and Valium to a joyless focus on exposure and distress tolerance. As for research on how to make treatment more palatable with fewer dropouts, I mostly hear crickets. People should be eating their evidence-based tofu, and that's that.

I am not a Luddite about ERP. I practiced it and taught it. I've seen it work firsthand. And I deeply respect the lived experience of people who feel it has changed or even saved their lives. So I get their fanaticism for it. But I'm also gently suggesting that some of you may be handing many of your clients nothing but tofu sandwiches, and dismissing many of them as treatment failures.

But in my humble opinion, perhaps we could reach more sufferers - and more clinicians - without throwing the evidence-based baby out with the bathwater. There is an approach that already works in fields like addiction, tobacco cessation, and social services. It's called harm reduction.

Harm reduction is exactly what it sounds like. If you are an alcoholic and can't quit, drink less this month. If you are hooked on cigarettes (only 15% of whom ever quit, according to the literature), vape for now. If your social services client is a hot mess, explore what strengths they can build on to be a little less of a hot mess this week. In short, ease people into long-term success by building short-term confidence, versus making them scale what, for some, is an impossibly high wall.

What might harm reduction look like in OCD treatment? Instead of promoting "torture therapy," think about evidence-based strategies that help but are more palatable – like controlling rumination, very gradual exposure, mastery instead of habituation, or the right kinds of cognitive approaches. Think of an "ERP Lite" that most people won't fail or drop out from, that we promote as the first line of treatment. Which can then, of course, be titrated up to torture therapy for those who truly need it.

This was frankly my own approach when I was in practice, and it actually worked quite well. Instead of asking people to make themselves uncomfortable, I asked them to stay comfortable and gradually expand their comfort zones - and had close to a 90% treatment response rate. But what one obscure therapist in upstate New York thinks doesn’t matter: what matters is what research shows to be effective. And we’ll never know unless more people DO that research.

"But ERP is the only evidence-based approach for OCD!" Umm … sort of. Just this month, a newly-published meta-analysis of RCTs on ERP concluded that successful ERP studies basically correlate with researcher bias. They also concluded that it is better than placebo but not significantly better than other treatment approaches, gains from it are modest, and its research outcomes aren’t duplicated in actual clinical practice.

So first of all, I think my evidence can beat up your evidence. Either way, we still fail far too many people whose suffering matters. And we desperately need to build an evidence base that looks beyond painful treatment approaches that too many people “flunk” and too many non-OCD therapists are reluctant to use. Which means doing better research that puts treatment acceptance front and center.

So would a harm-reduction approach help more people, with fewer dropouts and treatment failures? We won’t know until someone decides to make this a research hypothesis. And we should. Oh and, by the way, I'm allergic to tofu.

(Photo credit: Ponyo Sakana from Pexels)                           

OCD Treatment: When ERP Isn’t Working

 

“And when you're alone, there's a very good chance
you'll meet things that scare you right out of your pants.
There are some, down the road between hither and yon,
that can scare you so much you won't want to go on.”

― Dr. Seuss, Oh, the Places You'll Go!

OCD treatment tends to revolve around a simple hero story: learn to do things you’re afraid of, resist your compulsions, tolerate your anxiety, and eventually you'll get better.

Except when you don’t, as Dr. Seuss would say.

Exposure and response prevention, or ERP for short, is the current “gold standard” psychological treatment for OCD. Its name is also its strategy: you expose yourself to thoughts or actions that trigger you, and prevent yourself from responding with a compulsion. Eventually, you learn to get used to – or at least make peace with – whatever triggers you.

In an ideal world, ERP would always work. And according to behavioral research, it often does: depending on which studies you read, it helps around 60-80% of the people who do it. Unfortunately, when you count in factors like treatment refusal, treatment failure, dropout, and relapse, its actual effectiveness is closer to 50%. And even when it works, it isn’t a cure.

I am very familiar with this disorder, and with this treatment: I am a retired therapist who treated OCD for many years, trained over 100 clinicians on OCD diagnosis and treatment, and published refereed research on it. And I've also suffered from OCD for much of my adult life. So I’ve had the privilege of studying it from both sides of the couch.

I actually had very good outcomes overall treating it as a clinician. But here, I want to look at a topic our field rarely discusses: what to do when you’re one of the unlucky ones for whom ERP isn’t working. Let’s dive in.

Why does ERP fail?

There may be any of a number of reasons why ERP isn’t successful. Here are just a few:

You have other issues going on. We clinicians refer to these as “co-morbidities.” Trying to do exposure on top of, say, a severe depression or trauma may feel like trying to exercise with a 200-pound weight around your neck. Research has corroborated that issues like these can often interfere with successful ERP.

Your type of OCD doesn’t respond well to ERP. One such example is disgust-based contamination OCD, where you fear feeling unclean rather than being harmed – according to a recent research survey, “Many studies have found exposure to be ineffective, or less effective, in reducing disgust-related reactions … Moreover, if the effects are observed, [the] effects are not sustained in the long term.”

Your therapist didn’t click. Therapists are human like you, and no one strategy works for everyone. You might have felt rushed into exposures you weren’t ready for. Or you may have piddled around doing lame exposures while your core problems continued to get worse. Or there was a personality clash. Or you couldn’t build enough trust to engage in a difficult form of treatment. No one therapist has the right personality or treatment approach for everyone – even if they’re an OCD expert and you have OCD.

You aren’t ready yet. For some of you right now, ERP may be like how I feel at an amusement park: I don’t care how much you try to sell me on riding the Tower of Doom, I’m not going. Or there may be times when exposure would feel overwhelming on top of other major life stresses. However much OCD specialists might wish otherwise, dropout and treatment refusal rates for ERP remain stubbornly high according to the literature.

Perhaps the biggest reason that ERP fails is that, well, no treatment works 100% of the time. Even antibiotics fail at least 15% of the time, and facing your fears is generally a lot harder than gulping down a pill. Whatever the reasons are, you’ve got lots of company. It doesn’t mean that you are weird, defective, or have to give up on your OCD getting better.

Treatment strategies when ERP fails

Now, let’s look at some of the things you can do from here. Here are a few of my favorites:

Go slower. This was always my go-to strategy as a clinician, and it usually worked very well.

I often stood the logic of ERP on its head, for the express purpose of getting people to try it. Instead of focusing on bravery and tolerating anxiety, my instructions were to “start in your comfort zone, stay in your comfort zone, and see where you can take your comfort zone from week to week.” How well did this work? Actually, quite well – I even published an IOCDF poster paper about it a while back.

Dr. Allen Weg, a well-regarded OCD expert and author, has a great video that spells out this approach a little further. The bottom line is that ERP may still work for you, if you simply attack it in small enough steps – and focus on making gains instead of scaring yourself.

Treat the co-morbidities first. Perhaps you have things that are weighing you down and get in the way of doing ERP – like depression, trauma, substance abuse, grief, or major life changes. Sometimes it makes sense to treat these things first, so that you get the most benefit from your OCD treatment. And in my view, the best therapists for OCD are those who treat you as a whole person, and not just as someone who is or isn’t doing their exposures.

Focus on acceptance rather than exposure. Guess what – if you have OCD, you’re already doing exposure constantly. Unless you are stupendously talented at avoiding everything, you probably get triggered by your OCD each and every day – you have intrusive thoughts, feel contaminated, worry that you turned off the stove, or whatever. These daily triggers can become an opportunity to learn from exposure, without necessarily choosing more of it.

One growing strategy for managing these daily exposures is a full-blown, evidence based alternative to ERP known as Acceptance and Commitment Therapy, or ACT (pronounced “act” and not its initials). Like ERP, it involves tolerating distress and avoiding compulsions – but instead of exposure, the focus is on moving towards a life you value. A couple of recent self-help books (here and here) give a good overview of it, and studies have shown comparable effectiveness to ERP.

Develop emotional regulation skills. Are you highly sensitive and triggered by everything? There’s an app for that. Or more accurately, a treatment strategy. It’s known as Dialectical Behavior Therapy, or DBT for short.

DBT isn’t a cure for OCD. Rather, it focuses on skills like emotional regulation and distress tolerance. Developing these skills may, in turn, make it easier to engage in ERP or other evidence-based treatments for OCD. DBT is widely taught in groups or online in many communities, and good self-help books and, yes, apps exist as well.

Know when you need a coaching change. You may have found that working with Dr. Suck-It-Up was too much to handle. Or that your therapist didn’t know how to “titrate” exposure so that you were successful at it. Or at the other end of the spectrum, perhaps you really could benefit from more intensive care because of how you are functioning, and are spinning your wheels with your current therapist.

No one therapist is right for everyone, including me. And while there is sadly a shortage of trained OCD specialists nowadays, that doesn’t mean the first one you find with OCD treatment credentials is always the right one. This leads me to what I feel is an important and often under-utilized tool for getting the right kind of care for yourself: your gut.

There is no harm in getting second opinions and shopping around if therapy isn’t helping you. In fact, I would run, not walk, from any therapist who discourages this. And personally, I am biased toward therapists who help make treatment do-able and successful for you, and don’t just preach tough love. Remember, we’re really just plumbers, in the sense of being hired professionals who work for you – you’re the boss, and you get to call the shots.

Other evidence-based strategies. The research literature – or for the layperson, a good online search – will reveal many approaches for treating OCD beyond ERP. Some areas you’ll find include cognitive approaches (where the emphasis is on changing your thoughts or addressing compulsive rumination), meta-cognition (e.g. awareness of how you think), inference-based therapy, counter-conditioning, and more.

Note carefully that I’m not suggesting approaches that are considered to be pseudoscience or have been shown to have limited effectiveness. Rather, these are approaches that are currently under investigation for treating OCD. Are they as widely used as ERP? In general, no. But if ERP isn’t working for you, why not look at other approaches that might?

Finally, don’t shame yourself

I’m putting this point last for a reason. I feel one of the single biggest factors in getting well from OCD is HOPE, and blaming and shaming yourself for struggling with treatment just pushes you further from your goals.

Sadly, sometimes people in our profession don’t help. Not all of us, and hopefully not most of us. But some may subtly dismiss ERP dropouts as “treatment failures” or people who “won’t do the work” – when perhaps, for you, it was more like pulling on a door marked “PUSH.” Either way, I want you to focus on what you CAN do from here, and feel OK about it.

(For whatever it’s worth, when my clients would sheepishly tell me that they didn’t do any exposure, I’d congratulate them on using their good judgment – and then get to work with them on next steps.)

The late bluesman B.B. King once did a public service announcement for the US government about the importance of having a good breakfast. Here’s what he said: “Don’t like breakfast food? Have a sandwich. Or some leftovers. Just as long as you start the day with something g-o-o-o-d in your stomach.”

I feel much the same way about OCD treatment. Not succeeding with exposure therapy? Try some ACT. Or a little cognitive therapy. Or go slowly. Just as long as you start each day with something g-o-o-o-d for your recovery. Just don’t give up. Best of success!

What can I *do* about grief?

 Image by Ryan McGuire from Pixabay

Grief affects all of us, throughout the course of our lives. From the unimaginable pain of a tragic death, to life changes like illness, career setbacks, retirement or an empty nest, we all experience losses that need healing. Even outwardly happy events like marriage or graduation can leave people feeling lost and struggling with life change. And in the throes of a global pandemic, grief is more rampant than ever nowadays.

Over the past decade, I’ve worked with many grieving people as a marriage and family therapist, and recently completed certification training as a grief counselor. And the biggest question people ask me about their own grief is always: what can I DO about it?

This past year, this issue became personal as well as clinical for me. I found myself suddenly and unexpectedly retired from a very successful speaking and writing career, following a pileup of life stresses and health issues. It shattered my sense of identity and purpose, and I was in a very dark place for several months. During this time, I learned first-hand how much confusing, contradictory and just plain bad advice is out there as you battle your own grief.

But I as move forward with my own recovery – and continue to help others – I would like to put my clinical hat back on and talk about the things you CAN do when you are coping with loss. Let’s take a look at what I and others have found helpful.

The problem with “support”

Client: "I feel overwhelmed with grief. What should I do?"
Therapist: "Sit with your feelings and be present with them."
Client: "And then what?"
Therapist: "What do you mean, 'And then what?'"

This is a common view of grief counseling: provide support and empathy for a natural-if-painful healing process, without giving advice, strategy, or trying to “fix” anything.

Do I agree with this model? Sort of, but not completely. Yes, grief is a natural healing process that takes time. Yes, it’s important to feel your feelings and process them. And absolutely, I’m not in favor of pushing your grief away with things like drinking, drugs or distraction.

But sometimes “support” isn’t enough. Think about it – if you had a broken arm or a splitting headache, would you rather have listening and empathy, or do something about the pain? Too often, we leave people who are hurting very badly with little guidance except to sit there and suffer.

You may not be ready to socialize, engage people, or laugh again, and simply need a good ear. That’s perfectly OK. As for me, however, the kind of “support” described above feels like sitting under a wet blanket. The single biggest thing I personally needed to start recovering was HOPE. That something wasn’t terribly wrong with me. That I wasn’t going to feel this way forever. Perhaps most importantly, what I could do to cope and start feeling better. And this is exactly what many of my own psychotherapy clients sought from me.

So now, let’s look at some of the tools that I feel helped me and others.

Some practical tools for grief

Normalizing. This is a mathematical term that, in counseling, means letting someone know their feelings are normal. Because in addition to sadness and loss, one of the biggest things most people are feeling is “what’s wrong with me?”

In grief, it isn’t at all unusual to experience symptoms like poor appetite, weight loss, insomnia, tearfulness, anxiety, unexpected waves of sadness, and many others. You may feel like every ounce of pleasure has drained out of your life, and wonder if it will ever come back. One survey showed that most widows felt they were going crazy the first year after their loss. So first and foremost, people need to know that in most cases, what they are experiencing is normal and they are going to be OK.

In my first session with a grieving client, I would often say, “If I told you that you may need to spend the next six months to a year of your life taking very good care of yourself, while you heal from this loss, would you find that thought comforting or disturbing?” Most people found it comforting, because it gave them perspective and showed them a light at the end of the tunnel.

I am aware that I’m breaking a cardinal rule of grief counseling here by even suggesting a time frame. It might take one person three months to start healing and another three years, and I tell them that too. But experience has taught me that people feel much more hope when you give them some semblance of a map.

Cognitive restructuring. This is a lofty term for changing the stories you constantly tell your brain. It often works best when you do it in writing: listing your negative thoughts, looking for common errors in thinking, and then re-writing new and more rational thoughts.

This is a core tenet of what we call cognitive-behavioral therapy, or CBT. CBT doesn’t pretend to magically wipe away the pain of grief and loss. But it can make it feel more rational and tolerable. Here are some examples:

· “I’ll never feel better again” turns into “I’m going through a normal healing process.”

· “I could have done more to save my daughter” becomes “I used my best judgment at the time” (or perhaps “I am going to compassionately accept what actually happened.”)

· “Look at all the things I can’t do right now” turns into “This is a time to be kind to myself and adjust my expectations”

· “I am weak and defective” becomes “Here are the strengths I still have”

Behavioral activation. Much advice about grief revolves around how you should BE rather than what you should DO. To paraphrase Frank Sinatra, behavioral activation is more like “do-be-do-be-do.” A powerful evidence-based approach for treating depression, behavioral activation involves choosing activities – even if you don’t feel like doing them – and then seeing if they help or not.

So instead of sitting around the house, you go for a walk, meet the guys or the gals for lunch, take in a ballgame, or learn to play bridge. At first, it may feel like faking it until you make it. But in time, this leads to a roadmap of what daily activities work best for you.

Social support. When you are grieving, it’s OK to let people know you aren’t OK – and perhaps more importantly, let them know what you need from them.

If you aren’t in a place where you want to engage with people, that’s OK too. And not every human being who shows up in your life is nourishing or helpful – so it’s OK to take a pass on your opinionated Uncle Ernie, or that sibling who always pelts you with useless tips and platitudes. But often, the way out of grief is paved with connection with other people.

Self-care. Our minds and bodies have ways to feel better in the moment, if we learn to tap into them and use them. Techniques like diaphragmatic breathing, progressive muscle relaxation and body scanning aren’t cures for grief – and aren’t meant to be – but they are well worth learning and practicing to increase your coping skills and resilience. Same with doing things to be kind to yourself, whether it’s a favorite meal, binge-watching a favorite show, treating yourself to something special – or whatever works best for you.

Spirituality. God may seem mute sometimes when you feel trapped in the throes of grief. But this is a time of healing and reflection, and exploring and connecting with your faith is often part of that journey. For many people healing involves becoming part of something greater than ourselves, often in communion with others, and grief can be a sacred space from which deeper beliefs emerge.

Practical strategies. Finally, I feel the most important role of all for a grief counselor is to help people come up with strategies for getting through the next hour, day or week. Some of the most powerful and effective counseling I’ve done for grieving people has involved encouraging them to get out of Dodge before a painful holiday or anniversary, discussing what to say to people in their lives, strategizing how to get through a tough weekend, and more. I honestly believe that having a sounding board for navigating daily life is the single biggest purpose for seeing a counselor when you are grieving.

In addition, grief counselors often use tools to help people actively process their loss and start to move forward – these can include drawing exercises, structured journaling, rituals of connection, and more. If you are interested in exploring what you can do as self-help, a good place to start is the Grief Recovery Handbook by John James and Russell Friedman, available on Amazon.

Changing the way we look at grief

There is a common narrative about grief nowadays: It takes time. Don’t try to “fix” it. Accept painful feelings and sit with them. And if someone you know is grieving, just be present and listen to them.

Many of these concepts come from old-school psychodynamic therapy, with some trendy mindfulness sprinkled in. For some people, they suffice. For others, they don’t. Personally, I felt this worldview left me mired in goosh at a time when I was desperately seeking answers. So if what you’re hearing from Google or TED Talks isn’t really helping your own grief, you aren’t alone.

This is why I favor a more active approach – one that honors the natural healing process of grieving, and doesn’t promise a magic bullet to take it away, but gives people hope and a game plan for coping and feeling better. With the right support system – and more importantly, the right strategy – I truly believe it is possible to make these very painful transitions more bearable.

OCD Therapy’s PR Problem – and How to Solve It

An old joke from my Irish Catholic upbringing goes like this: A group of priests asked their superior if they could smoke while they prayed, and were told, “Absolutely not!” Later, they tried another tactic with a new superior: they asked if they could pray while they smoked, and got an enthusiastic “yes.”

What does this have to do with treating anxiety disorders like OCD with exposure therapy? A great deal. Because I believe that if you change the language you use with your clients about it, you can get much better outcomes.

You see, exposure therapy has a PR problem. It is effective: according to research, if you face your fears, stick with them long enough, and keep at it, many of them will go away. But if you read most books or articles on OCD treatment, they emphasize how much you have to suffer. How brave you have to be. How you need to suck it up and eventually face even your very worst fears. In essence, how treatment consists of torture, torture, and more torture.

Unfortunately, for many clients, this is like asking them if we can smoke while we pray – because for too many, the answer to doing this kind of exposure therapy is “no thanks.” The dirty secret of exposure therapy is that while it often works, according to the literature it only helps about 50% of sufferers once you count in treatment refusal, dropout, treatment failure, and relapse. We now help a lot more people than we did in the days before exposure therapy, but still leave way too many sufferers with no answers.

The reason for this, in my view, isn’t just exposure therapy itself. I feel it is also due to an almost gleeful focus within our profession on strong exposures and scaring the bejeebers out of our clients – at conferences, on social media, in articles and awareness campaigns. We’re combining some good science with a serious PR problem that in my view – as an OCD clinician – is unnecessarily keeping some people away from treatment.

For example, for this week’s OCD Awareness Week, people were encouraged to post videos of facing scary situations with the hashtag #FaceYourFears. Some OCD sufferers may be inspired watching people do things like swallow cockroaches or drive along steep cliffs in South America (both actual videos posted this week) – and I salute their courage! But others may see videos like these and say, “Um, if that’s how brave *I* have to be to get well, I think I’ll just keep checking my locks 20 times a day.”

Which leads to one of the most common questions I hear from my clinical colleagues: “How do I get my clients to do their exposures?” The answer, in my humble opinion, is to use a similar strategy that you probably used to get your children to eat their vegetables: go a little more slowly, and use the right language to make it more palatable.

Changing the outcomes by changing the language

When I was trained in exposure and response prevention (ERP) therapy at the IOCDF’s Behavior Therapy Training Institute (BTTI) in 2014, I had lots of questions about it – for example:

· How do you get clients to buy in to making themselves really uncomfortable?
· What are the potential ethical and liability implications of egging on a client to do something that might, in fact, traumatize them?
· How does it affect the therapy relationship when you are constantly pushing your clients out of their comfort zone?
·How do you deal with gender and power dynamics? I’ve had female clients openly tell me that, as trauma survivors, it’s triggering for some male therapist to push them to do exposure.
· Perhaps most importantly, is there a better and less painful way to do ERP, so that more people actually DO it?

So I resolved to try a kinder, gentler approach to ERP in my own private practice. After educating clients on how ERP worked, I gave them one simple instruction – choose whatever level of ERP felt comfortable to them that week, practice it every day, see where they could take their comfort zone from week to week, and report back to me. Totally their choice. And I made it clear that I would rather see them experience success than get freaked out, and would never judge them.

Listen carefully: I still instructed them to do ERP. I taught them all about sitting with their anxiety and reaching an “extinction burst” where the fear started to go away. All I did was change my language to make ERP sound easy, do-able, and effective. My approach was based around the idea that we all have a level of anxiety we are willing to tolerate and practice every day, as long as we willingly choose it.

This approach also informed how I coached people from week to week. If they bravely tried a big exposure, I congratulated them. If they tried a very small exposure, I congratulated them. And if they couldn’t bring themselves to do ANY exposure at all? I congratulated them for respecting their own judgment, and then broke things into even smaller steps like imagery desensitization, mindfulness, or simply slowing down, delaying or reducing their rituals – which, by the way, often gave them more traction to eventually start doing live exposure.

So how did it turn out?

Before I went to BTTI training, I attended a workshop from one of the giants of OCD treatment, and asked him point blank what he thought about a gradual approach to exposure. His thoughtful response was, “I’m in favor of anything that works, but I’m concerned people will just get stuck doing a bunch of wimpy exposures.”

He had a good point. But at least in my practice, I actually saw the opposite: when I put clients completely in charge of their exposures, and didn’t shame or push them, they got hooked. Often they went further and faster than I would have ever imagined. More important, they came back week after week and looked forward to our sessions.

Perhaps most importantly, this approach seemed to work at an epidemiological level. In a retrospective study of my OCD cases that I published as a research poster at last year’s IOCDF conference, here were my outcomes:

· Everyone improved
· No one dropped out or terminated prematurely
· Average reductions in YBOCS OCD scores were nearly 40%
· 90% were treatment responders, and 70% were full treatment responders

(My criteria for inclusion in the study were (a) dx of OCD, (b) at least 4 sessions of treatment, and (c) assessment via YBOCS. So I did exclude things like "one and done" sessions, people who had to relocate in the middle of tx, or people referred out due to serious co-morbidities.)

These outcomes are comparable with other studies I've seen in the literature for standard ERP. With perhaps one main exception - a longer course of treatment, averaging a little over 22 weeks. And it WAS standard ERP - just not presented as "torture therapy."

What are the implications for practice?

First of all, I am just one obscure therapist in the middle of upstate New York who had a part-time private practice and a fairly small sample size, and is now retired from practice. So the short answer is “I don’t know yet.”

That said, our knowledge base for treating OCD and anxiety disorders is still young and evolving. So in my view, it’s time we devoted more research to the question of whether we can make ERP more tolerable AND more effective for clients. Because I truly believe that if we can do more to solve the basic PR problem of exposure therapy, we can help a lot more people. And who knows, perhaps next year's hashtag might even be #FaceYourFearsGradually.