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.

Does Gratitude Make You Happier?

Many people talk about practicing gratitude as a path to happiness. Does it work?

The answer is “often but not always.” Imagining what you should be grateful for and focusing on it can, indeed, help you feel happier. But this technique works best if you understand the science behind it.

To me, experiencing gratitude is just one example of what we therapists call cognitive restructuring: a lofty term for changing the way you feel by changing your self-talk. Here are some examples of it:

• When you change “my life sucks” to “I have a lot to be thankful for.”
• Same with changing “I can’t deal with my control-freak boss” to “My boss is detail-oriented, and here is how I should manage my relationship with her.”
• Ditto with changing “I hate those Republicans/Democrats/Millennials/whatever” to “I don’t see the world the same way as them, but I try to understand why they feel that way.”

In each of these cases, simply changing your internal language helps you feel better and more in control.

What happens clinically when you practice gratitude is that you are performing a form of cognitive restructuring known as scaling: in other words, you compare your life favorably to your own previous perceptions or other people’s lives. When I was growing up, for example, a popular slogan was, “I cried because I had no shoes – and then I met a man who had no feet.”

However, for gratitude to really make you happier, you have to believe both sides of this equation: first, that you are better off than you thought, and second and more importantly, that you can make peace with the state you are actually in. In other words, you honestly perceive that your life is better than you were seeing it before.

Unfortunately, some people find it very hard to do this. Take a trauma survivor, for example: her emotional pain and sensitivity may loom very large for her, and realizing that she has things to be thankful for – like food, a roof over her head, or even a partner – may not change the how bad her current reality feels.

This is where the deeper principles of cognitive restructuring come in. A trauma survivor may not be able to feel gratitude, but she probably can change her narrative from “I suffer from trauma and life is terrible” to “I suffer from trauma, so here are tools that I could use to feel at least a little better in this moment, and here are goals I could strive towards in small steps.” This kind of narrative-changing uses exactly the same clinical principle as gratitude, but often works much more powerfully. Especially when you keep practicing it over time.

So should you try to practice gratitude in daily life? Absolutely! I personally do it every day: often I will reflect on how in this moment I am warm, safe, dry, well-fed (admittedly too well-fed sometimes), and wake up every morning with someone I love. But a good therapist would never shame someone when gratitude doesn’t help. More important, its underlying principles truly can help anyone feel much better.

Dealing with dread – a one-person case study

I am normally a pretty happy guy inside. And while all of us have good days and bad days, it has thankfully been a very long time since I was filled with real, live, lay-awake-at-night dread about anything.

That changed earlier this month. A broken tooth turned into a toothache that kept me up all night, and the next day the dentist’s verdict came in: I needed oral surgery to remove two badly decayed teeth, including a fairly complex extraction and a bone graft. Worse, it would be a two week wait until an oral surgeon could get me in.

This was a big, scary deal for me. I hate dental work, and the last time I had an extraction decades ago, it didn’t go very well. (How badly did it go? Well, for starters, I bolted the dental chair and walked up and down the street as an escaped dental patient, due to a bad reaction to the anesthesia.) So I wasn’t a happy camper. And my feelings alternated somewhere between wanting to get this thing over with, and wanting to escape to Peru until my teeth rotted out.

At the same time, I recently retired from nearly a decade of treating hundreds of people for anxiety, including many who were dreading feared events in their life. So I decided to make these last two weeks a one-person case study for what did and didn’t work in situations like this, based on my own experience as a psychotherapist. Here are some of the strategies that worked for me:

1. Distraction. Let’s start with the big one. Distraction is usually a bad thing when you are trying to overcome a fear. (Why? Therapists basically teach people to re-learn their responses to small doses of feared situations, and no learning takes place when you are distracted.) However, distraction is just ducky when you are dreading a short-term situation. For me personally, what worked best was:

·        RV podcasts. I own a motorhome, and discovered that each podcast was a glorious hour of being taken away to a world of camping and life on the road.

·        Keeping busy. I got caught up on work and bills, got some writing done, and even spoke to an audience of 100+ people at Cornell two days before the surgery. All of it helped.

·        Getting sweaty. My beautiful wife is a fitness buff, and going on long walks with her every day helped me get perspective, and also sleep better.

Interestingly, my two favorite pastimes when I am not dreading something – watching baseball on television and listening to music – were of little help. In my case, taking action was much more helpful then trying to be passively entertained while my fears ran amok. Understand that everyone is unique, so take the time to figure out what works for you.

Also, while opinions vary widely on medication – and I don’t normally take anything – in my case a small nip of a mild sedative was great for temporarily re-setting my mood. Your mileage may vary, of course, and always consult with your doctor first.

2. Knowledge is power. Researching the thing you are afraid of can be a double-edged sword. There is unfortunately no filter on what you hear from friends or the Internet, and what you find may or may not be helpful. But sometimes the right nugget of information can be useful.

In my case, a little research went a long way. I am not like most dental phobics: I’m not particularly worried about pain, needles or the like. But I am extremely worried about things like anesthesia and losing control. (So, for example, telling me to strap on a nitrous oxide mask would be like telling you to jump off a bridge.) But I actually found a website called Dental Fear Central, with a page devoted to my exact concerns – and discovered that dental anesthesia does not affect motor nerves. This helped allay my greatest fear, that my mouth and throat going numb would affect being able to breathe or swallow.

(Ironically, when I Googled “dealing with a dreaded situation,” most of what I found was useless piffle. Which is part of the reason why, now that I am more toothsome again, I am writing this article.)

3. Coping tools. If there was a Nobel Prize for dealing with dread, it would go to the people who invented tools such as deep breathing, progressive muscle relaxation, mindful awareness, and cognitive restructuring (a fancy term for rewriting your thoughts in less scary terms). And needless to say, times like this also call for cutting yourself as much slack in your life as possible.

The key thing about coping tools is that no one, including me, ever wants to use them. It is a drag to spend 20 minutes tensing and relaxing your muscles, or writing down your thoughts. But when I would push through and do it anyway, I felt better. So I made time every night to soothe myself with the same tools I often prescribed for my own patients.

4. The human connection. Finally, connecting with other people is an important part of getting support and – sometimes – perspective in a scary situation. My beautiful wife was not only a great source of support, but also a veteran of just about every dental procedure imaginable, so her advice was invaluable. A very kind old classmate who happens to be a successful dentist was a great source of information and comfort as well. And perhaps most importantly, I discussed my fears frankly with the oral surgeon beforehand, so I felt that I had at least some control over the situation.

So how did things turn out in the end? The procedure itself went surprisingly well: I had everything done under local anesthesia, and the oral surgeon did such a great job that I had almost no pain or swelling afterwards – I never even needed to take a single painkiller.

More important, in the two weeks leading up to the procedure, I largely ate, slept and functioned well. Except for a restless night immediately before the early-morning procedure, life went on pretty much as well or better than I expected, particularly given how much I was dreading this. If I were one of my own patients, I would have called this a pretty good clinical outcome.

Best of all, now that this procedure is safely in the rear-view mirror, I can bask in the warm glow of having faced up successfully to a fearful situation – not to mention having a mouth where nothing hurts. So in closing, understand that the right tools and skills can often help carry you to the peace that lies on the other side of a dreaded situation.

My First Do-It-Yourself Book Launch

I’ve lived a charmed life over the last 15 years – quietly cranking out one book after another for mid-major publishers, and watching many of them reach national rankings in categories like customer service and communications skills. With a lot of help. When you have publicists who place you in national publications, corporate sponsors with massive lists, and bookstore placement, you have a huge leg up. It’s kind of like making a great hamburger when you have the finest steak to start with.

Fast forward to 2017, and my first self-published book in my longtime “day job” as a psychotherapist. Self-help is a crowded field with literally thousands of titles out there, and while I’ve been doing it for the better part of a decade, I have no real platform as a shrink outside of my small town in upstate New York. But I still wanted to get my particular approach for treating fears and phobias in front of a wider audience, and knew this time that I would essentially be planting a tree in the middle of a very deep forest.

Still, my new book No Bravery Required did recently reach #1 nationally on its topic. With the help of a little bit of money, a lot of elbow grease, and no backers other than myself. Here’s how I did it:

Priming the pump. Well ahead of the book launch, I started publishing articles on the book’s topic. With my last book, I had great press including a feature article in Time Magazine, but I knew there would be no Time this time. Instead, I leveraged my existing blogging platform – I am a monthly contributor for a NY Times bestselling author and TV personality, and I have my own therapy blog – as well as this article for The Mighty, a national website for mental health issues with over 700,000 followers on social media and 150 million readers.

Getting reviews. Ansel Adams once said that in photography “it takes a lot of milk to get a little cheese.” Getting reviews on Amazon was very similar. These reviews were important because the better quality paid launch partners – which I will discuss next – required a certain number of positive reviews first. So I offered a free electronic review copy to our online community of over 400 regional therapists, and also mass mailed potential reviewers in my social network.

When it comes to getting reviews, you will discover that people are fundamentally busy, and this part was probably the closest I came to making a pain in the ass of myself. But with enough gentle persuasion and some one-on-one marketing, I eventually got what I needed to move forward.

Lining up paid partners. The real key to do-it-yourself book promotion is creating a so-called countdown deal on Amazon – offering the Kindle version of your book for 99 cents for a short time – and then paying to promote this on book launch sites with large lists of readers who want to hear about free or 99 cent books every week.

The 800-pound gorilla of paid promotion sites is BookBub. It costs much more than the others (think hundreds of dollars for many categories), and I would have gladly paid it, because it has a huge list and tremendous ROI for many people. But getting in at BookBub is kind of like making the guest list for the Oscars. I tried and, as expected, did not make the cut. I’ll consider them again if I ever make the New York Times bestseller list or whatever.

Ultimately I ended up going with BuckBooks (highly recommended, if you can meet their strict acceptance criteria), Awesome Book Promotion, RobinReads, BargainBooksy, and Bknights on Fiverr – total cost around $180. I also launched an Amazon sponsored pay-per-click ad campaign that generated over 10,000 impressions by launch day for just a few bucks, a very good deal.

Creating the buzz on launch day. Finally, I created a free goodie for people in my social media network who purchased the book on launch day – an edited and curated collection of articles on workplace stress, published as an ebook with a nice professional cover – and made a series of announcements leading up to launch day on Facebook. And on the actual launch day, many of my Facebook friends were incredibly kind about sharing this offer with their lists as well.

Then it was time to sit back and watch launch day happen! (In my case, sneaking a peek at my book’s rank in between therapy sessions.) One annoying snag was that the number 1 book in my category that day was actually a national humor bestseller that was only tangentially about fears and phobias, but still listed in that category – which raised the bar for how well I had to do. But thankfully by day’s end I had topped this book as well, with an overall Amazon rank near the top 2500.

In the end, I did get my #1 ranking for books on fears and phobias – and also a top 5 ranking in the very crowded self-help category of anxiety disorders (where many of the major self-help books live). It won't stay at that rank forever, of course, but I'm still pretty happy about that, and not just for my ego: a good launch and good reviews reportedly make a long-term difference in how likely Amazon is to promote this book in search results. (My previous book, which launched at #1 in the large category of customer service in 2013, still sells very well after over four years.)

But perhaps the greatest reward was an unsolicited reader review on launch day from someone who felt this book would finally help him or her conquer their fears. This is why I really went through this exercise in the first place – to add my voice to the dialogue about treating anxiety and help people. And I truly believe that a good launch campaign is the best way to do this in a crowded marketplace.

My new book - No Bravery Required

I am very pleased to announce the release of my latest book, on a subject very near and dear to my heart: a simple, clinically proven strategy for painlessly treating fears and phobias.

Based on my successful longtime Anxiety Camp program, No Bravery Required looks at the key areas that good therapists use to treat fears and phobias, including mindful awareness, physical relaxation, cognitive restructuring (e.g. changing the way you think about a scary situation), gradual exposure, and social and communications skills for social anxiety.

The core point of this book is summarized in its title: losing your fears involves specific tools and skills, not bravery. And when done correctly, getting well should be much easier than staying ill. The strategies in this book have been proven over and over, both in the Anxiety Camp group program I have run since 2009, and in the hundreds of individual clients I have treated over the years.

To order your copy - in paperback or Kindle format - click here.

What Emotionally Unstable People Do Better Than You

When I describe someone as emotionally unstable, it isn’t an insult. It is a clinical description, just like having brown hair or wearing glasses. So I mean it in the nicest possible way.

This is because emotionally unstable personality disorder, also known as borderline personality disorder or BPD, is an actual diagnosis. And it is often quite treatable for many people who suffer from it. Which brings me to the topic at hand – emotionally unstable people who are successfully treated do something that would also benefit each and every one of us, if we did it. They learn to behave counterintuitively in their worst moments.

Here’s an example. Relationships with borderline personality sufferers often feel like living inside of a food processor, because one minute you are their best friend in the world, and the next you are the cause of all their problems. This is because they have an intense fear of abandonment, combined with a diminished capacity to process negative emotions. Which means that if you forget to respond to their text message, or sound a little frustrated about something, it can quickly turn into a flashpoint.

So here is how you treat this: you help them to recognize familiar patterns of behavior, and then behave differently when they happen. For example, let’s say that Joe is a BPD sufferer who is upset with his wife Sally because of something she said. Here is how the conversation might go:

Joe: You are always rejecting me! I can’t stand it anymore! I feel like jumping off a bridge!
Sally: Joe, do you think you’re having a borderline moment right now?
Joe: You’re right, Sally, I probably am.
Sally: So how about doing what we’ve planned for these moments – binge-watching your favorite TV show, and then coming back and talking with me in a couple of hours?
Joe: Sounds good – see you then.

Listen carefully: this conversation would sound very unrealistic to most people. Joe would normally not feel like watching TV when he is upset and frantic about Sally, and would not appreciate having his disorder called out. But in this case they have learned – often with the guidance of Joe’s therapist – that naming what is happening and taking a break will work for him in moments like these, so they agree ahead of time to do so. Which means they get all the benefits of a relationship with a BPD sufferer – which is often intense and passionate – while mitigating the drawbacks.

Now let’s circle this same idea around to you and me. *We* don’t inherently know what is best for us in the moment either. So we also need to plan ahead for what to do in our worst moments. And once we have a game plan for those moments, we can learn to master them.

Here is a personal example: every year, I close my therapy practice over the holidays. And because I am usually so busy, I always believe that having all this time off will be fantastic! But then the same thing always happens: within a couple of days, I feel depressed and out of sorts from being out of my routine, and feel stuck in the house by the cold weather.

Now in *that* moment, going back to work seems like the last thing that would help me feel better. But sure enough, going back to work the first week in January always lifts my mood again. So I have learned to plan for purposeful activity over the holidays.

The same thing is true for you. Dreading a fearful situation? It may be time to take a walk. Angry about something? You may need to give it time rather than acting on it. Feeling stuck in your life? This may be the time to connect with your friends. Your worst moments will often go much better with a thoughtfully composed plan - that may, in fact, go against your human nature - which you execute every time you are in that situation.

So take a tip from emotionally unstable people: acting on your feelings is not always a good idea, and making an alternative plan of action in advance is often the key to peace of mind. Because as Benjamin Franklin once said, those who fail to plan often plan to fail.

If I Were President: Creating Access to Mental Health Care

Guess what – I’ve just been elected President of the United States. (Just kidding, this election year is crazy enough already.) But if I were, here are three things I would change about access to mental health care in this country:

Provide universal coverage. You need mental health care. You have insurance coverage. So you go out and get mental health care and pay for it with your insurance coverage, right?

Wrong. Often people are limited to closed lists of in-network providers (many of whom are full), can’t see certain classes of therapists such as LMFTs (like me) or LMHCs, or face other roadblocks to care. And the worst offenders are often taxpayer-supported programs like Medicare, Medicaid, or the VA.

My solution would be to pass a nationwide Any Willing Provider law. If you are a licensed psychotherapist, you can provide services to anyone. Period. And insurance must pay for it. Period.

Let psychotherapists practice nationwide. Therapists can now technically practice anywhere, thanks to online technology. But there is one huge roadblock standing in the way: a stupid and outdated crazy quilt of state licensing laws.

If I practice outside of New York or Arizona, where I am licensed, I could actually face felony charges in some states. My malpractice insurance would also become void. It would literally be easier and legally less risky for me to treat someone in Uzbekistan than in, say, Ohio.

Worse, every state has its own incompatible requirements. Many have different course and credit hour requirements, forcing you to go back to school. Some will not accept a distance learning degree. And California, because they are special, makes everyone start all over again as an intern and then take their own exam. State requirements not only dramatically limit access to online therapy, they often trash the careers of good therapists who must move to another state for personal or family reasons.

If I were President, I would create national licensure for therapists. Or at least require the easy fix of license reciprocity. If you have been practicing therapy for, say, five years and haven’t killed anyone, there should be no good reason you cannot practice in any state of this great country.

Mandate coverage of telepractice. Finally, the last piece of the puzzle is providing financial coverage for online therapy. Telepractice is now legal in most if not all states. The problem is that insurance usually won’t cover it, so you can’t have it unless you can afford it yourself. This in turn denies care to people who could really use online therapy, like the housebound, people in remote communities, shift workers, and areas with few therapists or long waiting lists.

Legislating this has turned out to be extremely slippery. New York, for example, now has a Telehealth Parity Law mandating such coverage – but it is limited to specific types of therapists (not including LMFTs, unfortunately), and is full of loopholes: for example, it does not mandate how much insurers would reimburse for such sessions, requiring follow-up legislation. As President I would order everyone to cut the comedy and just cover online therapy at par with regular in-office therapy.

Of course, I am not going to be President anytime soon – thank goodness. So instead of wasting your vote on me, I am going to ask you to do the next best thing: become aware of legislation affecting access to mental health care in your state, and make your voice heard so that everyone gets the care they deserve. Thank you!