Understanding OCD Beyond ERP

What if OCD isn't about uncertainty, but about doubting the wrong things? Kristina Orlova, LMFT, shares her own journey living with OCD and how her understanding of treatment has changed over nearly a decade of clinical work. She talks about rumination, the compulsion she didn't know she had, how ERP and especially imaginal exposures changed her relationship with intrusive thoughts, and what inference-based CBT (I-CBT) adds. Whether you live with OCD, support someone who does, or are deciding which approach is right for you, this is an honest look at what recovery can look like. This content is educational and is not a substitute for one to one professional care.

Transcript

So today I wanted to talk a little bit more about my own personal journey with OCD. And specifically, People have asked a lot of questions about ERP, ICBT, ACT, Different therapies, If I've ever taken medication. So I want to be honest and upfront with you and share some of the kind of updated understandings I now have about things. And generally just where I stand in terms of my own opinion on different treatments. So when we finish this episode, I think what you're going to walk away with is hopefully a better understanding of the difference between the different modalities that are available. And what I really hope that you get out of today is that you have a better grasp of the difference between how at least now I understand doubt and really an obsessional doubt process versus uncertainty and real life uncertainty that we live with and how now really conceptualizing those two things very differently. And really that's the piece that has changed how I now see the work that I do with clients and even for myself. I personally have dealt with relationship OCD just right, Or we could say feeling off OCD, And I would say kind of more morality, Ethical aspects of OCD. I've had pockets here and there of more contamination based. But generally, Those have kind of been more my topics where my OCD brain would center around. A big piece of my experience used to be relationship-based OCD, And I, For the longest time, Had no idea what that was. I didn't even know that that was a thing. I really thought that OCD was just, You know, Tapping or touching or washing your hands a bunch of times or lining things up, And that was kind of the end of it. When I got into this niche, This specialty. And I went through the Behavioral Therapy Training Institute at the International OCD Foundation. I started learning so much about all the different ways that OCD can show up. And really kind of over the years now. I believe at this point I'm pretty much at almost a decade of working just with the OCD and anxiety disorders population. 20 years overall in the mental health field. I will say that what I've come to really understand is What's most important is understanding how OCD, The disorder, Actually works. Instead of deep diving into all the different kind of what we call subtypes or themes. While it is, I think, Relative and helpful to understand your theme, I think what's more relevant and helpful is to know how the disorder actually works. I don't come from a research-based background. I'm not a scientist. I do come from clinical training and doing the clinical work for years. I've done intensive outpatient programs. I've done weekly sessions. I've done groups, I've done trainings, Workshops, Created an OCD specific kind of journal planner that has all sorts of different worksheets that are based on exposure response, Prevention, Acceptance, Commitment, Therapy, Just so that you could have everything in one place. For example, I've done trainings on rumination. That was one of my huge compulsions that I had and didn't even know I had it or that it was a compulsion. What did I do? How did I get to where I am now? I would say I am in recovery. I would say pretty much most of the time, I'm not really bothered. By OCD aspects. I'm not bothered by my OCD brain, If you will. I generally am able to really live my life and kind of really focus on, You know, How do I want to live my life? What are the things that are important for me? And really keep it moving. And I think what I've found over time is initially when I was doing exposure response prevention, I mean, I loved it. I personally really loved it. I think it's a beautiful treatment. To do it well and effectively, It is important you provide education first. Education, I think, Is a huge component because it gives a person a chance to understand what we're kind of dealing with, What we're going to be doing about it, How we're going to do it. So you have to create that foundational aspect first. Then we go into understanding, You know, What is it for you that shows up, That activates this whole cycle. And then from there, We're able to start to build your individualized plan of exactly, You know, What will we want to work towards facing for you so you can start to actively learn something new. And so for me, When I got into that process of teaching clients, But also realizing for myself, That this is something I'm dealing with. And so many things started to make sense when I started to reflect on my life. In general. Um, I personally fell in love with imaginal exposures. So imaginal exposures were really powerful for me. Um, I know they're not for everybody and that's fine, But I love them. Um, They really helped me be able to take things that would come kind of in my mind. My mom would kind of grab hold of them so tightly. Um, And then I would ruminate so intensely. I'd go over something, You know, Thousand different times in my head. I would review it. I would reanalyze it. I start to research. I start to listen to podcasts. I would even get into using tarot cards trying to look at it from the astrological standpoint. I'd look from numerological standpoint. I mean, I would deep dive. And frankly, All that would ever really do is give me more anxiety because I would start to come up with more, Well, But what about this? And what about that? And so I was getting so caught in so many hypothetical situations that I really would get completely lost and carried away. And the amount of guilt would be insurmountable, Frankly. When I would do an imaginal exposure script, It helped me create a whole different relationship with my thoughts. So instead of before, I used to be really kind of acting like, Okay, I am my thoughts, Like a lot of people and thinking I'm this bad, Horrible person because I have these horrible thoughts. And when I started to work with them on paper, And then I also would do recordings, I'd also at times just type it out. I'd start to use other things like there's apps where I'd put in certain hot words for me and then have them randomly appear. So the more I would allow myself to be around them, I completely changed my entire relationship and started to recognize, Hey, These are thoughts I'm having. They're allowed to be there. I don't have to endorse every single thought I have. It's not just because I thought I immediately have to believe it or do something about it. And then realizing that, Well, I don't do that with other thoughts that I have. So. I don't have to treat this differently just because this comes with some anxiety, But that doesn't change fundamentally what it is. So in that way, I have to say, You know, That particular exposure practice was powerful. Response prevention for me, A really powerful tool is learning how to understand what does rumination really mean and understanding What does it mean to compulsively ruminate, Right? To continue to feel like you have to think something over and analyze, And you have to keep digging and digging and digging to try to get to the bottom of something. And, You know, Lo and behold, Of course, You never end up getting to the bottom. Or if you do get to the bottom of something, It's very short lived. And then you get caught up again in hypotheticals. So once I learned what rumination is and how that compulsive aspect, That urgency comes up and drives that process, I was able to start to pay attention to those kind of internal. . . Well, It's really like internal thoughts and analysis and things and, And really through writing it out and looking at it and capturing it and increasing my awareness of it is where I started to separate out and, And get better discerning and realizing, Okay, Right now I'm not thinking in a way that's, I'm actually problem solving or I'm doing something useful. I'm going in a circle and I'm really winding myself up and I could feel it. It has a familiar experience to it. So when I, Once I got better at discerning and recognizing what that was. Then it became easier to start to step in and make a choice, Make a different choice. And that's the intervention. And that was part of the response prevention process. It's a process. It's not like, You know, You learn step one, Two, Three, And then that's it, Right? It's a process of learning, It's a process of discovering, It's a process of being able to really take it in and make it yours, And building a lot of awareness and insight around these internal features, And being able to say, Oh, OK, Wait a second. I see what this is now. And I can now choose to do something different. So those were some of my personal favorites with that. And then of course for the feeling stuff. For me, A big piece was, Again, The compulsive rumination feature. Catching myself at times. You know, Like literally nothing's going on in my life. And I could, I could suddenly see my brain, It starts to look for stuff. It's like scanning and going, Okay, Well, Wait a minute. Did anything happen? Something must have happened. Something, Something feels off. Something's not right. And so I start to look and try to connect and, And, And figure out what's off. And I would pause and say, Wait, Christina, Did something actually happen? Because if it didn't, Then you're creating something here that we don't need to create. So we could just like pause right there and get back to the activity you're doing at hand. And that would be an example of reconnect back to what you're valuing in this moment, Which comes from acceptance commitment therapy. And really focus on that. And whatever little pieces come up and down, Notice it, Let it be there in the background, But we're staying focused here. So practicing moving on and not getting caught up in these little side quests, If you will. So that was a piece that I did with a feeling when few things felt off for a lot of times really no good reason and a bit piece of it was giving myself permission to handle and tolerate and allow all those feelings you have in your body that are really uncomfortable. Um, Right. Whether suddenly your stomach is turning or maybe your head is really kind of, A lot of thoughts are going through there. At times my chest was really tight. I felt like somebody was like grabbing inside of it and squeezing my heart. Um, You know, My hands couldn't get clammy and it's not pleasant, But I also, You know, Realized, Okay, I'm feeling this stuff in my body. I know it's my fight and flight. But there's nothing right now that's going on that I need to really attend to. So just let that feeling be. And sure enough, Over time, That would kind of be also another way of exposing, Right, Is exposure to the uncomfortable feeling that's present and really not do anything about it, Not fix it. Not try to make it go away or self-soothe and just let it naturally ride its wave out. And by doing that over time, My brain and my whole system relearned like, Okay, We can have this feeling. It's still don't like it, But I can have it. I can tolerate it a lot better than I realized. And so in that way, Started to get out of my own way. Now fast forward, I started learning ICBT and inference-based CBT. And at first I really thought that I understood it, I knew it, And I thought I was already doing it. And I think several well many people I think had that initial understanding and it thought they were as time progressed and I got a little bit more into it and started asking if people would want to try it with me and You know, I've had some amazing clients who said yeah, Let's give it a whirl So together we started diving into it and together we started to learn and be really is because they gave me that permission while I was learning on my own for myself and with them and that over time I started to realize, Wait a second, There's something kind of more happening here. And suddenly, I finally kind of had this moment where it clicked for me and I understood, Wait a minute. What inference-based CBT is really targeting and talking about is that You know, When we start to question something, Right? Like that first question I might have in my example, Something might be off. That's a conclusion. That's what an inference means. It's a conclusion, Right? It's something I'm concluding. The question becomes, Well, How did you arrive at that particular conclusion? Why did I infer and conclude something must be off? I could have inferred anything else. Why that? And so ICBT really says, Well, If we look Before that, There's already some sort of internal beliefs you're carrying or stories or something already that you have that leads you to conclude that. So there's some sort of a thought process, A reasoning process, Right? Like reasoning is how we make sense of things. So there's already a way we're thinking about stuff that leads me then to conclude these things. But not only that. There's also this whole understanding of who we think we might be, Like that I might be, You know, This really horrible person that does something really, Really bad. And wrong and I will be punished for it and punished in a really bad way or I'll be rejected Um. . . Cast away. You know, I know these all sound really extreme, But that's kind of how OCD the disorder works is we start to focus on these pieces we're so afraid of being and becoming. And, And they really do feel like pretty catastrophic and pretty big deal. So for me, That was one of mine is this, This vulnerability around this. And so if you'd actually look from the side, Who and how I was, I think you could tell like, Sure, At times I was still learning. And when I was, You know, Much younger, I was kind of wild child and, You know, All over the place, But inherently it's not like I was a bad person. I had good intent. I tried my best. I did a lot of people pleasing, Worked really hard in my friendships and everywhere else. But I still would make mistakes, You know, I'd still sometimes do things that weren't great. And so really being able to kind of slow down and understand that full spectrum of your sense of self was something that was missing. And so with ICBT, I started to learn that, Wait a second, I'm not just dealing with uncertainty here. I'm dealing with the fact that I'm doubting things in a very particular way. And also only over selective pieces. I'm not doing it all the time and I'm not kind of questioning things in this way across the board everywhere. So then I realized, Wait a minute, This is what we call an obsessional doubt process. An obsessional doubt works very different than an everyday doubt. And we're doubting things that we really should not be doubting because we kind of have information available to us. But we don't really even realize that because we think that we don't have information or whatever we have, We deem it as not enough. We deem it as somehow it's not, It's not relevant or no, I need more. And so we don't even realize how much of the time we're dismissing things left and right and how many things are left off the table and not even a part of our conversation because we're so focused like tunnel vision on this kind of one area. And then we start to construct this whole big, Story to support that, That we completely miss a whole huge other part of the conversation that we're not having. And so. Once I started to pay attention to that, It was like a whole different way of learning and it took me a minute, But then I realized, Wait a second. I don't have to walk around constantly entertaining that maybe I'm this bad, Horrible person. But what I can do is come back. To really embrace the totality of who I really am in reality, Right? In real time, Which is, Yes, I am somebody who has made mistakes. I'm also somebody who has had success. I'm also somebody that I know in my heart of hearts, I know I'm a person of integrity. I know I do my best, But that doesn't mean that I might not hurt somebody, But am I hurting somebody because I'm intentionally trying to hurt somebody? No, It's not like that. But do we sometimes hurt people unintentionally? Yeah, It happens. Right? So once you kind of wrap your mind around the stuff, It suddenly has you step back and realize, Wait a second, We are, I think really get deeply kind of separated from remembering who we actually are in our totality. And we get really wrapped up in this internal narrative that we're caring about who we could be and who we might be. And then what we start to do is we start to pull in information from anywhere and everywhere. That will support that hypothetical. Before you know it very quickly, We are suddenly no longer living in the world of the here and the now and really taking things in as they come. We are now having our imagination and kind of all these hypotheticals are everything kind of starts to take over and it gets superimposed onto reality. And you know, When I say that it can sound like slightly esoterical or what the heck does that mean? But it really, Very literally means to be able to really kind of stop yourself for a minute and slow down and really relook again at where are you truly getting your information? And do you really think that way all the time across all the different aspects of your life? I'm pretty sure because I've now done this enough and I realize, Wait a second, For example, When it comes to work, I don't ever think that way. I really take in information very differently. I take things as they come. I conclude stuff based on what I have. Then I kind of have an informed kind of decision that I can make from that information and then I make a choice and move on with life. And that's generally what I do. But then in these other areas that are my personal vulnerabilities and sensitivities, I don't do that It's like I change the rules and now I say well here in this area I can't do that now. There's different rules here. And so I can't just trust my basic common sense I can't trust the current context. No, There must be something else. I'm missing something I have to look deeper and so these are all the kind of ways that our OCD brain essential place tricks on us and we get deeper and deeper into really the imagination where if you think about it, We are coming up with these really, Um, Strong stories and those stories are very evocative. They have emotions in them. There's visuals that come up and so often, You know, And I started noticing for myself, Wait a minute, Like I'm having this whole story I remember relationally, You know, About, Um, Well, Now my husband, But I was coming up with this whole story in my head about this one situation a couple of years ago. And I really distinctly remember getting so caught up in it that my heart, I thought it was going to fly out of my chest. I was starting to get panicky, Cold sweats, Just like, Oh my God, Oh my God. And that's right when I was also learning ICBT. And I remember pausing for a moment saying, OK, Hold on, Christina, Hold on. What do you actually know? And when I actually paused and said, Okay, That's one version, That's one story. And gosh, From that kind of angle, There's so much I don't know and everything seems like it could be horrible. And I'm literally about to have a panic attack. Slow down, What else? And when I did that and kind of walked myself through using some of the steps I learned, I was able to reconnect to say, Okay, Well, What I really know is just this piece of information. That's kind of it. That's all I have to work off of. And then I had to pause and realize, Wow, There's kind of an area here of information that I don't have. I don't know. I truly don't know it. Right. So there's real uncertainty right now. But what I realized I was doing is I was filling in the blanks. With a whole lot of things that could be and might be, Instead of saying, Hey, This is all I know. Here's stuff I don't know or don't know yet. I kind of have to wait, Even though I don't like it, But I have to sit and wait a little bit and either then get more information and then see after that what makes sense to conclude or I have to embrace I might not have that information so I have to truly be okay essentially with the fact that I'm gonna have to live with not knowing something. And that is something that does happen in life. And so that process of reorientation and realizing those things really helped to start to break this down a bit more and helped me update my own understanding about when I'm truly, If I'm really doubting something kind of in a normal, Reasonable way, I can notice it because I usually when we're doubting, It just means that like, Okay, Maybe I need to go check it one more time and be reminded and you can resolve it. Like if I'm not sure how long. . . Is the trip going to be? I don't know, Flying somewhere. Well, Let me go and look it up, I don't know, On Google Maps or Google Flight or Kayak or whatever, And I'll see the length of time. I can look up the flight, Make sure, Oh yeah, It looks like it's on time. I have information. I'm no longer doubting or questioning anything. I'm done. Now, If this is a situation where I am doubting something, But I'm doubting it in such a way where I really can't even get an answer, Or I just have a lot more hypothetical questions, That's a clue for me that, Wait a second, I'm starting to enter a different process here where I'm really disconnected from anything that's actually contextually relevant or common sense. And I'm going into a whole different process now. So that's one way that I've learned to distinguish now and realize when I'm doing something, You know, When I'm doubting something that's reasonable and when it's really not, It's obsessional. When I doubt something obsessionally, That's where I'm more likely to start to conclude things inaccurately. Somebody else actually said it, I can't own it, But conclusion confusion. You're inferring something that's really not based on anything accurate. Hence, Inferential confusion. That's really what you're treating in that model. Kind of have a different understanding of uncertainty and real true uncertainty that we have to face at times. And when is it that it's not about uncertainty, It's that we're doubting something that we really shouldn't be doubting. I know that sometimes hearing these kinds of things, Can make you feel a little confused or wait a second, What are you really talking about? So I really want to encourage you to really listen to the words I just said and really take a minute to really Think through and understand for yourself the whole concept of You know, When in life is it that you truly don't have some information and you have to sit and wait like a doctor's office, Right? When you maybe have to wait for results. And while you're waiting, It's tough, Right? It's not pleasant, But you have to wait. And how common is it that you're going to want to fill in the blanks? While you're waiting with something, Oh God, What if it's a bad disease, What if it's this, What if it's that? And then you kind of have to pause and catch yourself and wait, Right? You have to say, Okay, Before I keep running away with that, I don't know, I have to wait. So we all have situations in life where we have to truly just wait. Um, We have also times where we really don't know something and we might not ever know something. For example, Like I don't know when I'm going to die. That's, That's really a different level of uncertainty that I have no answers for that. I will not have an answer for that. Right? So what do we do with that? Well, Generally we embrace and accept that and we say, Okay, And let me get back to living my life and kind of doing the best I can and live the kind of life I want. You know, When we're doubting something, We want to recognize that, You know, How am I doubting? Because OCD is a doubting disease, Right? So when we're going to what if this, Or it's that, Or I am, We want to slow down and ask ourselves, When I'm asking myself these questions and I'm concluding this, Where is that information coming from? Is it from something that's contextually relevant in the present moment? Am I really using my common sense? Does this make sense? Or am I really taking information and using it very out of context or taking something from 15, 20 years ago and applying it now as if it's a hard fact? Am I in that process dismissing who maybe I say I have been in the 15 year span? And instead of acknowledging anything about that experience I've had, I'm only focusing on that select of one piece from, Like I said, Let's say 15 years ago and applying it in the present moment where maybe it doesn't have any business in the present moment. So we have to kind of slow down and really look at our own thought process and how we arrive at to things that we're concluding and where is it really coming from and how are we putting it together in our minds. So that we can really help ourselves stop being so confused in this obsessional doubt process. And so that's kind of the more updated version and understanding that I have, And it's really helped me profoundly to Notice when I start to get pulled inwards and start to want to create a whole story in my head about things and I can always find reasons from things I read, Things I saw, My own past behaviors and so on, But I realize, Wait a minute, I'm kind of I'm creating this, I'm kind of forcing this outcome instead of stopping and say, Hold on, Let's drop that for a minute. And what do I actually know what's right in front of me? And that quite often paints a very different picture. Now I know the way I'm describing it might seem really simplified. I'm really just having this conversation with you so that I can do my best to help you understand this at just a more fundamental foundational level. But if you know you wanted to kind of deepen your knowledge and understanding. There's plenty of resources out there for this process. But I guess what I want to leave you with is this. I don't think there's one way to treat OCD anymore. I really think that there's multiple ways. Like I said, I love ERP. I've loved some of the interventions I've learned from there. I've also really loved ICVT, And I've loved the different layer and depth of where that took me. I've really loved aspects from acceptance and commitment therapy. So I think there's room for combinations of things. And I think what matters most is that, You know, Looking for a provider and kind of checking in with yourself with what seems to, What do you align with? What seems exciting and interesting for you? I have plenty of clients nowadays in my practice who really love ERP and we do ERP and it's amazing. And I have some clients who want to do ICBT and we do ICBT and it's amazing. You know, I really can't say. At least from the clinical perspective. That this is right for this and that's right for that. What I can say is that, You know, We're all human beings and we have to find our own path and find a path that's going to work for us. And so hopefully, You know, Do have a good evaluation with a specialist. Talk to a couple of different providers. And then also check in with yourself with how do you want to work and what would feel good for you. Any work you do, You typically want to take your time and do it one step at a time. And in that way, You can be really effective with things. So I hope you got some great nuggets out of this today. Yeah, This is just a little bit about kind of my own journey and where I am now. And I would say that I am in recovery and that OCD really doesn't bother me. Here and there, Little pockets might creep up, But nothing like it used to be.