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OCD Family Podcast
S4E159: What If I'm the Villain In A Story My Brain Made Up? FAQ's about I-CBT Treatment for OCD with Michael Parker, LCSW
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- [00:00]
A
Want a recipe for success? Step 1 Visit ocdfamilypodcast.com courses Step 2 Click on my link to browse OCD Training School's amazing course catalog. Step 3 Enroll and Step 4 Enjoy learning with no added cost to you. You can support the OCD Family community while grabbing some continuing education or learning how to bridge yourself to self help strategies for OCD. Again, that's ocdfamilypodcast.com courses and use my special link to sign up today. Hi fam. Welcome back to the OCD Family Podcast. Today we are diving into some frequently asked questions about Inference Based cbt, also known as icbt. I see how consistently ICBT conversations are amongst the most downloaded episodes I release and honestly I think that speaks to how hungry people are for nuanced, accessible conversations that helps make sense of this evidence based model in a way that feels practical, compassionate and hopeful. Whether you're brand new to inference based CBT or you've been deep diving into it for a while, you're definitely not alone in wanting to better understand this approach. And today fam, you are some lucky duckies because we have colleague, trainer, therapist and I hope I can count him as a friend. Michael Parker, Licensed Clinical Social Worker I'm Nicole Morris, licensed marriage and family therapist and mental health correspondent and let me be the first to say welcome to the family, the OCD family that is. I am here to create a community of support for family members, spouses, partners, parents, adult children as there may be adult words and chosen family of OCD sufferers and their community. I've had over 22 years of experience in the mental health field but please please note that this information does not qualify or substitute as a diagnostic evaluation, therapy or treatment and it is presented on an as is basis. Please follow up with a qualified mental health provider in your area regarding concerns for yourself or loved ones. Thank you for joining us today. Now let's get started. Okay. Alrighty. How are we doing? It's been busy and well I like traditionally to publish on Fridays. We had a very full weekend of PTA events and end of the school year business. But I am so glad that we can take some time and have a chit chat with Michael because Mike is a gift really to our treatment community. Michael Parker, as I noted at the top, is the clinical Social worker and private practice located in Pittsburgh, Pennsylvania. Michael is widely known for helping clinicians, suffers and families better understand OCD and ICBT through his YouTube channel OCDSpace as well as his educational platform ICBT Training online so if you have been hearing more buzz around ICBT but still find yourself wondering things like wait, isn't this just reassurance seeking? Or how is this different from other evidence based models like Exposure and Response Prevention or ERP or Inferences in the name? What exactly is inferential confusion? Because lots of people have confusion and we don't even have to infer it. They're pretty vocal about it. So if you've asked yourself any of these questions, this episode is for you. And if you have been involved learning or even using these ICBT tools for a hot minute, chances are you've heard questions like these. So even if you're more seasoned in this approach, I encourage you to give this episode a listen because I'm guessing that you're fielding some of these very popular questions as well. And you know what we say here, fam. We're better together. So Michael and I are going to spend time unpacking some of the most common questions and misconceptions people have when first learning about icbt. We're also going to explore how the model conceptualizes OCD differently from more traditional behavioral frameworks. And we're going to talk through concepts like doubt, feared, possible selves, which further goes into distrust of senses, obsessional reasoning. I mean, we cover a lot of ground. But here's the good news. Whether you have lived experience of ocd, you're a family member or loved one loving on your OCD warrior, or a clinician, this content is approachable and hopefully digestible. But wait, there's more. Toward the second half of the episode, we're actually going to walk through a practical case conceptualization exercise together using an OCD vignette that neither Michael or I had previous knowledge of. In fact, we used ChatGPT to just whirl up a little doozy for us. And honestly, CHAT doesn't always nail it, but we were pretty impressed with the vignette for today. So we're going to take that, slow it down and tell you from a therapeutic perspective how we would conceptualize the case within the tenets of ocd. Now, this isn't therapy, this isn't training, this isn't consultation. I know I say it in my intro, but it bears repeating. But for anybody like me going like how? How what? How do we make sense of this? What does that actually mean? Or is still stuck on the meat meatiness of a term like inferential confusion, I see. You worry not. We're going to break it down and you'll see in real time Just how Michael and I would sift through, explore more, and create a general roadmap for ICBT treatment. Okay, we're almost ready. Can you feel the excitement? I know I can. But before I properly introduce you to Michael, I just wanted to cover a few quick housekeeping notes. Today's episode is actually the penultimate episode for season four long form content. Say that three times fast. Which means our next episode is going to be the season finale where we will be welcoming back none other than Dr. Anthony Pinto, who has recently co authored a self help book along with Dr. Michael Wheaton that is at the very least available for pre order depending on when you're catching this, and available more broadly as of July 1, 2020. Now what's the self help book for? None other than Obsessive Compulsive Personality Disorder or ocpd. OCPD is an OCRD and fam. If you're newer to us, I swear we won't be chatting all acronyms. But OCRDs are OC related disorders. And just like ICBT is one of the top downloaded conversation topics that we talk about in our time together, OCPD is also one of the most sought after conversation topics across my entire catalog. So that will be the season finale next episode. Because going into the summer, while I still publish all summer long, we actually shift into shorter form content called the Water Cooler Chats. And I do this so that I can spend more time with my kiddos while they're on summer break because we're the famous. So of course I gotta take the time for my fam irl, right? But I do enjoy bringing these Water Cooler chats your way. And then I usually do do a longer episode recapping the International OCD Foundation's annual conference. So that is the plan again for this summer. And stay tuned for all of that. Okay, Last but not least, I just wanna acknowledge my relative silence or at least the reduction in published content this season. Truthfully, I made the intentional decision to prioritize life lifing over performance. And actually I'm pretty proud of that because as a recovering perfectionist, it is hard to strike that balance. So while I intended to bring you this episode, and I'm just going to be completely honest, completely transparent, because here at the Fan, that's what we do. We keep it real. I recorded this episode back in October with Michael and he has been so incredibly patient, kind, gracious, understanding. Which is not a surprise if you know Mike. But I also do want to extend a genuine apology and a thank you to Michael, because he does incredible work. He is widely known for helping other clinicians understand tricky concepts in, dare I say, simpler ways. I mean, it is a real skill. When you have something that's really meaty and makes it make sense, it's truly a gift. And so I'm so thrilled to share this interview with you. And Mike, thank you again for your time, for your understanding, for your grace, how you build an environment even in the digital neighborhood here where everyone is welcome to learn. You are a hope bearer, Michael. And I just thank you again for taking the time. So, without further ado, fam, let's get to chatting because Mike has waited. Has he waited? And I can't wait for you to hear more. Okay, well, welcome back to the OCD Family podcast. And today we're in for a treat family because we have none other than Mike Parker, who is a licensed clinical social worker and in private practice in Pittsburgh here in the U.S. mike, welcome to the show.
- [09:53]
B
Thank you, Nicole. I'm happy to be here.
- [09:55]
A
Oh, so happy to have you. Because today we're going to be discussing all things inference based cbt. And you really have such a good way of helping people understand more about O C D more broadly, but also you have a YouTube channel called OCD Space where you have been really helping to expand learning and understanding on inference based cbt. And, and so first things first, we're gonna have a lot of fun during this episode. But I'm so curious, how did you get into treating OCD in the first place?
- [10:30]
B
Yeah, so that's like a lot of people actually by chance, but actually maybe just getting into the mental health field in general was kind of my first step. You know, I had been in college and I was just like, I'm a lit major, you know, maybe I wanna be a writer or something like that. And explored every career out there, writing, teaching, and all the while I was always kind of working in the helping field and helping people with intellectual disabilities and just great experiences there, Met lots of amazing people and then finally accepted that, you know, this is what I should be doing with my life. Went in this clinical direction, went in the social work direction and found my comfort zone just working with individuals on their personal issues they're dealing with. My personal struggle was always social anxiety. I had crippling social anxiety in middle school and high school to the point of just like depersonalization, derealization. And so that's where I initially went, you know, just helping people with social anxiety. I moved to Pittsburgh and there's a Huge mental health system in Pittsburgh. And so I'm looking at all these jobs and just applying to different jobs. And I applied to this OCD IOP for kids and, you know, got the job and really didn't know what I was doing with OCD and learned and, you know, as as many people in this field, just completely fell in love with the population, the treatment approach and, you know, just started my career right there. I've been working with OCD ever since.
- [12:00]
A
That's really cool. And so in case you're wondering, family IOP is intensive outpatient, which would be kind of a higher level of care, almost like going to Monday through Friday classes of therapy, that kind of level of care. And that, yeah, I'm sure was quite a introduction into the population. But you're right, we fall in love with the population. I myself, when I started treating ocd, didn't realize even myself that I had lived experience of OCD because I just always coded that as anxiety. And so one of the things, and we may even talk about that a little later, kind of differentiating generalized anxiety from OCD because we treat them a little differently because of inferential confusion. But before I get ahead of my skis, we're going to start talking a little bit about icbt. So we were talking before we were recording about when you started to learn more about icbt. ICBT for the newer fam listening has been around for a couple different decades, but more internationally domestically is really gained more traction and understanding, really through grassroots understanding and teaching and training. And so when did you first kind of catch wind of ICBT and what caught your curiosity?
- [13:20]
B
So I caught wind of it about three years ago and it was like, actually many people through Facebook of all places and in our therapy community and ocd, there's an amazing Facebook group that, you know, we are all connected to. And there was these two individuals, I think you've had them on this show, Carl Robbins and Mike Hetty, kind of making some waves, making some interesting claims that I'd never heard before about OCD and treatment. And I'm, I'm a very curious person. I hear things and I don't really get defensive. I get more interested. I'm like, okay, so I hear you calling in the question, like a lot of things that I'm assuming about OCD and how we treat it and just kind of followed along with what they were talking about and actually joined an ICBT specific Facebook group in addition to the main O C D group and just have learned a lot through that process. I've joined consultations, I've taken trainings with some of the amazing people out there. I should say that I'm indebted to so many people, you know, Mike and Carl, and just a whole big group of people with lived experience with OCD who really took to ICBT early on and started teaching people about it. So, you know, I've. I've just been very lucky to learn from all these amazing people.
- [14:40]
A
I would agree with that, that it's a very giving and sharing community. And what I would say more broadly about the OCD specialty and the community of practitioners is that overall there is a protectiveness about wanting to really preserve the fidelity of evidence based treatment. And so, yeah, when people come out and say, like, maybe this could be resolved a different way, especially if it's a cognitive way versus a behavioral way, it's a little bit like a mousetrap because it's like, boom, what do you mean? Right. And it comes out of this place of protectiveness and really wanting to do our clients well. But there's no cure for ocd. And so as we continue, we want evidence based treatments, as many of them as we can get, that are going to be viable options to help people have meaningful relief, be able to get to subclinical levels, meaning they're functioning well in their life and they're not limited by OCD and its bossiness and by their imaginations. And so, yeah, it's definitely a very giving community and you're a part of that. What you're doing too, through OCD space is amazing. And you're a trainer now as well, so I know that you're definitely helping lead the way with that. So what we're going to do is we're going to talk a little bit about some common questions that come up in icbt. But also I'll just let you know, family, that Mike's YouTube channel really targets and addresses common ICBT questions. So we won't reinvent the wheel too much. I'm going to direct you over to OCD space and I'm gonna have a link for his YouTube channel over on this episode's vlog at OCD Family Podcast. But if you're real, real new to inference based cbt, maybe Mike, if we could do we all work on truncating this elevator pitch, right? It used to be much harder. It's gotten easier over the years.
- [16:45]
B
Yeah.
- [16:45]
A
But maybe we'll give a broad overview and then we'll do some of the greatest hits questions everybody has when they first kind of hear about it, especially if they're more well versed or have a previous understanding. Exposure and response prevention, also known as erp. And so, yeah, we'll start there and then we have some fun things planned later. Fam. So stay tuned for that. Okay, so what would you say is your elevator pitch for I, C, B, T?
- [17:11]
B
Okay, so, yeah, you know, it is interesting. I do actually have one. There would have been a time where I would have really struggled with this. But I would say that, you know, first things first. I would say, when you're thinking about learning icbc, take the conceptualization that you've been given by ERP and traditional CBT and ACT and try to just erase that from your mind to start the idea of avoidance and fear. We're actually not going to conceptualize that with ocd. What we are actually looking at is that an obsession is a doubt. And that was the biggest hurdle for me early on. I really wanted to understand what doubt means because I, you know, I took the word down. I was like, oh, an intrusive doubt. That's just an intrusive thought. And it starts with a what if? Yes, that's. That's what I wanted to do with that word.
- [18:02]
A
Well, in my. If I can just say real quick too, sometimes we'll hear OCD referred to as the doubting disorder, even from a more kind of traditional ERP standpoint. So it does feel like, yeah, I use those synonymously. Aren't those the same? But you're distinguishing a difference, so I'll let you continue. But I was, I just thought, like, yeah, there's, there's a tendency for a lot of people to interchange those.
- [18:25]
B
Yeah. And the idea of that doubting disorder has always been around, but I've never seen it laid out, conceptualized like it has been with icbt. Because ICBT is very much rooted in human reasoning and doubt is an aspect of reasoning, and so it really explains doubt. So with, with an obsession being a doubt, what we're basically saying is that the individual with OCD is calling something into question. It's not just having an intrusive thought. They're literally questioning something really foundational, really important in their life. It is not something they're counting on anymore. It's not something they're relying on. They believe it's something they should not trust. That's kind of the end result of doubting something. And so we're really looking at how someone came into this situation of doubting something really important. What is the thought process there that led someone to do this. And so there's just so much now to really get into cognitively with people with OCD with this whole new conceptualization. And so, you know, really a doubt is just the definition I use is calling a previously trusted state of affairs into question.
- [19:37]
A
Yeah.
- [19:37]
B
And so we're really starting from a place of there's certain things you need to trust in life. And, you know, with icbt, we tend to hear the word certainty thrown around, like there's certain things you should just be certain about. Does that mean theoretically, 100% certain that nothing bad will ever happen? No, it doesn't mean that at all. It just means I don't feel like I need to think about that question, that on a typical day I just walk around like I can count on that. And so that could be our health, that could be our goodness, that could be a number of things.
- [20:10]
A
And an example of that family is like, if we were to go sit at our kitchen table, we don't doubt that we're going to be able to sit there without it like bottoming out beneath us, unless we see like a janky looking chair. And then we're like, that's not the seat I'm taking. That's obviously broken. So we have some functional certainty going, this chair can hold me or that chair definitely can't. And we should drag it out to the garage or maybe put it on the curb. So examples like that.
- [20:38]
B
Absolutely. And it's. And we want to be really clear because this was an area where people got tripped up. This does not mean that it's not possible for the chair to break.
- [20:47]
A
Right. Right.
- [20:48]
B
It might break.
- [20:50]
A
Right.
- [20:50]
B
But we're living like it won't.
- [20:52]
A
But. Right. We'd be pretty surprised if it broke because it looks intact and we can see that we can pull it out and it maybe sounds intact. All our sense data is like, you good?
- [21:04]
B
Yeah. And so it's, it's making a rational choice, a reasonable choice, a very practical choice to live a certain way. And we recognize, you know, once I've questioned my goodness or my competency to this level of ocd, I have logic my way into a hole and I can't get out because I can't function now because I, I'm worried about something that I'm not supposed to be thinking about. Yeah. You know, and, and the way I think about, like one thing I'm trying to get better at with ICBT is to really paint the picture of what you're supposed to be doing. We spend a lot of time talking about what you're not supposed to be doing. Don't doubt.
- [21:46]
A
Right.
- [21:46]
B
What does it look like when you're not doubting? So, you know, you're walking into your kitchen and you're thinking about what you want to make for lunch, and you're thinking about, you know, maybe I. Maybe it's time to get new plates. Maybe I need a new piece of Tupperware. Yep. Just, you know, those are the sort of concerns that are on your mind. Those are the sort of concerns that life presents you with. And we would notice there's no information saying, think about if there's dangerous bacteria on the cutting board. We would notice that. That's possible. Sure. But so is anything that's. You know, we don't get sucked into something because it's possible. And what we'll find is that, you know, this individual is a competent, clean, responsible person who watches the cutting board all the time, even when they cook raw chicken on it. And this is not anything that needs to be addressed. And so this is a very different approach than the other approaches, because you might say that, oh, that sounds like act or that sounds like, erp, you're shooting for the same goal. But notice that we're saying you don't have to address anything. You don't have to accept anything. You don't have to tolerate anything. We're saying that when you walk into the kitchen, you don't even need to accept the possibility of dangerous bacteria. If you're thinking about accepting it, you're already too far into the doubting thought process. Back up, when you walked into the kitchen, what. You know, how did that happen? How did you even start thinking about bacteria? Because we don't want to accept that. We want to say, let's fix that thought process that's making you imagine something that has absolutely no evidence in reality.
- [23:24]
A
Yeah, really good points. And I'll just say again, if you're tuning in and you're brand new, welcome. If you're not brand new, welcome. But if your main theoretical understanding for OCD comes from an exposure and response prevention lens, you're probably going, but. Right. And so we're gonna. We're gonna problem solve some different questions that come up pretty commonly, and we're gonna go through some case examples that'll help us. Just think out loud about what that case formalization looks like, and I think that'll help as well. But, you know, I will say, like, when we talk of different OCD themes, especially one like contamination, and if you are working with or are someone. Or have a loved one with contamination ocd. You can already hear that. But, but, but arguments, right? One of the things I will tell my clients sometimes is like when I walk in, do you know how to make a peanut butter and jelly? Granted that you're not allergic to peanuts. You go in and you make a peanut butter jelly sandwich and you go down and you sit at your table and you go to take a bite. And if you have a thought like, but what if I put motor oil in it? Like, that would be really random, right? Why would I think that? And so I know it's hard to compare. What if there's bacteria on the counter to. But what if I put motor oil. But our point is like, I don't think any of us really need to prioritize thinking there might be motor oil in our peanut butter and jelly sandwich. And I, I don't even know. I don't know if that sandwich has ever been made. So we're gonna address a lot of different things. But I understand. Especially if you or your loved one's life have been like just flipped upside down by the potential of unseen invisible bacteria or something in the kitchen. I realized that sometimes it's hard to not already start to argue with butt. But. But when we start kind of thinking theoretically from an ICBT lens. And so I don't want to cut you off, Mike, if there's any more to the elevator of pitch, please continue.
- [25:24]
B
I mean, I could keep going on, but I'll, I'll pass it back to you.
- [25:28]
A
Okay. It was a very good broad overview. And again, if you're like, what? Go check out OCD Space, check out previous episodes on ICBT here at OCD Family Podcast, or go check ICBT online. Also, Mike is doing ICBTrainingOnline. Com, so there are lots of opportunities. And I think saw on a video, Mike, that you have both professional courses and a self help, correct?
- [25:53]
B
Yes. So something for clients and something for clinicians.
- [25:56]
A
Okay, so we're going to get into some common questions. And the first one I kind of jotted down that I hear most often. But I don't know, I bet we both hear quite a few different questions and that's this. So ICBT sounds like you giving yourself like reassurance seeking or like ruminating. Like if I'm walking in and I'm debating about I don't need to debate or I'm trying to avoid thinking about bacteria on the counter. To use the example you introduced earlier, that just sounds like you're compulsing I don't understand how that could be helpful. So there's our first question. Is ICBT just reassurance seeking? Is it just rumination? Are we just promoting compulsing?
- [26:41]
B
Yeah. So I'm seeing a few different questions here, actually. And so, you know, just to start off with the idea of reassurance, I'm going to steal something from Mike Hetty, which is that why do we have a normal version of all compulsions except reassurance? Why do we allow ourselves a certain number of hand washes and certain times, and reassurance is like, no, never. Anybody asks you a reassurance question, say, no, I'm not even going to answer that, because. So I want to start from that premise that there's definitely a healthy version of reassurance for everybody. People with ocd, people without ocd. That being said, we all know that you can get into a very bad pattern of reassurance seeking. We can. You know that your mom becomes the person you call whenever you're triggered and you ask those questions. And the, you know, you're asking oftentimes a question that that person can't even answer. Like, mom, do you think I hit someone on the way to work? And mom says, no, I don't think so. So, you know, we want to recognize there's definitely a reassurance seeking compulsion that exists, and we always want to be aware of it and not give it and not feed that. But what we're going to find with ICBT is we are getting out of a lot of the problems with compulsive reassurance seeking that could exist with more traditional cbt. With traditional cbt, we might be saying, let's prove that you didn't hit anybody. You know, let's look at the evidence for and the evidence against and let's directly try to disprove this idea that you didn't hit anybody. That is getting into an argument from OCD from the get go, because OCD always has the argument in the back pocket. It's possible, right? It doesn't matter what happens in that conversation. There's always. It's possible. And so I, I'm. I'm trying to achieve the impossible. It might sort of temporarily help me feel a little better that someone else doesn't think I hit someone also. But ultimately it didn't prove or disprove anything.
- [28:44]
A
Yeah, Mike, and something you said earlier that highlighted this point that you're distinguishing really well. You're saying you can't outlogic OCD and ICBT is not about out logicing. And earlier you talked about actually understanding how we logicked into ocd. Those might again sound like little semantic differences, but they're pretty big differences when it comes to the difference and where we go from our normal reasoning process into obsessional reasoning. Would you like to expand that anymore?
- [29:17]
B
Yeah, thank you for bringing that up. I feel like that is the. Is it? You're so right. It feels so subtle. It is this like different universe sort of distinction. Actually, once it's in your head.
- [29:29]
A
Yeah.
- [29:29]
B
When you're talking with a client, you're always looking at, how did they get into this? How did you talk your way into this? How did you logic your way into this doubt? How did this question that we might have in the past called an intrusive thought and now we're calling a conclusion or an inference. How did you reach this conclusion of I need to doubt? You know, so let's look at the person who drove somewhere and is having that hit and run question in their mind. How did you doubt the fact that you didn't see anything and you're still thinking it could have happened? We're looking at how you got into that situation. And you know, this is why I love ICBT actually, because I've always been interested in, you know, reassurance is the perfect topic to look at this. I want to really understand OCD and I want to understand why someone is asking a question that the other person in the room that they're getting the reassurance from is not concerned with at all. You know, this seems like something more than avoidance. This seems like something more than fear. And we are looking at. Yeah, how did you talk your own way in your head into this doubt?
- [30:36]
A
Yeah, really, really good points. And you know, in my off time, when I'm not nerding out about ocd, I like to watch legal cases and they talk about making reasonable inferences quite a bit too. Sometimes we use that evidence and that Quirt mindset too, sometimes to conceptualize different tools and learning within. I cbt. But I was watching a case somewhat recently and one of the examples they give, and I'm sure we've heard them around these spaces as well, but was like, you're coming to a conclusion. And sometimes people were like, no, no, no, no, there might be bacteria there. I'm worried that, you know, I'm not coming to a conclusion. It was already there. It was, I'm like trying to escape the fear of this. But the court case example was like, how do you know that the mail came. Did you see the mailman come deliver? Your ma went and checked the mailbox this morning. It was empty. I didn't see the mailman deliver the mail. But we have a community mailbox. Only the mailman could get in there. And by this afternoon it was there. So I can make a reasonable inference that the mailman came. I can conclude that. I usually don't even care. I'm like, good, the mail's here. I mean, no, no shade on our mail, people. But it's not something that's like tripping me up during the day. But you could see how that same scenario with bacteria on the counter. We have to. To a conclusion that something threatening must have been there that could result in some kind of consequence that would feel very distressing and then enters how we're responding. Right. And so trying to understand that inference, which is like the bulk of I cbt. Inference based. CBT in and of itself is a conclusion. I concluded the mail came. I didn't think about it. I just thought I got the mail. Right. But I'm actually concluding the mail came. There was a conclusion that caused me to act on pulling mail out of the mailbox.
- [32:32]
B
Yeah, absolutely. And, you know, one of the keys, like, I love that you bring up the other examples because, you know, when. When you brought up the fact that, you know, Mike, as you're giving your elevator pitch, I just hear all the but, but, buts.
- [32:44]
A
Yeah.
- [32:44]
B
What we're going to notice is there's all sorts of arguments someone's going to have against this initially. Like, but. But there could be, you know, dangerous germs on. On that counter. Yeah, yeah, yeah, absolutely. But we want to recognize that everybody with OCD and everybody without OCD is functioning in a very different way. Typically, we are not just walking into a kitchen and thinking about bacteria. And oftentimes what we're doing is not only do we, you know, sort of reach conclusions like the mail came, but we often reach conclusions where, like, that's not even on my radar.
- [33:21]
A
Right.
- [33:22]
B
You know, there's. There's so many possibilities. Like, you know, the one I like to use is just, yes, there could be a serial killer on their way to your house right. Now, I've never said that to anybody and seen them look out the window to check.
- [33:35]
A
Right, right.
- [33:37]
B
Yeah, I guess, you know, sure, it's possible.
- [33:39]
A
Yeah.
- [33:40]
B
You know, and so it's like, clearly you didn't even have to address it. Like, you are just living like, it's not even. Even though it's possible. You know, and sure, someone will say, you know, bacteria might be more possible, but still, it's only still just possible, right?
- [33:56]
A
It's possible to have motor oil in your peanut butter and jelly sandwich. It's possible. Very unlikely, yes. Especially if you don't even own motor oil. But even if you do, you know, you can kind of trust that even if you zoned out, even if you dissociated a bit, you're good. You're good. So, yeah, I like that. So we've, we've covered the reassurance and rumination. I think we really covered between the logicing in versus logicing out. We can't out logic, like you said, Mike. So there is no argument there from ICBT saying, yeah, let's try and logic ourself out, and then getting caught in perpetual rumination, because we realize that is, to borrow another line from Mike Hetty, a fool's errand that's not going to lead you anywhere. But we can come to more logical inferences. We could say, to your point, Mike, why does one person worry about going and getting the mail and did the mailman come, and other people don't even give it a second thought? It's just like a rote part of their routine. Or maybe it's not even their job and they're not even worried about it. Right? Somebody on the house gets it, whatever, it all works out. And so, yes, those are really, really interesting questions. All right, fam, if you're getting value out of our conversation, but you haven't hit, subscribe or followed OCD Family Podcast, wherever you enjoy your podcasts and YouTube, please take a moment, no time like the present, to hit that button. It's free, it's easy, and it ensures that not only will you never miss an episode, but that more folks can find the OCD Family community. Because, fam, we know we're better together. Now, back to today's chat. Another question I have come up pretty often, and I see echoed at almost every conference since ICBT has started to get a little more speaking room. And that's. So this kind of sounds like erp. ICBT kind of sounds like erp because. And again, ERP Family is exposure and response prevention. Because if you don't come to that inference and, you know, you're just kind of like going in the kitchen and making dinner, then it's like an exposure. You're going in and the, you know, is the bacteria there or not? I'm just gonna make dinner and I'm gonna live my life. What Would you say about that and the combination or trying to combine tools from ICBT with erp, can it be done?
- [36:27]
B
Hmm, yeah. So I guess one thing I would say is I don't want to come across as critiquing other approaches to ocd because, you know, there's just amazing OCD specialists out there and there's ICBT people that are doing more ICBT than erp, people doing more ERP act, whatever it might be. And it's all about taking that approach and just really just being tenacious with that OCD and helping that client address it from that angle. And it can be really done from a lot of different angles. The one thing that will really distinguish the ICBT from ERP is from erp we are like laser focused on avoidance. Like, where's the avoidance happening? And let's remove all that avoidance. It's very behavioral and there will be some CBT thrown in the mix, but there won't be much attention to this idea of doubt and this reasoning process of not trusting the senses, going into the imagination. And that's really what we're going to focus on with icbt. When you walk into that kitchen, I'm as an ICBT therapist, going to be laser focused on the doubt and the reasoning and how you're getting yourself to this place in your mind. Someone with an ERP approach is going to be like, okay, what, why didn't you touch that? Why are you asking for reassurance right now? This is all avoidance. We're going to eliminate all these compulsions and just not reassure and just completely expose yourself to the anxiety provoking situation. So really strict, traditional ERP is just going to be all about what are all the compulsions. Eliminate all of them and expose yourself to the thoughts, the situation, the feelings, whatever it might be. And that's going to be the definition of erp. I know people do a lot more cbt, do a lot more act, and they're starting to even think, think in terms of icbt, some of the ideas there. And so we might even be seeing ERP that is evolving to some degree. So some people might say, oh, I, I do that with exposure. But we would say, well, you know, ERP looks like this though, if you're doing it by the butt, so you might be adding a lot to it.
- [38:35]
A
Yeah, my understanding, I would say like, you know, in erp they're pretty firm on a thought is just a thought. We don't really need to dissect it. And really, by helping the brain learn new responses the thought becomes whatever. If it, it dissipates, it minimizes or it doesn't matter, or even when it pops up, we go, oh, that's a trash thought. I don't have to worry about it, right? I can live my life anyway. They're really focused on the learning in the brain, and so they're not really concerned with how we came up with that thought. They're concerned more about helping the brain learn a new response that can ultimately bring freedom and healing and recovery for a person. It's really a downstream approach. When we think about icbt, it's more of an upstream approach, meaning if we start kind of at the beginning, like, if we figure out how we concluded that and we realize, you know what? I'm not using my. I obviously made peanut butter and jelly reasoning with this bacteria on the counter, and I can start to pick apart and go, oh, my gosh, I actually constructed this conclusion to draw the inference that I'm probably in danger in my own kitchen. And we can resolve that error. Then do we get stressed? Well, I don't get stressed when I make peanut butter and jelly. So it's not really I'm exposing myself to making peanut butter and jelly. It's just that I've been able to conclude using my normal reasoning and trusting myself. And that marks a big difference.
- [40:12]
B
Yeah. Yeah, absolutely. Yeah. One, one thing I've, I've been doing more when I'm doing ICBT is more prompts to do certain behaviors in session to, you know, which can almost look like exposure. But, you know, like you said, exposure is really based on the idea of intrusive thoughts. Not that you're coming up with this thought. You're just experiencing passive, scary thoughts. You know, with icbt, we're looking at how you're, you're reaching these thoughts. But yet if someone is saying, like, I, I, I fix, you know, every time I have a certain thought pop into my head, I fix it or I try to remove it from my mind. When we're doing icbt, at some point we'll probably have to say, well, let's, let's during session just like, have that thought. And that could look like a very similar prompt to an exposure. But what we're actually going to be doing is maybe some preparation before having the thought, you know, I'm going to be working with that client. Do you actually think and believe that, you know, thoughts have power and that person might say, well, you know, maybe not everybody, but I believe mine do, you know?
- [41:16]
A
Yeah.
- [41:17]
B
And then we'll we'll, we'll do a lot of work in figuring out how that person came to believe this about themselves. We're looking at the feared self. We're looking at a very specific, reasoned story that makes them believe this. We're often unpacking magical thinking and realizing that this person doesn't actually believe a lot of these things, that if we really activate the reasoning and the common sense for that individual, they don't believe it. So we might really activate those mental processes before doing the behavioral experiment in session. So we'll do a lot of preparation and that's all gonna look like reassurance from an ERP perspective. But from an ICBT's perspective, we're saying, no, this person has the mental faculties to identify. This isn't actually what they believe about thought. And so let's activate that for that person. And then after they have the thought on purpose, let's explore what happens for them. We might notice, oh, they're having a certain feeling. They're saying they're having a not right feeling. Let's explore what that is. Oh, it's just anxiety, actually. Let's learn about anxiety. So we're unpacking so many things that are going on internally for a person. And then honestly, this is the beauty of this approach. It's obviously evidence based, so that's the first reason I'm doing it. But then I start doing this with clients. I'm like, oh my gosh, they're getting it. You know, the week between sessions they said, you know, that experience we had when you hadn't made me think that's not on purpose. And we hawked it through and I got back in touch with everything. I think like, that really helped me not do that this week, you know, maybe a few times to start. And so, you know, I, I, as I've gotten more competent with icbt, I've started to mix in more prompts to do what we might call our exposures to just get into that situation. Because sometimes we're dealing with avoidance too. Even when you do learn icbt, that person is still maintaining that boundary of what's being avoided. And we have to, you know, prompt our clients to break through that barrier. But we're doing it in a very different way. But, you know, that's, that's what I would say is sort of like my version of kind of mixing the two.
- [43:28]
A
Yeah. When I think of doing some reality sensing exercises, we describe in ICBT that when we're in our obsessional reasoning, we're really in this OCD bubble. And we think it's to protect us, and we're trying to not become what we think OCD says we might possibly be. And so we're trying to protect against that. But also we learn, like, that's kind of what's entrapping us. Not just kind of. It is what is entrapping us. And that bubble's isolating us. Right. And so there is a tool that can be used within I CBT to really even figure out how do I get out of this bubble, how do I go in purposely to get out? How do I, like, realize I can make that switch? And then when I am in, if I get caught up and I'm like, oh, shit, I got. I got pulled into to this doubt big time. I can know how to pop and switch gears and just take myself back out to my regular peanut butter and jelly reasoning. And so it's different than an exposure, though. It's really like a light skin switch where we're like, oh, actually, this is. That's the fake news version. We don't have to. We don't have to worry about that. And one of the things I guess would be worth saying again to anybody new is I CBT is really based around this concept of inferential confusion. And that's where we're really confusing what evidence we're getting kind of here in our. Our reality with what we can imagine is possible, which anything is possible, like you said. So there's lots of fodder for inferential confusion to come up. And so with that, maybe we could talk a little bit more about inferential confusion, Because I think when you were speaking about, oh, that's just anxiety, I thought, oh, yeah, we should ask too, as part of our Q and A here, can you use ICBT for just anxiety? But I think we probably need a little more meat on that inferential confusion to tease that one out. So anything more you would say about inferential confusion?
- [45:36]
B
Yeah. So, you know, thanks for bringing up that term reality sensing, because, you know, that's. That's basically what I was describing. And that is the ICBT version of behavioral work that we do. So inferential confusion is basically the underlying mechanism, I guess you could say, of OCD from an ICBT perspective. It's what we're targeting. And so we're really looking at three aspects to inferential confusion, which is distrust of the senses and the common sense, overreliance on possibility. Right. And then the tendency to apply out of context, logic to the self. Yeah, you know, and so it's, it's, it's really. It's really beautiful because, you know, you talk to anybody with OCD and you'll see like, oh, yeah, I definitely do that. You know, and they'll grab onto, you know, one, two or three of these aspects of inferential confusion. But, you know, we're really looking at what is the difference between someone with ocd, someone without ocd, someone with OCD who has an obsession in this one area and not in this area. What is going on differently here? And we're seeing a reasoning process that starts with a distrust of the self in some way. And I'll emphasize that that's not some sort of mystical kind of thing like, oh, you know, you have OCD and so you just don't trust your sense. You know, you just don't trust yourself. It can sound almost like this, like, intangible thing that you can't do anything about. We want to make it clear that, like, you've logic yourself into not trusting your senses. You've decided that since you can't see bacteria that you're not going to trust what you see and what you sense in the reality of the senses anymore. You've logic your way into that. And so, you know, but that's, that's the start. That's sort of the foundation of it. And then once you don't trust your senses, or you don't trust your common sense, or you don't trust yourself in some way, then we see that there's no place to go when you don't have your senses. There's no place to go but your imagination. Because all the information you can actually gather has to come through the senses. And, you know, if that's gone, you know, possibility, possibility, possibility, possibility, flooded with possibility, immersed in possibility, and then having these very real imagined experiences in the imagination and then also just, you know, not knowing yourself, not not collecting real information about yourself leads to all sorts of things. That third element of inferential confusion, all sorts of things being applied to yourself. Oh, you know that thing I read on the Internet about that guy that killed his whole family? What if I'm that person, you know, because I don't ever collect information about myself anymore, I don't trust it. And now I'm prone to this sort of reasoning. So it's all a bunch of reasoning errors, you could say, that have gone awry and led to the obsession.
- [48:28]
A
I love that. Yeah. And inferential confusion is the vehicle to how we Conclude, make these inferences. And if we can reduce inferential confusion, then we can again more easily stay in our normal reasoning process in our peanut butter and jelly process. Any of my clients that might be listening will know I describe inferential confusion as like the TAMU version of reasoning. It looks just like the real thing. It functions using the logic and the credibility that our normal reasoning does, but it's applied to these fake ingredients that you can't necessarily trust. You're like, why is this a fourth of the price? Are these things the same? They're not the same. They're not the same, but they look the same, they feel the same, right? And so when inferential confusion is flaring, when it's really loud, we're like, well, I gotta take this seriously. Cause I, to me it's just as black and white as making peanut butter and jelly. Right? And so part of inferential confusion, part of the whole treatment, actually a huge part of the treatment is really understanding how to really reduce that, how we're logicing into the doubt and how to reduce inferential confusion. So to that end, when we look at OCD versus just anxiety, because they can look very, very similar. Another question I'll get, can I use ICBT for anxiety then? Because, you know, I think like that maybe that could be helpful. Can I use that kind of treatment approach to resolve my generalized anxiety?
- [50:07]
B
Yeah. So with icbt, we're gonna be looking at how someone with OCD has gotten locked into a possibility that has no sensory information that prompted it, that that was direct evidence. With generalized anxiety, we're gonna see some actual reality based aspect to the concern and we're just gonna see an exaggerated response. And so depending I'd say with someone who's having an exaggerated response to a real trigger like a test or a health concern or something that's really going on in their life. I think there's still utility to using icbt, but it's really more focused on the idea of someone who's getting absorbed in specific possibilities over and over again because of a story, because of an OCD story, because of OCD reasoning. But you know, what we'll, what we'll find though is even with someone with generalized anxiety, some of those same traits, we're going to see that that person might have a fe self, we're going to see that that person might tend to have the same exaggerated anxiety in very specific areas in life. And so, you know, we can also unpack what's going on mentally and cognitively with someone who's just having generalized anxiety with just some awareness that, yeah, you know, like you do have a real health problem, for example, you know, you do have this ongoing thing in your life that's really causing a lot of anxiety. It might even be if it's trauma related, you had this real trauma. We're always just acknowledging reality a little bit more when it's generalized anxiety, but also noting that it's still also a place where we don't have direct evidence that right now you need to be absorbed in this possibility.
- [51:52]
A
Yeah, really good points. And it's important to say anytime we're treating OCD and say it co travels with something like trauma, we separate out the trauma and we treat trauma differently than we treat the ocd. And so even if we're thinking about inferential confusion, which OCD is very opportunistic, so it can really dive in after that trauma trigger and cause some inferential confusion. But we're going to also be very intentional about treating that trauma with an evidence based trauma therapy. And if you're not trained in that, then you refer to somebody who is and partner with them because it's really important to recognize those things. But yeah, you know, as you were talking, I thought in your definition of generalized anxiety and there's some kind of real basis for the understanding. I think sometimes this can get a little muddy for people when they think about real event OCD as well. Because you could go, maybe the real event is you do have cancer or you do have a congenital heart condition or whatever the thing is. And so you're worried about that. But also, again, you have this blend of inferential confusion diving in. Can you kind of explain what we do or how we would think about that and help the client?
- [53:07]
B
Absolutely. Yeah. So good timing. I actually just did a video on real event ocd, so I'm prepared fully for this.
- [53:13]
A
Okay.
- [53:14]
B
Okay, so a little bit of a hot take here. I actually don't consider real event OCD to be a subtype necessarily, because when we're looking at the different subtypes, and this has been my approach since taking on more of an ICBT approach, we're looking at subtypes that are differentiated by dap. And so, you know, someone with negligence OCD is doubting their competency in some area, someone with scrupulosity, their moral ocd, their goodness in some area, if we just say real event ocd, we don't know what that person is doubting at all. And so what we'll find is that someone who's struggling with a real event has some kind of other subtype. That's really the foundation of that concern. And what happened with the real event is it came along and it seemed to confirm that doubt. You know, whatever that other doubt was that they had. This real event seems to be the evidence that the doubt is true. And so I tend to conceptualize it as, you know, with ocd, you are basically living with a feared possible self. You're living with this awful OCD story that something bad's going to happen, and then what happens is the real event occurs and it's blown up in the mind to be like, the end all. Be all of proof that your feared possible self is true, that the doubt is true, and your life is, like, ruined now. And so I actually think of it as when you're creating your narrative, this becomes kind of almost like the end to the story. Because if you talk to a lot of people with real event ocd, they're like the most hopeless version of ocd. They just feel defeated. They feel like, I'm not even fighting ocd, I just know this now. And they're kind of walking around in that state. And so we really need to say, well, let's put this event in a totally different context than the way you are putting it, because you just dropped it into your OCD story. And your fear of possible self is sort of the conclusion to your story. And that's not how this works at all. Like, that fear of possible self you were walking around with and that doubt, that was never actually reality based in the first place. So we want to resolve all that stuff, and then we want to look at this event and recognize this is not an end. Right? This is just an event in your life. This is something to learn from, to grow from, to figure out how to deal with in some way. And so that's kind of, you know, my take on that situation.
- [55:44]
A
Yeah, it kind of reminds me a parallel of when someone has a physiological response, whether it's a granule response or some kind of bodily sensation, where they're like, oh, my gosh, that's evidence. And so that's. That's a response to the story. Right? And you can have real events that. That really add in that credibility that, oh, my gosh, if this was true, I am so screwed. But it's different. It is different than really concluding a doubt right now. You've been told, say it's a terminal diagnosis you've been told, or somebody you love has a terminal Diagnosis that flat out sucks, no matter which way you slice it. But if you think, and maybe I'm responsible because I missed that, maybe there was somehow you could have superseded the genes and all the different things that came together that ultimately created this diagnosis, maybe it was a failure of you to notice or the one time you didn't put on sunscreen or whatever the thing is. Right.
- [56:51]
B
Yeah.
- [56:51]
A
And so in terms of thinking differently, it's not that you can't have distress. Absolutely. I mean, I don't. I think there's a problem if someone is dealing with a real event that is difficult and they're not feeling some kind of distress. But that distress gets coded as, see this. This shit is evidence. This is. This is going down. Yeah, yeah, Good. Good distinction. So I have my last question here. The difference between the feared possible self and you've mentioned the feared self a couple times here, and the core fear. Cause that one comes up a lot.
- [57:28]
B
I mean, the. The feared self core fear thing is the idea would just be that with. With icbt, we are trying to identify the initial doubt where you make contact with your imagination. And so let's say we've got a new monitor, changing diapers, and she's having thoughts like, what if there's something on my hands and I get my baby sick? Or something like that. What we'd see with a core fear is, is there's kind of a focus on, like, what the person is voicing as their scary situation. And in icbt, we call that the consequence. So, you know, it might be, I'm scared I'm going to get my baby sick. But what we may find with that person is the very initial doubt is, what if my hands are dirty? You know, this person is washing their hands, and then after they wash their hands, they're still thinking, what if my hands are dirty? There's just this lack of trust in reality and lack of trust in the senses. And then, you know, then eventually I think, well, if my hands are dirty, then I'm gonna get my baby sick and then we're gonna be in the hospital and I'll feel guilty. And there's a whole, you know, there's a whole, like, thought process that happens after that. We actually want to just resolve, like, what if you just walked around like, your hands aren't dirty? Because that's what other people are doing, right? Just assume they're not. You know, especially after you wash your hands. Assume you washed your hands well enough. Don't doubt, don't question, don't go into the invisible things, then we don't have to worry about your baby being sick. You know, that's. That's downstream. And so with the feared self, we're looking at, what kind of person worries that they're going to be careless enough to not wash their hands well enough that they're going to get someone sick?
- [59:09]
A
Yes.
- [59:09]
B
That's kind of where we're really getting to core issues here that are happening with the reasoning as early as possible in that sequence.
- [59:19]
A
Yeah, I like that. And in case you couldn't tell, Mike, I think in analogies, for better or
- [59:24]
B
worse, I appreciate that.
- [59:26]
A
Endless numbers of analogies in my head. And one I've been discussing. Have you ever read or watched the lion, the Witch and the Wardrobe?
- [59:36]
B
Let me see. I'm going to guess it was third grade, reading it aloud in class.
- [59:40]
A
Probably. Probably. For long story short, folks, there is a wardrobe, and it's a portal into Narnia, okay? So what I will say is, when I think of the core fear, it's like that biggest, baddest, scary thing that could happen in Narnia, right? And Narnia is a magical, imaginative place. And, yeah, a lot of shit can go down in Narnia, okay? But when we think about the feared self and we think about coming to a conclusion, we have to realize, like, at some point, I opened the door to a wardrobe in the here now, and I went into my imagination. I ended up in Narnia. And so if I never go into Narnia, if I go, oh, I'm at the wardrobe, I'm gonna stay here. I'm gonna stay here because I got a birthday party later and I'm gonna see this new movie, which I haven't done in years. So that's funny that I bring that up. But, you know, I get plans or whatever, and I like reality. It's not fun in Narnia. I get really panicked in Narnia. Then we're learning how to not cross into that threshold. And so if we learn how we're logicing ourself in, then we can go, nope, you know what? Miss me with that. I'm just gonna stay here. I'm just gonna stay in here now. I'm just gonna stay in the present, and I'm not gonna worry about that. So that's one analogy I use. The other one I use is thinking about the feared possible self is just kind of the mother of all. Instead of dragons, we're the mother of all doubts, right? And so if we see all the little things kind of happening and the ways OCD is popping up for us, it's the overall theme. So my analogy here is think of, like, a TV show or a series. Okay, I'm just going to use Schitt's Creek because I have that one fresh in my mind. A client brought it up, and I was like, hey, I'm here for it. I love Schitt's Creek. Overall, the series is Schitt's Creek, but if I go to an episode or even, like, a relationship dynamic or even a season, those could be different stories being told. Okay, so which one's Schitt's Creek? Oh, it's all Schitt's Creek because it all fits in the universal production concept of. Of the theme of the show. And it doesn't mean that this dynamic between these two characters is any less Schitt's Creek than this one over here. It's all part of the same arc. And so our feared self is if I could be an irresponsible person or if I could be inattentive and I could be immoral, then all these different scenarios can come up over the course of my seasons, my episodes, and ultimately my show. Right. So feared possible self is this idea that you might. Could possibly be this type of person versus that core fear really being like, what would the ultimate end all? Like, ooh, I couldn't deal if it came true from this scenario. And it's that base fear that in exposure and response prevention, we want to target. We want to target that core fear when we're doing that behavioral approach to help the brain learn a different response. And so those are some of the examples. They're very different examples. Narnia and Schitt's Creek. But, hey, I, like, helps my brain.
- [62:57]
B
That's great. Yeah, yeah, yeah. I think. I think that's. Yeah. Such a good point. You know, the feared self is going to connect a lot of things that seem really different from one another. You know, the. The idea that I'm going to miss something, you know, that's my feared self. I'm unobservant in some way, is going to connect things. Like, you know, what if my supervisor's mad at me? And I didn't notice in our last meeting that I said something wrong, and she's really upset, and she's thinking about how much she doesn't like me right now. And it could also be why I also worry about not having washed the towels well enough later in the day. And, you know, so. So many different things, you know, it could be, could lead to a relationship OCD issue of what if I. I'm not noticing that my. My partner doesn't love me or something like that, you know. So we're looking at something that really connects what seem a lot of different fears and doubts, right?
- [63:48]
A
Yes, exactly. Hey, real talk, if you've made it this far into the pod, chances are you love learning about ocd, so why not take it up a notch, head over to ocdfamilypodcast.com courses to browse the OCD Training School's incredible lineup. And when you use my special link, you're not just investing in great education, you're also supporting this podcast at the zero extra costs with courses ranging from self help to continuing education for clinicians, offering live and on demand options to fit your needs or your time zone. The opportunities are vast. OCD training school has your back. And when you use my link you have the fam spec too. So go check it out@ocdfamilypodcast.com courses. And now back to the show. Okay, so we've covered a lot of really good Q and A and now we are going to switch gears a little bit and we're going to leave lean in to chat GPT to come up with a case vignette and we're going to think about it from an ICBT lens, from an ICBT framework and just think about some different considerations we might have for such a case. So what I'm going to do is I'm going to share my screen. Alrighty. So that you can see this and then we're going to like mad lib style, type in maybe a certain theme. What do you think? What theme should we go for? A theme that gets tricky.
- [65:20]
B
Do you think ChatGPT could come up with Harm OCD?
- [65:24]
A
Yeah, it'll probably be like, I can't go into explicits, but it could create an emotional story about it. We'll see. We'll help and guide and direct it. Okay, Chat create a vignette of a person of any age, socio economic status, orientation, whatever, and they have ocd. They struggle with harm based themes. Are they in treatment or not? What do you think, Mike? Let's say not, not in treatment because
- [66:00]
B
oftentimes you're just, you know, struggling by yourself.
- [66:03]
A
Right, That's a good point. Let's make it five sentences or less. A real basic one.
- [66:10]
B
Okay.
- [66:11]
A
All right, let's see what it came up with. Oh, Evan. Oh. Oh, very. They're. They. I don't know, they're Doing some long sentences there.
- [66:23]
B
This is interesting.
- [66:24]
A
Yes. Have you ever. Yeah, this is how I use ChatGPT. I use it for vignette examples, things like that, but. Yeah, yeah, yeah. Okay, so we have our vignette. So this is the, the prompt I gave CHAT GPT for anyone listening. It's creative in yet of a person of any age, socio economic status, orientation and they have ocd, they struggle with harm based themes, they're not in treatment and they're gonna make it in five sentences or less. Now here is what chat came up with. So Evan is a 32 year old paramedic who lives alone in a modest apartment and is known by co workers for being calm under pressure. What no one knows is that every night he hides every kitchen knife under lock and key, terrified he might lose control and hurt someone in his sleep. He replays memories of the day over and over, desperately scanning for proof that he didn't accidentally harm a patient or say something that could cause a tragedy. He avoids spending time with his nieces now, afraid being alone with them might prove he's dangerous. He doesn't realize this is ocd. He just believes he's protecting the world from himself. That is a damn good vignette.
- [67:42]
B
It sure is.
- [67:44]
A
It is. Okay, so Mike, Evan, what are we gonna do for. Dear Evan, good morning.
- [67:51]
B
Well, first of all, I want to point out ICBT can be a process in the beginning, you know, and so any therapist that wants to do icbt, any client that wants to do icbt, keep in mind, there's a lot of unraveling. Sometimes, sometimes a client may not be aware of all the thoughts they're having and the full scope of the ocd. And the therapist might be trying to learn ICBT in the beginning. So that's nothing to be scared of. You know, with time everything gets figured out and identified. But you know, what I'm looking at right now with Evan to start is what is the doubt? So we really would introduce the person to the idea of a doubt. This what if or this maybe or this could be idea that oftentimes like numerous different doubts getting explored and we just kind of write down as many as possible. And so we'd want to look at all these different, what are those doubts happening at work, in meetings, when talking to someone in the hallway, when sitting in your office alone, and then when you come home, what are the what ifs when you're near the. You know, oftentimes these can go really out there. Like could this behavior have been, you know, harming Someone, it's not just going to be these knives. We're going to see all the different ways that this person might be thinking they're harming someone, harming a partner or children or co workers, and just write those out as much as possible. And then once we get a good list, we're trying to then narrow it down to a primary doubt. And the primary doubt's gonna be the main sensory issue. You know, the aspect of the five senses or the common sense or. Or the self in some way that this person has brought into question. Just to throw out an idea here, with a vignette like this, you can never be completely sure about what's going on in someone's mind. But we could take a good guess that this person is probably doubting that there's some sort of potential inside of them to hurt someone else. We don't know exactly how they're coming to that conclusion. It could be like one of the sentences says here that they're going to lose control. They don't want it to happen, but they actually may have a potential to lose control inside of them and do something they don't want to do that would be against them. The person might also just think that there's a bad kind of side of themselves, an immoral or violent part of themselves they're keeping in check. You know, maybe they read some Freudian theory and heard that there's this hidden dark self inside of you or something, and they've really misread that and think, oh, you could be secretly a serial killer or something like that. But we're just going to look at what is the doubt here to really hone in on what needs to be resolved for this person. Because once we notice this person thinks that they could lose control, there's the possibility, there's the doubt that we want to help them resolve. Yeah, yeah.
- [70:41]
A
So we really would want to slow down that process, learn about how that doubt appears in many different scenarios, whether it's when he gets home and has the lock up the knives. Why is that? When he is scanning, it talks about scanning for evidence that maybe he did or didn't. Actually, it says didn't, which is an important distinction.
- [71:05]
B
Yeah, yeah.
- [71:05]
A
But it can be did or didn't. When people are scanning, they're looking for proof or. Or more things to draw in the relevancy that maybe they could be this feared possible version of themselves. And so, yeah, yeah, if Evan was coming in to work, first of all, he doesn't think this is ocd. So if we're like, it's O C D. He's gonna have to really understand the psychoeducation of how OCD is functioning from that I. CBT perspective. And then secondly, it really is going to be that slowing down. Because I bet the second Evan wakes up, if not in his dreams, Evan is already in Narnia. He's already concluded that he might be this really dangerous person. And so we have to really slow down and go, what happened? Well, I was conscious. I was awake. Okay, and what happened when you were awake? Well, I had this idea. What if that a patient I helped in the ambulance yesterday was actually hurt because I hurt him. What if I did that? Okay, and what would it mean if you did do that? Well, that'd be the worst idea. I don't know how I could live with myself. Or, you know, it could look a lot of different ways and we would just map that out. We would go through those different sequences. We'd start to understand the different doubts that poor Evan is being plagued with. But yeah, there has to be some kind of buy into that. This might be OCD to get him probably in the therapy office in the first place.
- [72:35]
B
Yeah, absolutely. Yeah. And. And yeah, so we're seeing a lot of doubts like, what if I'm going to hurt someone? What if I'm, you know, capable of that? And then the feared possible self, you know, it sounds like it might be I'm just capable of losing control. That's going to happen to me at some point. And when I finally lose control, it's going to be really, really bad. You know, so there's this kind of almost like a movie plot hanging over this person's head of the bad things gonna happen anytime you can feel the dread, you know, and this is what this person's gonna be feeling like on a daily basis, that they're living with that feared self about themselves and it's just a matter of time before I actually just do something. And then of course, there's all these consequences of being found out as a crazy person, ending up in jail and. And all kinds of stuff like that. So, you know, that's. Yeah, those are the kind of starting points with icbt.
- [73:26]
A
Yeah. If we could have him have another off the wall doubt, we could expand a snapshot in treatment, maybe look at feared self or real self. What do you think?
- [73:37]
B
Yeah, sometimes it really helps to have someone look at another theme. So we often can start out that way instead of diving right into their specific situation just so they can do that. Learning that you mentioned so much of therapy is about learning, learning how do I function, where am I having the dysfunction and how can I function better? And part of that learning is looking at how I'm not doing this thought process in other areas in life. You know, if I, if the therapist brings up a contamination example, I can see like, ah, that I, I don't worry about that at all. Even though that's, you know, possible also. And so I can start to see that I'm fully capable of living this way because I do it in all these other areas. One thing I did want to mention with this specific one is we do notice that evidence that we want to reconnect this person with and trust. And we do see that other people see him as, you know, someone who's calm under pressure. And we would of course find that he has never done anything awful to anyone ever before. And we want to say this is all information to trust. And when we do look into the reasoning, we're really trying to figure out why this person doesn't trust this information. That's the really cool thing about ICBT that I don't think you get with other treatments is why is this person like, have no history of attacking anyone and people all see him as calm and this is basically what reality is. Why has this person confused, completely decided to not trust this information? And then they're going to have, they're going to come, come out with all the reasons why they think that information that's available is insufficient, untrustworthy, lacking in some way. And then we really have something to work with. Yeah.
- [75:26]
A
So let's update Evan's profile a little bit on that then. So Evan. Let's say Evan has been in treatment for maybe two months now and is learning icbt. Tell us why Evan doesn't trust himself. Also bring in a how about a DP Dr. Theme.
- [75:56]
B
Sure.
- [75:57]
A
DPDR theme might blend into that not trusting self pretty well.
- [76:05]
B
Five listening. That's depersonalization. Derealization.
- [76:10]
A
Yeah. Five sentences or less which you were sharing about your lived experience within your own social anxiety. So nice little full circle moment.
- [76:19]
B
Yes.
- [76:20]
A
Okay. All right, so here's what we have for Evan. After two months of doing ICBT treatment, Evan is starting to understand that his fear isn't really about knives or losing control. It's about not trusting his own mind. Years of intrusive harm thoughts convinced him he had a dark side. Hey, you called it Freud. Okay? And he began to believe that even a passing thought meant he was capable of acting on it. When Depersonalization and derealization hit those surreal moments when he feels detached from his body or like the world isn't real. He becomes even more afraid that he might snap and do something terrible. His compulsions were never about safety. They were attempts to outrun self doubt. Therapy is helping him see that fear isn't danger and thoughts aren't actions. Okay, so it kind of has a mixture so far. It did some of the work for us a little bit there, Mike.
- [77:14]
B
Yeah.
- [77:14]
A
But what do you think. What do you think on where Evan's at right now? And what would you want to explore more on, especially within those themes of his reality sensing and his distrust of his self and senses?
- [77:28]
B
Sure. So we definitely would want to just provide some education on depersonalization and derealization as normal symptoms of more intense anxiety and help them realize those are not dangerous situations. And we really want to set it as our goal to help Evan from not going into the OCD bubble. You know, that's. That's really our goal because when he's in the bubble, he's. The anxiety is going to be very high. Derealization is going to be happening. He's going to be disconnected from the reality of his senses. It's going to be very hard to work on reasoning when he's in that place. And so as much as possible, we want to calm down Evan's anxiety and get him to be able to reason. And, you know, oftentimes that will be talking about someone different than himself, talking about different themes, and then gradually working on trusting himself, realizing that there is not, you know, a dark side to the self, that the knowing the self is. Is honestly a pretty shallow process. More shallow than someone with OCD thinks it is. It really is about how did you spend your day? You know, what do you actually want and not want, and what are your values? And, you know, what do you think about, like, how you should treat your co workers and your loved ones? Like, yeah, let's unravel. Let's bring the real self back to light. So we have an alternative to the OCD self that is taking up all the real estate in your mind right now. We got to reconnect with who you really are. And the more information we pull in there, the bigger the real self story becomes. And then we got some traction.
- [79:09]
A
Yeah. And, you know, the real self. So, for example, if we said to chat, share three things Evan did between waking up and going to work. So, okay, they're like.
- [79:21]
B
They're nuance again, give us compulsions.
- [79:24]
A
Yes. So he stood in front of the bathroom mirror for several minutes, checking his eyes to make sure he felt real. He was trying to shake off a wave of dpdr Again, that's abbreviation for depersonalization. Derealization. Before brushing his teeth, he texted his sister to confirm his nieces were okay. A reassurance habit. And then he also locked the kitchen drawer of the knives twice. You know, did all this different stuff.
- [79:49]
B
I was just gonna say that these are compulsions, but oftentimes in compulsions, we see the real self.
- [79:55]
A
Yeah, I think we can distill it down for real self stuff. So if you're like, who gets up for work and takes their job seriously? Right? Like, what kind of person does that? What does it say about you that even in the midst of all this kind of hell on earth that you're living, you are living in Narnia in real time? You're still like, I'm gonna show up and do my job. What kind of person does that? I think we could see some real self attributes of, well, you know, I'm responsible. Yeah, you are. Okay, what else? You know, every dentist is going to smile somewhere happy to know that in the midst of this distress, you're still brushing your teeth. What kind of person takes the time to do those different oral hygiene habits and really take care of themselves and get ready for a day? Right? Who. Who texts their sister and even cares if their nieces are okay? Because, yes, we can see the compulsion side of it, but the reality is you really care about your family. What kind of people really care about their family? And so being able to see real self, we can just break down the minutiae. Even if compulsions are, like, leaking out of a person, which we know from our warriors that sometimes that's just the way it is. Right? But we still see the real self trying desperately. Like, Evan doesn't want to have hurt someone. This is a very ego dystonic feeling. This is very unwanted and not in line with his values to be hurting people. Okay, so that tells us a whole lot more about Evan than OCD ever could.
- [81:24]
B
Yeah. And if we can get him back to that place of just living and making decisions and reasoning based on the real self, he will not be in that bubble anymore. He won't be going in there. And as. As we've emphasized, not logic ing his way into ocd, I wake up and I notice little pull the doubt, I ignore it. I go on with my day. I think about my real self. I function as if I'm a responsible person. Someone people can count on, someone who maintains control over his actions. And that's what I'm gonna base all my reasoning on now.
- [81:59]
A
Yes. Excellent. Okay, so that was fun, and I feel like I could do that all day, but I know that we have things to do, and so any last things you would want to share? Before we say goodbye to the fam,
- [82:12]
B
I just want to say thank you for bringing up the vignette that's really cool to show people in real time what we're doing and how we're approaching it and how that might be different from other approaches. And. Yeah, I just, you know. Yeah. Check out my YouTube channel. My goal, really is to proliferate the treatment and to make it easier for people because there's a little bit of a reputation that it's difficult to learn. And, you know, some of that is warranted because it is very different when you're entrenched in CBT and erp. It's a whole new way of looking at things. And of course, just with the name, we're. We're already up against difficulty. It sounds really complicated.
- [82:50]
A
Yeah. Yeah.
- [82:51]
B
But I really want to just emphasize that once you get the basics, it's really not that complicated, and you can learn it just like all the other approaches out there. It's just about looking at things from a different angle.
- [83:03]
A
Yeah. Well said. Well said. Well, thanks again for coming and hanging out with the fam, Mike. This was really cool. And as we were saying right before we started recording, we've seen each other around our practitioner spaces for a hot minute now, so it's nice to have an actual sit down with you and be able to talk about the amazing strength and the amazing resource of our OCD warriors and their loved ones. And so thank you. Thanks for taking the time. Check out his YouTube channel, everybody. Again, linked over on this episode's blog. And thank you again.
- [83:37]
B
Thank you so much, Nicole. This was a pleasure.
- [83:40]
A
Intrusive thoughts. All right. I don't know about you, but I found that conversation to be so helpful, not only because Mike helped us to break down some of those more common questions when it comes to icbt, but also using that vignette to practically apply them to give us those snapshots of what it may look like in treatment. Oh, so good. So another big thanks to Mike for his time, his attention, and his patience. But most of all, Mike, we thank you for sharing your skills with the FAM and with our broader OCD community. We are lucky to have you. All right, and that brings us FAM to the intrusive thought segment, which for Newer family joining us is my application segment of the show. It's that part of the show where I encourage us all to take a nugget or two from what we learned together and to put it into practice this week. Because hearing helpful dialogue is one thing, but knowing how we can apply this stuff makes such a difference. So for today's practice, we are going to revisit this concept of reality sensing as well as the role emotions or feelings play in it. So if you'll recall, Mike talked about what reality sensing exercises might look like in session. I believe one of the examples he used was a person experiencing that not just right feeling, really just being an example of anxiety and how this yields an opportunity to provide some of that psychoeducation about anxiety as well as validating the. You know what, that really we get why you feel anxious in response to that OCD story. And when we think about the OCD story, a common example that my colleagues and I use in treatment is it's like hitting up a scary movie or binge watching a psychological thriller on your favorite streaming platform. I mean, do you ever get nervous or freaked out? Maybe feel your heart start to race or have the sweat factor increase? Why does this happen? Fam because in reality, we know that we're not in the thriller, living the thriller. And even more so, we know writers and crews and actors and clever editing is the magic behind the jump scares and the intensity. But we still react because we get pulled into the story and then we get spooked and then we react again. But as Mike and I discussed, OCD loves to try and use the presence of that emotion as factual evidence for it. Its case. Feelings are not evidence of the doubt being true. Let me say that again because if anything else, it bears repeating. Feelings are not evidence of the doubt being true. Feelings are evidence of feelings, period. So you may be feeling anxious. Yeah. Or scared. Yeah. Or horrified. Yeah. But let's not fuse emotion with truth. Fam. So this week, if and when distress shows up, whether you're an OCD warrior, a supportive loved one or practitioner, I encourage you to try asking yourself the following question. Is this feeling evidence of blank or is it evidence of a story that feels really emotionally powerful to me? So for example, for the person that Moses into their kitchen or hey, avoids it altogether because of that fear of contamination from the invisible bacteria or virus, we are going to pinpoint what the feeling is and ask, is this feeling evidence of danger or is it evidence of A story about a possible hidden contaminant. That feels really powerful to me. Make sense? Okay, let's practice a few more examples just in case. We'll mix it up a bit. So for the example of a person with. With dpdr, that depersonalization and derealization, just like our client Evan was able to identify, it wasn't so much a harm or danger issue, though on the surface it very much appeared that way. But when we looked at how the doubt was functioning and what it really meant for Evan, he really worried that he was this dark person or that he might suddenly lose his ability, his agency, to control his actions. So if Evan were a real person practicing this exercise, it might look something like this. Is this feeling of not feeling just right evidence that I could snap or lose control at any moment? Or is it evidence of how distressing this story is and why that understandably made me anxious? Just like when I watched the Handmaids 2. If you know, you know. Now, do you notice a theme here? Famous. I'll give you a hint. Many times when we're filling in that blank, we're just filling in that doubt, if not the mother of all doubts, that feared possible self. So for my last example, I'm going to use one of my own. So my feared possible self, or FPS, as the cool kids say. Because hey, we don't have enough acronyms yet, am I right? I joke, but my FPS often centers around neglect. What if I neglected something, whether it was something I needed to do or think, or a way I needed to intervene that might possibly could lead to a dire, unwanted or distressing outcome? So if I take that FPS and I apply it in our practice for this week might go something like this. Is my worry evidence that I didn't lock the door when wrapping up the day and getting ready for bed? Or is my worry evidence of the story that an unlocked door could lead to a break in, which could lead to some unknown potential harm for me or my family, which all could have possibly been stopped by me. Because, you know, these bad guys, they don't know what to do with a locked door. They're like, oh, locked. I guess this isn't our hit. Is it that? Is it my reaction to that story? Because that story is really emotionally powerful for me. It's catered to all the things I loved and value the most. My family, our lives. Ah, yes, that one. Yeah. 10 out of 10. That story sucks. And it makes me anxious. AF and it's gonna get me every time that I get pulled into it. You know what I mean? It gets me in the feels. But the feels aren't factual evidence. They aren't lie detectors. They're not truth tellers. They're simply evidence of a powerful story activating a powerful feeling. They're evidence that we're human. And this recognition, although just a little pivot in how we're applying our reasoning, definitely helps to loosen OCD scripts. So fam, Happy practicing this week. If you try this exercise and find it works well or frankly, not at all, girlfriend, I'd love to hear about it. You can tag me on social comments DM for the DL if you know what I mean, or even shoot me an email. But I have a good feeling about this one, which is evidence of what fam? I believe it's evidence of the power of our hope. Now that's my kind of story. Thank you for joining me and our OCD Family Community. If you enjoyed what you heard today, please like and subscribe to the OCD Family Podcast wherever you enjoy your podcasts. Did you find this content helpful? Please consider leaving a review. The more people that know they're not alone, the better. For more information regarding today's podcast, please visit OCD family podcast.com and remember to join the email list while you're there. It will provide you with the most up to date information, resources and the download on the family chatter. Oh yeah, nothing says family like Mike Parker and me talking all about icbt. That's right, I went there and you can too. At OCD Family Podcast.com Therapists ready to shape the future of Pediatric OCD treatment Join the Next Steps in Pediatric OCD On Demand course from Angela Adamson Springer LCSW and learn how to adapt Inference based Cognitive Behavioral therapy for kids. 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