Dr Jon Abramowitz: Living well with OCD (#483)

Summary

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The OCD Stories, Episode #483

Guest: Dr. Jon Abramowitz
Host: Stuart Ralph
Title: Living well with OCD
Date: April 27, 2025

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Overview

In this episode, Stuart Ralph welcomes back Dr. Jon Abramowitz, a prominent clinical psychologist and professor specializing in OCD. The conversation centers on Dr. Abramowitz’s latest book, "Living Well with OCD: Practical Strategies for Improving Your Daily Life," which targets those living with unresolved OCD symptoms, those not yet ready for therapy, and those seeking ways to integrate OCD management into daily life. Alongside the book discussion, Dr. Abramowitz shares new research on postpartum OCD, delves into various cognitive-behavioral and acceptance-based strategies, and offers words of hope for listeners at all stages of their journey.

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Key Discussion Points & Insights

1. Postpartum OCD Research

[02:12]

• Dr. Abramowitz discusses a recent five-year longitudinal study (in collaboration with Johns Hopkins) following approximately 250 women from mid-pregnancy to six months postpartum.
  • The study assessed OCD symptoms and various risk factors (cognitive, biological, socioeconomic, relationship, mood).
  • Early findings: Women with tendencies to misinterpret intrusive thoughts as significant were more likely to develop postpartum OCD.
  • Prior prevention programs found that cognitive-behavioral interventions aimed at correcting these thought misinterpretations reduced OCD symptoms post-childbirth.

“People who tend to believe that those thoughts are important, they're more likely to develop OCD symptoms. People who are able to see those thoughts for what they are... you're less likely to develop OCD.”
— Dr. Abramowitz [06:31]

• Intrusive thoughts in new parents (e.g., concerning accidental harm to the baby) are extremely common and not predictive of intent or action.

“[The nurse] said if you have intrusive thoughts about harming the baby, then you're in trouble... I stood up and I kind of shut her down. Like, no, that is not true at all... Everybody thinks that way.”
— Dr. Abramowitz [08:15]

2. Motivation Behind "Living Well with OCD"

[11:47]

• The book is aimed at people who:
  • Aren’t ready for ERP (Exposure and Response Prevention),
  • Have residual symptoms despite treatment, or
  • Are seeking management strategies outside of traditional therapy.
• Focuses on practical advice for daily living with OCD, such as disclosing OCD at work/school, getting accommodations, and maintaining relationships.
• Not a treatment manual per se, but a "living guide" for life with OCD.

“This book is for folks in each of those three categories... It covers what can I do to manage my symptoms if I'm not ready to do actual treatment... How do I live despite this?”
— Dr. Abramowitz [12:38]

• Dr. Abramowitz reframes "treatment resistance" as therapies sometimes failing the individual, not vice versa.

“People aren't treatment resistant. The treatments can be, you know, can fail individuals with OCD.”
— Dr. Abramowitz [13:55]

3. Acceptance and Commitment Therapy & Other Strategies

[16:24]

• Integrates ACT (Acceptance and Commitment Therapy) techniques and concepts, cognitive therapy, and inference-based CBT, aiming to empower people regardless of their treatment status.

ACT: The Value of Living Well Despite Symptoms

[16:24]

“Even patients that I would say have done really well still from time to time have some OCD symptoms. So how do you manage that? There's no book out there until now about how to do that.”

Urge Surfing

[18:31]

• Technique from ACT, borrowed from addiction literature: Encourage clients to observe and ride out compulsive urges rather than acting on them.
• Describes using the "wave" metaphor—visualizing the urge peaking and then subsiding—to help clients endure the discomfort.

“If I just kind of hang in there and ride it out, for lack of a better term, kind of like you're surfing a wave... eventually it does crest and it does come down.”
— Dr. Abramowitz [18:48]

Competing Responses

[24:33]

• Do something behaviorally incompatible with the compulsion to block the ritual (e.g., put on gloves instead of washing hands, leave the location). Inspired by habit reversal therapies used for behaviors like skin picking and hair pulling.

Self-Monitoring

[23:14]

• Track rituals and behaviors to increase awareness and foster change.
• Supports the adage: “What gets measured, gets managed.”

  “If you want to change your behavior, the best thing you can do is to self-monitor.”
  — Dr. Abramowitz [22:30]

4. Diffusion & Changing Relationship to Thoughts

[29:43]

• Uses diffusion (from ACT) to help clients relate differently to obsessive thoughts—objectifying them, giving them a character, or repeating them aloud to reduce their emotional charge.

“If I can give it some sort of quirky characteristic or a funny accent, then I can see it differently. I'm objectifying it... and all of a sudden, the threatening qualities of it are gone, or at least less and less.”
— Dr. Abramowitz [32:05]

• Metaphors:
  • “Passengers on the bus” — You drive the bus; intrusive thoughts are just backseat drivers you can choose not to obey.
  • “OCD as a con artist” — Understanding the ‘tricks’ makes it less powerful.

5. Self-Compassion & Values

[35:25]

• Stresses self-compassion—OCD is not a person’s fault nor their identity.
• Encourages developing affirmations and clarifying core values.
• Builds resilience and reframes OCD as one facet of a complex self.

“It's one thing to have OCD and beat yourself up about it and lose compassion for yourself. It's another thing to have OCD and respect yourself despite it.”
— Dr. Abramowitz [36:44]

6. Inference-Based CBT (ICBT)

[38:10]

• Describes ICBT as cognitive therapy focused on challenging the flawed logic behind obsessions, comparing these beliefs with external evidence.
• Suggests integrating helpful ICBT elements for those not helped by ERP.
• Argues that all effective OCD therapies share more similarities than differences and should be synthesized for clients’ benefit.

“ACT, ERP, ICBT, cognitive therapy, all of these techniques have more in common than they have differences... we do best for our patients and clients when we take the best out of all the [therapies].”
— Dr. Abramowitz [39:21]

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Quotes & Notable Moments

On the ubiquity of intrusive thoughts:

“Everyone does. Yeah, I'm a dad... What if I push? What if I did something wrong while I was changing her? What if I drown her in the bathtub?”
— Dr. Abramowitz [06:37]

On therapist responsibility:

“People aren't treatment-resistant. The treatments can fail individuals with OCD.”
— Dr. Abramowitz [13:55]

On urge surfing:

“If they're able to see that urge for what it is... and ride it out... it does crest and it does come down.”
— Dr. Abramowitz [18:31]

On diffusion:

“I love the idea of objectifying intrusive thoughts... If I can see those thoughts differently, instead of taking them at face value literally as threats, [they become] less scary.”
— Dr. Abramowitz [30:15]

On living with OCD:

“You can live well in spite of it.”
— Stuart Ralph [45:08]

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Timestamps of Key Segments

• [02:12] – Postpartum OCD research findings and prevention implications
• [11:47] – Why write "Living Well with OCD"? Motivation and audience
• [16:24] – Integrating ACT, ICBT, and practical management approaches
• [18:31] – Urge surfing explanation
• [23:14] – Self-monitoring, behavior tracking, and competing responses
• [29:43] – Diffusion exercises and reimagining obsessive thoughts
• [35:25] – The importance of self-compassion and values clarification
• [38:10] – What is ICBT and how can it be integrated?
• [43:48] – Words of hope for listeners living with OCD

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Words of Hope

“If you're struggling with OCD, there are things that you can do to manage obsessions, compulsions, and that big footprint that OCD leaves... Even if treatment hasn't gotten you to where you want. That's what my book is about.”
— Dr. Abramowitz [43:48]

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Final Thoughts

Dr. Jon Abramowitz offers a compassionate, practical perspective on everyday living with OCD, regardless of one’s stage in treatment. Through anecdotes, actionable strategies, and destigmatizing perspectives, both he and Stuart Ralph assure listeners: intrusive thoughts are universal, management is possible, and living well is achievable—OCD or not.

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Transcript

[A]

You're listening to the OCD Stories podcast hosted by me, Stuart Ralph. The OCD Stories is a podcast dedicated to raising awareness and understanding around obsessive compulsive symptoms. I do this through interviewing inspired therapists, psychologists and people who have experienced OCD. Welcome to the OCD stories and welcome to episode 483 of the podcast. And in this one I chat with Dr. Jonathan Abramowicz. John is a clinical psychologist with a private practice in Chapel Hill, North Carolina specializing in the treatment of obsessive compulsive disorder. He's also professor of Psychology and Neuroscience at the University of North Carolina. He's also authored several books including Getting over ocd, the Family Guide to Getting Over OCD and Living well with ocd. We discuss his latest research on postpartum ocd. His new book, Living well with ocd, Acceptance and Commitment, Therapy, Urge Surfing, Competing Responses, Self Monitoring, Diffusion, Self Compassion, Inference Based cbt, Words of Hope, and much more. OCD can feel overwhelming, but help is closer than you think. NOCD provides expert led evidence based therapy for children and adults affected by OCD with convenient online therapy from licensed specialized therapists and real time support between sessions. No NOCD makes getting the right treatment easier than ever. Start your journey [e-mail] or the link will be in the episode description. So it's great to get John back on. He's been on several times before, always really insightful and I love the way he expresses himself. So great to have him on. I hope you guys enjoy it and thank you to you guys as always for listening. I deeply appreciate it. Without further ado, here is John. Welcome to the podcast John.

[B]

Thanks. Thanks for having me back. It's always a pleasure.

[A]

Yeah, it's been quite a while now, so it's great to finally have you on again. You're obviously always welcome. So I guess just an update with you professionally like what's been going on, what sort of research you've been doing, that sort of stuff.

[B]

Yeah, thanks for asking. We have just finished a five year study on postpartum OCD and we were following it. Ended up being over 200 women, closer to 250 women followed here in Chapel Hill, North Carolina at UNC and also in Baltimore, Maryland at Johns Hopkins. We collaborated with folks at Hopkins and we followed them from about halfway through their pregnancy until six months postpartum and at four stages. We assessed their OCD symptoms, we assessed cognitive factors, we assessed biological factors, we assessed socioeconomic factors, relationship factors, all mood, all sorts of cool stuff and we are right now data crunching and looking at what are the predictors of who develops OCD symptoms, who doesn't. What's one of the protective factors? We know we had some people with OCD in the sample. We know we had some people who developed OCD in the sample who developed OCD symptoms. So the next couple of years will be a lot of cool stuff. Looking at numbers, presenting it at conferences, and writing journal articles and stuff like that. So we're very excited about that. That's the main thing. The main thing. We have other studies going on, but that's the main thing.

[A]

Yeah, that's really interesting. So. So if I'm clear, were these sort of 200, 250 sort of random women, or did you say they all had OCD initially?

[B]

Great question. No, they did not all have ocd. They all had some factors that we believe are risk factors. So, yeah, many years ago, like now, 20 years ago, research that I did when I was still back at Mayo Clinic, we found some risk factors, not surprisingly, the way that people interpret unwanted intrusive thoughts, like, you know, obsessive beliefs. This idea that if I think about something bad, it means I'm going to do something bad, or it means I'm a bad person. The significance of thoughts. We wanted to find women who didn't necessarily have ocd, but they were elevated on that tendency to misinterpret intrusive thoughts. And our main hypothesis, or one of the main hypotheses of the study, was that people who had that risk factor, which we found 20 years ago, but it was a smaller study, that folks who had that risk factor would then be more likely to develop OCD than people who didn't have that risk factor. And so far, the numbers are suggesting that that is accurate, which is really cool to find. But we also looked at other factors as well.

[A]

Wow. Okay. So you sort of found, say, 250 women that you thought could be prone to developing OCD.

[B]

Exactly, yeah. And that has important implications for prevention efforts for postpartum ocd. And again, we did a smaller study, Chiara Tempano and I. Chiara led this study. Again, it was probably like 15 years ago. It did a study on a prevention program for postpartum ocd, she found. And that was, again, a collaborative study. She was at Florida State University at that point in Tallahassee. And we collaborated between Tallahassee and here, and we found. I'm forgetting how many women it was who had these elevated risk factors. Half of them. We gave them a kind of cognitive behavioral intervention meant to reduce the tendency to misinterpret intrusive thoughts. And the other half just got education about mental health in the postpartum. And we found that people who had the education about. I'm sorry, the folks who had the cognitive behavioral intervention aimed at reducing, you know, the tendency to misinterpret intrusive thoughts, sure enough, they had fewer OCD symptoms in the postpartum relative to folks who just got the control condition, which was just learning about mental health.

[A]

Yeah.

[B]

So there is something to this idea that if you have a tendency to misinterpret intrusive thoughts and you get pregnant and you have a baby, and you have intrusive thoughts about your baby, which everyone does. Yeah, I'm a dad, you know, I don't know about you, but yeah, I had intrusive thoughts. You know, what if I push? You know, what if I beat the baby too hard when I'm burping her? What if I, you know, did something wrong while in. Something inappropriate while I was changing her? What if I drown her in the bathtub? People who tend to believe that those thoughts are important, they're more likely to develop OCD symptoms. People who are able to see those thoughts for what they are, they're. They're brain farts. They're basically your mind telling you, like, what you shouldn't do because you're a new parent and it's all, you know, new, and you're responsible and all that. If you see those thoughts for what they are, you're less likely to develop ocd. Yeah. Cool stuff, I think.

[A]

Yeah. Yeah. Really cool. Yeah. And I definitely had those intrusive thoughts when my daughter was born. Yeah. I even started doing little avoidance behaviors. And then I knew what was going on and had to face it, which was erp. And it was uncomfortable and horrible. But then they went. Within a month, you know, they'd stopped. Yeah. Where am I going? It kind of makes that sort of CBT intervention you were mentioning that preemptive one. Makes sense that we should almost give that to all kids, regardless, you know?

[B]

Absolutely. I mean, when. And I would. I'll even make a broader argument. When kids are in middle school, we should be teaching them how to think critically about their own thinking. Right. So just because I think someone is talking about me behind my back doesn't mean that they are. Right. Just because, you know that that's mind reading. Just because I have an unwanted thought and I think this means something bad, doesn't mean that it really does we should be teaching people cognitive therapy skills at a really young age to. That would prevent. You know, the other thing that, that, that. That I found out was so my wife and I were going through, you know, prenatal education, like, you know, several weeks out before having the baby. We would go to these classes. You know, here's what's going to happen during labor, and here's what's going to happen. How do you swaddle the baby? And all these wonderful things that are important for parents to know. And one of the things that the, the. The nurse who was leading the class. And again, my kids are like in their 20s now, so this is a long time ago. One of the things she said was if you have. It's normal to have the baby blues, some depression, but if you have intrusive thoughts about harming the baby, then you're in trouble. You have postpartum psychosis, you're dangerous. You should go to a psychiatrist. And I was doing research. I was at Mayo Clinic at the time. And I stood up and I kind of shut her down. Like, no, that is not true at all. You will all have interests of thoughts, unwanted thoughts about the baby. And I would bet everything that, you know, none of you will ever do anything. You don't want to misinterpret them as significant because they're just. They're. They're not. Everybody thinks that way. And I should. The lady kind of got upset at me, and I showed her the study that we had done showing that, like, 90% of people have these thoughts, and it's certainly not the case that 90% of the people actually harm their babies. And so they made. They actually made a change to their good.

[A]

Yeah.

[B]

To their education program.

[A]

Yeah, she was, she was arguing with the wrong person.

[B]

Yeah.

[A]

Yeah, yeah, yeah. That has changed. Like, you know, when I had my daughter and the. The midwife came round, like, must have been within a few days, and my wife was having intrusive thoughts. I think I've shared this before. I check with her before I put this live, but she was having intrusive thoughts. They were scaring her. Yeah, she was buying into them. Even though I'm saying this is just intrusive thoughts. Like, we don't need to read into this. And. And the midwife came, was just like, yeah, it's just intrusive thoughts. Nothing to worry about. Like, she just shrugged it off and in a nonchalant way, which is the correct thing to do. But it was really great to see her be educated in that Way of, like, we don't need to take this seriously, you know, shows. There has been change. I'm sure that's not the case. And there are some midwives out there that might be scared still, but it's changing.

[B]

Yeah, that's good.

[A]

Yeah. So, really interesting start to the podcast, but we're here to talk about your book, Living well with ocd or your new book. There it is. Anyone with video can see it. It's got a real, like, 70s vibe. The COVID I don't know.

[B]

I love that. I know. I. I didn't. I don't design them. The publisher. Trying to get it to be clear on the screen. The. The publisher, you know, designs that. They kind of tell you. They tell you what it's going to be called. They tell you what the COVID is going to look like. You can. If you really, you know, wanted to stand up to them, I guess you could say, no, that's unacceptable. But I. I like it. Yeah, it's got a good 70s vibe. I'm a child of the 70s, so I was all in on that.

[A]

Nice. Yeah, Looks good. So I guess initially, like, why write this book? What was the motivation?

[B]

Great question. I mean, we've got a really effective treatment. We got a couple of treatments that can be helpful, but they don't work for everybody. And not everyone is at a place where they're ready to engage in the therapy. And even I think that even in the best case scenarios, most people, even if they go through a good course of cognitive behavior therapy, exposure and response prevention, there are still going to be residual symptoms. OCD just has a large footprint. This book is for folks in each of those three categories. When we do ERP with folks, even again, in the best circumstances, we don't address things like, how do you tell other people about ocd? Usually we don't address things like how do you manage OCD symptoms in your job? Relationship stuff? Sometimes it gets brought in, but not always. Then you have folks that are just not at a place where they're ready to do exposure therapy. This book covers all of that. It covers, what can I do to manage my symptoms if I'm not ready to do actual treatment? Medications, Cognitive behavior therapy. What are some things I can do to get by? These are not treatment strategies. They're management. How do I live despite this? How do I talk to other people? Like maybe people I work with or work for, People I'm dating, Teachers, family members. How do I talk with them about having ocd? How do I get accommodations if I'M working or if I'm in school. So lots of suggestions and tips and things like that throughout the book. It's called practical living well with ocd. Practical strategies for improving your daily life. And that's, you know, that's what this is about and that's who it's for.

[A]

Yeah. Okay. So the people that either haven't. Haven't been able to make progress in these therapies or maybe are resistant to it right now or don't want to do it right now.

[B]

Yeah. And I don't like to think of people with OCD being resistant to the therapy. I think of the therapy failing people with OCD when it doesn't work. People aren't treatment resistant. The treatments can be, you know, can, can fail individuals with, with ocd. Yeah, there are just some people who are just whatever reason, they're not ready. Look, doing ERP is challenging. It seems scary. And so, you know, here's, here's some things that you can do while you're kind of deciding. And there is a chapter on the book in the book about, you know, how to think about how to understand the therapy so that maybe you will decide to do treatment. But this is not a treatment book. This is not how to do exposure therapy. There are tons of great resources on how to do that. This is, this is very different from that.

[A]

Yeah, yeah, no, I agree. And obviously you've got a really good book, Getting over ocd, which is a really good treatment self help book. And yeah, so when I said resistant, I didn't mean. Because I don't believe in treatment resistant either. People. I hate when my clients say to me, I'm treatment resistant. I'm like, no, you're not. You just haven't figured it out yet. Or your past therapists haven't figured out yet. Yeah, I meant, when I said resistant, I meant like resistant to start therapy. So they haven't even gone through it yet. Yeah. And resistant might be negative. Hesitant, but yeah. Okay, that's interesting and it's good that you wrote, wrote that book because like you said, there's, there's a lot of good books out there now, yours being one of them. Getting over OCD for helping people. But yeah, maybe there's no books for those that are in those categories.

[B]

There's just not a lot of resources for. I have ocd. I'm not ready to do the hardcore treatment. How do I manage? How do I live with either OCD symptoms that are untreated or the residual OCD symptoms? I think of Myself, I know what I'm doing. I've been doing therapy for a long time with folks with ocd. But I'll be honest and say that not all of my patients are cured. I don't even know what that means for ocd. Everyone still has some unwanted thoughts and some compulsive behaviors and things like that. And even patients that I would say have done really well still from time to time have some OCD symptoms. So how do you manage that? There's no book out there until now about how to do that.

[A]

Yeah. And I think that's where like, acceptance commitment therapy comes in. Right. Of. Yeah, you may still have some symptoms, but that's not really important. What's important is, are you living life the way you want to live it.

[B]

Exactly. And I've incorporated a lot of ACT stuff into this book. A lot of stuff from cognitive therapy, a lot of stuff from inference based therapy, which is a cognitive therapy. These are strategies that don't involve. Don't have to involve doing exposure therapy. And. But they can be useful for how to manage your symptoms.

[A]

Yeah, yeah, I know it's a lot of ACT in the book because obviously I know, you know, many years ago now, right, you. You decided to sort of get more interested in act, or at least in the research sense, and you teamed up with Michael Tuhig and, you know, you did sort of did that really good study, you looking at ACT and ERP combined, which was great. So it's great to see that. I guess the fact that you're still using a lot of it shows that you still buy into it, believe it, and it stood the test of time for you.

[B]

Absolutely. I use ACT a lot. I think that it's really helpful in. And I use it combined with exposure and response prevention. I think ACT is really helpful for getting folks on board with that treatment, helping them to really get the most out of erp. Not everyone likes act and it's not useful for everyone because it involves a lot of abstract thinking. But I tend to use it with a lot of my patients and clients. Along with exposure. I kind of weave it. Kind of weave it together.

[A]

Yeah. It works so well in combination. Right? Yeah. And so, yes. I mean, looking at my notes here, I've jotted down a few things in the book. One is you talk a lot about, like, urge surfing, which is obviously an ACT skill. And I don't know, I just wanted you to talk about that a bit of, like, why you really thought that was important to include that and how that may help Someone.

[B]

So, you know, compulsive urges can come up. Sometimes they're expected, sometimes they're unexpected. And we know that folks with ocd, if they kind of lean into that urge, and instead of just doing the ritual, they kind of are able to look at it a different way. Again, I'm getting all acty. Right. If they're able to see that urge for what it is, this is this desperate, seemingly desperate urge to put something right, to get reassurance, to get rid of some sort of distress. But if I just kind of hang in there and ride it out, for lack of a better term, kind of like you're surfing a wave at the beach, eventually that might kill. Really strong at first, but eventually it does crest and it does come down. And I kind of have borrowed that from the literature on cravings. For folks that are trying to change their eating habits, folks that are trying to stop smoking, folks that are trying to stop using drugs and alcohol, there's a literature on, you know, just kind of give it some time and you can get through that. And, yeah, I think that can be. That can be helpful.

[A]

Yeah, absolutely. And of course, all urges dissipate. And as you ride out the urge, what you've not done then is the compulsion, which you're then rewriting the OCD cycle.

[B]

Yeah. And I think also there's something about just the imagery. Right. That helps. Most folks just don't think about it that way. They're like, oh, I got to do this, otherwise something terrible is going to happen. And if you can change that imagery, then I think you have a chance to ride it out.

[A]

Yeah. So do you get your clients to almost visualize it like a wave, like, I'm at the crest right now and now watching it fall?

[B]

I do. Yeah. I don't use it with everyone, but I think that that's helpful. I found it useful for a lot of folks. They kind of. They're like, oh, yeah, I never thought about it that way, you know?

[A]

Yeah, yeah. And of course. So wherever these. You know, the people that read this book, even if they haven't gone into therapy or they have done and it didn't help them. Yeah. We know that riding the urge or response prevention is helpful for everyone. So anywhere they can use this skill is. I guess that's why you wanted it in there, to keep that in mind.

[B]

For them, of just another strategy that folks can. Can. Can try to use. And, you know, there are. There are tons of strategies in this book, not all of them, but are going to be useful. For everybody. So, you know, folks pick and choose. And if imagining your urge to ritualize as a wave doesn't work for you, fine. You know, there, there are other things that you can do as well.

[A]

Yeah. And what I liked about the exercises as well, you might spend a paragraph or two talking about them and then you moved on to the next exercise, which for someone like me with my attention span, it's helpful to just. I just want the information. I want to practice it right now. I don't want to four pages before I can even because I've lost interest. And then. Yeah, and then I'm not doing the skill. And then it's pointless. So it's.

[B]

Yeah, yeah, these are quick hits. It's like, yeah, you know, here, here are the things that you can do and, and here's why they can be helpful. But I don't spend too much time. And so some of them are like, you know, like, get out your pen and paper and write this stuff down. I tried to minimize that. Most of them are just things that you can, you know, you can just kind of, you know, behave your thinking differently, but again, not to the level of, you know, here's your exposure hierarchy and spend, you know, three hours a day confronting your fears. Or there, there's just nothing like that in there. Other things that folks can do for their compulsions would be like using a competing response. Right. Do do something for a little while that's the exact opposite of, of what the ritual was going to be or modify the ritual, you know, a little bit. So do the ritual, but just change it up. If you have to count to a certain number, count to a different number. Right. Or so a paper and pencil one is actually writing down. Research suggests that if you want to change your behavior, the best thing you can do is to self monitor. Write down the behavior you want to change, keep track of it. That goes for. That's why, you know, in therapy, I have folks write down their, their rituals once they begin therapy. But if you want to change your eating habits, if you want to change, you want to stop smoking, stop drinking, exercise more writing down your behavior just, it just helps you to focus on your behavior in a way that we don't typically do if we don't write it down.

[A]

Yeah, that's interesting. Yeah, it's what gets measured, gets managed. Right. That's.

[B]

Oh, I love that. I'm going to steal that from you.

[A]

Well, it's not mine. I think it's. I think Peter Drucker said it. I think he's like a management guy, and I think. I think that's his quote. Yeah. What gets measured gets managed. I always keep that in mind for everything in my life. Oh, wow.

[B]

That's awesome. I love that.

[A]

Yeah. I cut out sugar about 207 days ago now. Well, I say sugar. It's in everything. You can't cut it out completely. But I cut it out of sweets or candy. I cut it out. Not Chris. Like fizzy drinks. I don't drink soda. You know, all that cakes, dessert, none of that. So. But for me, I have, like, a thing on my app which tells me how many days since I've had that. And so when I have that craving, I can just visualize the day count and I know that it's an urge that will pass, and sure enough, it passes, or I help it pass by. Maybe I'll have a date or something like that. You know, a fruit that takes away the. Yeah, yeah. So I think, yeah, if I didn't have it measured, I would have given in. I need a tracker. I need. So, yeah. And when you say competing responses, can you give just a couple more illustrations to that?

[B]

Yeah. So doing something that would hinder your ability to do the ritual. If you are concerned about, let's say. Well, yeah, if you're checking the doors, right. Go to a different room or go for a walk or something like that. That is incompatible with. With checking. I just get out of the situation. If you are washing your hands, I don't know, put on some gloves or stay out of the bathroom or, you know, that. That's kind of an easy one. Distract yourself. Do a hobby, exercise, do some other enjoyable activity that's incompatible. You know, go play a video game so that you're not checking the. The. The door. Right. Washing your hands or. Or doing a mental ritual or something like that. So just something that. That, you know, for at least a little while until the earth passes you. You know, you can't. You can't do.

[A]

So I imagine. Yeah, that's interesting. I imagine this is obviously really useful then for things like trichotillomania, dermatillomalia, where you want to pick. And if you do something different.

[B]

Yeah, it's part of. So I kind of took that from the habit reversal literature, right. Which is the treatment that we use for skin picking, hair pulling, all that kind of stuff. These kind of habit disorders that sometimes get grouped together with ocd, but I think that they're. They're treated differently than ocd, but we can still use some of those strategies to Help folks living with OCD to kind of get through that, that urge.

[A]

Yeah. It reminds me of like, I've heard before with smoking, like have a sugar free lollipop every time you want a cigarette or vape. Because then it's that action of something in your mouth. You can't put a cigarette in your mouth if you've got same idea.

[B]

Exactly. It's an incompatible behavior. Yeah.

[A]

Yeah. Okay, cool. And that seems like such. I mean, I've realized I do that with my clients. I just never thought about it in the way you've talked about it, which it's interesting to have that framework, but it seems like a really simple thing that everyone listening can do. You know, when that urge is there, do something different.

[B]

Yeah, exactly. Now, if you're doing therapy, exposure and response prevention, we don't like. Distraction isn't necessarily the first thing that we recommend. Right. But you know, I, I would rather someone that I'm working with, if they have this urge to wash their hands, you know, the best thing to do would be to lean in and think about, you know, and do more exposure and kind of think about, oh, they're Germans, maybe crawling on me and not, you know, and go eat something and stuff like that. But you know what though? If they go and play a video game and. And then an hour later they've forgotten all about the urge to wash their hands. Wonderful. We'll take it.

[A]

Yeah. Yeah. Because I, I thought about that because obviously traditionally in the erp, as you say, you wouldn't do that. But, but in day to day life, that's just normal living. You get triggered. You don't just sit there for 40 minutes riding out as you like you may do in therapy. You go live your life and then the urge goes. So that's how, I guess how I bring in, act within ERP in like we might do, dropping anchor during an exposure, which of course is somewhat a distraction. But what I'm actually trying to do is just bring him into the here and now. And sure enough, the suds drops quite quickly, which we could look at, we've distracted them. But. But that's what they do in life anyway.

[B]

That's what they do in life. People sometimes say, you know, oh, I got to do exposure therapy and I just got to sit with the anxiety. Sit with it. Right. And no, no, no, it's not about that. It's. It's about acting with your anxiety, operating with it, proving to yourself that I don't have to be bullied around by my intrusive thoughts, my anxiety, the uncertainty. I can play a game. I can go to school, I can go to work. I can hang out with my friends, I can eat. So, Yeah, I agree 100%.

[A]

Yeah. I think that's where actors had a real positive value on erp. Because I think for some people, that view of ERP is just sitting with it. It's just too hard.

[B]

You don't know how many people, how many patients have said, so what? I just got a confront my fear and just. And just sit there with it. That's what my other therapist told me to do. And maybe that's why that therapy didn't work, because it's not about just sitting there waiting for your suds to go down. In fact, what that can do is actually make it worse because you're sitting there kind of looking at your watch like, how come my anxiety hasn't gone down? As if the only way to have success is if suds goes down. And that's just not true. What's like you were saying, what success is about is being able to act with anxiety, act despite intrusive thoughts and uncertainty. And so, yeah, I don't want folks sitting with anxiety. I want them acting with anxiety. I want. I want them to know I can do whatever anxiety doesn't have to bully me into just sitting around.

[A]

Yeah, yeah, exactly. Oh, yeah, well said. And you've also put in diffusion in the book. So, you know, a few exercise I wrote down here from the book is obviously like, name it. You know, write it down. Say a lot. I think you say, you've got the example, I think about murder in there. And. And you say, well, we'll just say the word murder like 100 times or transform it into an object. What does it look like? What does it have a shape, color, just. Yeah, anything you want to speak, Speak on that.

[B]

I, again, this comes from act. I love the idea of objectifying intrusive thoughts. And I think I've been using this more and more, especially since I kind of really dove into this deeply when I wrote the book, helping people to change their relationship with their thoughts. So let's suppose go back to what we started with, talking about postpartum ocd, and I'm giving my kid a bath, and I have this thought, what if I touch her genitals or something like that? And what if I'm a child molester or something like that? And I can look at that thought, I can look at the text of that. I can focus on what the thought is screaming at me. And, yeah, that's pretty bad. That would be a bad thing if I did it. I'm not supposed to do that. I'm the kid's father. At the same time, I can objectify that thought and I can look at it a different way. I can see it for what it is. Huh? Maybe this is my brain just reminding me of things that I shouldn't do and that I would never want to do because I'm a careful dad, being me. Maybe this is my brain telling me, you know, oh, a person with OCD would be really worried about that. And so just, it's kind of, you know, what your work is all about. So, of course you're going to have those thoughts. If I can see those thoughts differently, instead of taking them at face value literally as threats, if I can see them as, you know, this is just what a brain does of a new parent or to help myself do that, if I can give that thought, like you said, like a personality, right? Like, what kind of work would it do? What does it look like? Does it have a beard? Right? Does it wear glasses? Is it this old crotchety guy from New York City who sits on a park bench and says something like, you better be careful that you don't molest your kid. Right? If I can give it some sort of quirky characteristic or a funny accent, then I can see it differently. I'm objectifying it. I can laugh at it, and all of a sudden, the threatening qualities of it are gone, or at least less and less. And so, you know, again, I recommend folks give that a try. You know, a metaphor from ACT is the one of the passengers on the bus, right? You're driving the bus, and you get these. These passengers that get on the bus, and they start to tell you where you should go, and, oh, you shouldn't go this way, and you shouldn't do that. You should do this instead. And you can listen to the passengers and you can do what they're telling you to do. You better not turn there. You don't want to go there, right? But if you're the one driving the bus, then, you know, you can't let the passengers tell you where to go. You hear them and you're going to say, okay, thanks very much, but, you know, today I'm not taking your advice. I'm going to do what I want to do. And that's, you know, another thing that I want folks to be able to do is to, you know, they're. They're. You can't ignore these thoughts, right? You can't push them away. I mean, you can, but you only think about them more. You don't want to do that. You got to make room for them. But you can make room for them in a healthy way as, as I describe, and in a way that will change what they represent, change their meaning, change your relationship to them, and they become less scary.

[A]

Yeah, yeah, yes.

[B]

But you know, all this stuff.

[A]

Yeah, no, it's, it's good to get your take. Yeah. So diffusion is, is such a, a key thing I think about in therapy and work with clients and when they can get that and they can get good at naming and seeing their OCD for what it is, and they're, they're so far down the line in a good way, you know? Yeah, yeah, yeah. It's hard for a magician to fool us when we can see through all the tricks, you know.

[B]

It's a lovely metaphor. That's exactly right.

[A]

Yeah. It's not mine. I think I heard that Magician 1, one of the guests said it recently. So I won't take credit for it.

[B]

I mean, it really is. I use a similar analogy, which is OCD as a con artist. And it's hard to get. You won't get fooled. If you understand the con artist's agenda. Right. And what the con artist is trying to do to get you to do these rituals to follow its, you know, strategies that it wants you to do, it's going to throw all this stuff at you, it's going to throw these thoughts at you, it's going to throw these urges. And once even, you know, once you tell yourself, well, this thought doesn't bother me anymore, it's going to tell you that, well, now you're a bad person for not being upset enough about this thought. So the con artist has its agenda and once you understand how that works, then you can defuse it.

[A]

Yeah, Yeah, I like that. Yeah. Yeah. Almost knowing its place. Okay. It doesn't get me this way. This next line is going to be this, you know. Yeah, okay. And you talk about self compassion as well in the book. You know what, why was that important.

[B]

To include, you know, folks with, with OCD often, you know, depression goes along with, with ocd, as does functional impairment. And people often will get very down on themselves. And I think the first thing, it's one of the earlier chapters in the, in the book, if you have OCD or if you've been unable to get good results from, from therapy, is to accept yourself. OCD is not who you are. It's a Part of who you are. But people are complicated, we're complex. We all have lots of different facets. And so understanding that ocd. Don't define yourself as ocd, it doesn't diminish your value as a person. And so, you know. Yeah, being able to develop, I have folks develop affirmations that they can include in their, in their daily routine. Right. Positive, inspiring, I guess, affirmations and identifying what, what are your core values as a, as a person and recognizing where OCD interferes with them and maybe where OCD doesn't interfere with them and, and I think that helps people to build resilience once they're, once they have some self compassion, then that helps them to be able to move towards those values, to be able to maybe even decide to go into treatment if they want or to just kind of live their lives despite having, having ocd. But you know, it's one thing to have OCD and beat yourself up about it and, and lose compassion for yourself. It's another thing to have OCD and respect yourself despite it. And that's what I want people to be able to do.

[A]

Yeah, yeah, I like that. Yeah, yeah. It's kind of, it's not, it's, it's, it's something I have versus it's my fault or I'm this bad person. It's. No, it's just. You don't hate yourself for having diabetes, right? Hopefully not.

[B]

Something that happened. People don't, don't, you know, decide I want to have ocd. No one would ever decide that, that they want it. It's not, it's not anyone's fault and stop looking for, you know, things to blame it on. Oh, it's my genetics, my parents genetics or you know, because my parents toilet trained me the wrong way. I have ocd. It's not, it's just not that simple.

[A]

No, no, of course not. Yeah. Interesting. And earlier you mentioned, briefly you mentioned icbt just, just to get, you know, your take because obviously a lot of my listeners, not a lot more of them are starting to notice piques their interest and so, yeah, just to get your take on it.

[B]

Yeah. ICBT is a cognitive therapy where you help folks to look for flawed logic that is thought to underlie how a person responds, believes their obsessional thoughts. And I think there is some use in kind of comparing that flawed lot, learning about that flawed logic, comparing the flawed logic that some people use with concrete evidence from your five senses, your common sense and things like that. I think that again, if someone is not at a place where they're ready to do exposure and response prevention, or maybe ERP has failed them or hasn't gotten them completely where they want to be. I think that there are some techniques from ICBT that can be helpful, you know, that can help folks to maybe take things a step further and look more carefully about, you know, what they're thinking.

[A]

Yeah. Do you ever see sort of some of the principles of ICBT being integrated into ERP enact, or do you think it has to be a standalone?

[B]

It's a good question. I think there are folks out there who have really strong opinions about that one way or the other. At the end of the day, my feeling is that act, erp, icbt, cognitive therapy, all of these techniques have more in common than they have differences. I think that to some extent there's turf battles. Don't call it this, don't call it that. Good ACT involves exposure. Right? Good. If you're doing good exposure, you're doing act. Right. Your exposure is the best form of acceptance. Right. There are different emphasis in there. Right. In act, you don't emphasize suds and you don't emphasize how anxious are you. It's more about how open are you to your thoughts. Right. Which is not what we would emphasize in, in erp. Well, I think ICBT has a lot of those overlaps too. It's a cognitive therapy. So you're helping people to change their thinking. Excuse me, change their thinking. And there's no better way to change thinking than actual experience. And there are, and I'm not an expert on icbt, but you know, I, I know enough, and I've spoken with enough folks who do the therapy that there are aspects of the therapy where you are helping the person to kind of go into reality and test out reality. Well, that's, that's exposure. You know, you might not call it exposure, but you're getting some sort of actual in vivo experience with, you know, I'm going to, I'm going to do this and I'm going to think about it differently and I'm going to see what happens. And you know, that's very similar to what we do in exposure therapy. So I think that there are, and certainly some of the things as I learned more about icbt, some of the cognitive aspects of that have definitely come up for me working with patients doing strict exposure before I even heard of icbt. So again, I think that there are a lot of overlaps and therapists really, rather than saying, I only do this therapy and I would never do that other therapy. I think we do best for our patients and clients when we take the best. The best out of. Out of all the taking the best of both worlds, drawing from different therapies that do overlap a lot, that all come from the same basic cognitive behavioral model of ocd. The idea that to change ocd, we need to change the way that people behave. We need to change the way that people think in ways that just contribute to the development of fear and obsessions. So I think pulling from those different domains is really in the best interests of our clients. Yeah, there are plenty of people that would disagree, but that's my feeling.

[A]

Yeah, I mean, we've had a long time. Yeah, we've had people on the podcast that obviously, I think I've asked that question and they've said, no, it kind of needs to be its own thing. And I get that. And look, erp, when that, you know, 20 years ago, obviously it was built longer than that, but 20 years ago they would have been saying the same thing. You can't integrate. It has to be standalone, otherwise it's not evidence based. And. And I get that. And now obviously we accept act within erp. No one really bats an eyelid anymore at that. So who knows what ten years down the line. You know, this might be a completely redundant conversation at that point, but I think, yeah, where we can. Integration is always better for the client. Not always a lot of the time.

[B]

And there certainly are some aspects of ICBT that are different than exposure and that are eye opening to clients. And again, I've incorporated in my book because I think that they can be helpful strategies for folks to use if they don't want to do exposure or have done exposure and have maybe gotten all that they can get out of exposure.

[A]

Yeah, exactly. And it's nice to have another therapy that people can try. It works, then great. If it doesn't, it doesn't.

[B]

That's exactly.

[A]

Yeah. So, yeah, I guess, you know, if someone's with OCD is feeling hopeless right now, which I'm sure is a lot of people with ocd, because it can do that to you. What message from your book do you kind of most want them to hear or. Yeah, what from the book would kind of give them a bit of hope.

[B]

Yeah. If you're struggling with ocd, there are things that you can do to manage obsessions, compulsions, and like I said in the beginning, that that big footprint that OCD leaves, there are things you can do to learn how to interact skills you can learn for how to interact with family members to reduce stress. OCD causes a lot of stress in families. Very often there are things you can do to. To get what you need to be able to have a fair footing in school, to have just the same opportunities that folks without OCD would have. Right. Accommodations at work also. And so, you know. Yeah, you don't have to. It sucks to have ocd. It's one thing to have ocd, maybe more than sucks to have ocd, but you also can learn some strategies for how to live well with it and how to kind of take back your life from it, even if treatment hasn't gotten you to where you want. And that's what. That's what my book is about.

[A]

Yeah. Yeah. And I think the Living well with ocd, just in the title, it's. I think a lot of people feel that I can't live well until I've got rid of the ocd. And I think it's. No, no, you can live well in spite of it.

[B]

That is a really good point, and I couldn't agree more.

[A]

Nice. Well, is there anything else you wanted to share today?

[B]

No, I think we covered all the. All the main stuff. Thanks a lot. You know, it's always a pleasure to be here. I look forward to my next visit.

[A]

Yeah, it's always a pleasure to have you on. Thank you so much. Thank you for listening to this week's podcast and thank you to our patrons who helped make this episode possible. And if you would like to find out more about Patreon and the rewards and benefits, and then there will be a link in the episode description. If you enjoy the OCD Stories podcast and would like to support us, please subscribe and rate the show wherever you listen to the podcast. And thank you to NOCD for supporting our work. If you want to find out more about nocd, you can click the link in the episode description and quick disclaimer. Guys, this podcast is not therapy. It is not a replacement for therapy. Please seek treatment from a trained professional. And until we speak, take care, SA.