Ethan Tuccienza: Exposure to emotions (#527)

Summary

The OCD Stories Episode #527: "Exposure to Emotions" with Ethan Tuccienza

Guest: Ethan Tuccienza, LCSW, Clinical Director at Behavioral Psych Studios LA
Host: Stuart Ralph
Release date: March 1, 2026

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Overview

In this episode, Stuart Ralph is joined by Ethan Tuccienza, a licensed clinical social worker and director at Behavioral Psych Studios LA. The discussion centers on the concept of "exposure to emotions" within OCD treatment, combining principles from Exposure and Response Prevention (ERP) and Dialectical Behavior Therapy (DBT), and discusses practical ways to help clients tolerate distressing emotions such as shame, guilt, sadness, and disgust. Ethan draws from professional experience, personal journey with OCD, and new therapeutic approaches like DBT-PTSD to offer a nuanced look at why exposure to emotions is not just for trauma survivors, but for anyone struggling with OCD or emotional dysregulation.

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Ethan’s Therapy Journey and Approach (02:12–06:11)

• Therapist Origin Story:

  • Ethan started with ambitions to become a movie critic, but transitioned to therapy due to a desire to directly impact people’s lives.
  • Trained at Columbia's DBT program. Initially engaged in Jungian therapy but later gravitated towards behavioral models like DBT and ERP.
  • Realized personal OCD through ERP training:

    "After I was trained in ERP, I was like, oh, I have OCD. Just a lot of things clicked…The fact that it’s become such a life-changing thing for me personally, knowing what it is, doing it for myself, seeing the dramatic benefits of exposure." (03:57)

  • Became passionate about exposure therapy for treating various issues.

• On DBT (Dialectical Behavior Therapy):

  • Best known for treating borderline personality disorder, but broadly applicable for emotion dysregulation.
  • Describes “comprehensive DBT”: individual sessions, skills group, phone coaching, therapist team meetings.
  • Emphasis on therapist fallibility and mutual support within teams.

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Exposure to Emotions: What and Why? (06:25–11:20)

• Exposure in Behavioral Therapies:

  • DBT is about regulating emotions — not just crisis skills, but also managing everyday feelings and urges.
  • Ethan bridges DBT and ERP: "A lot of these skills are just about learning how to deal with our emotions, which everybody's got." (07:53)

• Trauma, DBT, and Limitations:

  • Traditional DBT recommends waiting to address trauma, but Martin Bohus (creator of DBT-PTSD) challenged this.
  • DBT-PTSD protocol: Instead of avoiding trauma exposure, it integrates careful, supported exposure to emotional pain as a key to long-term change.
  • Ethan highlights Germany’s healthcare environment, which enabled robust trauma research.

• Core Takeaway:

  "The thing that really helps people change…is when they get more exposure to emotions that they find aversive, that actually is really what affects change for them." (10:40)

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The Role of Emotion Exposure in OCD and Broader Therapy (11:20–20:36)

• For Whom and Why It's Essential:

  • Ethan applies emotion exposure broadly—not just for trauma survivors, but for anyone with OCD, anxiety, or mood issues.
  • Core idea: All emotions, even painful ones like shame or sadness, are functional and essential to address.
  • Invalidating environments amplify shame and can generate trauma-like symptoms even without traditional trauma:

    "Feeling chronic and prolonged shame is really a life threatening thing…shame is the emotion that is tied to social rejection, and on an evolutionary lens, it can actually feel very threatening." (13:33)

• Shame Exposures and Healing:

  • Using exposures (in vivo or imaginal) to reduce reactivity to shame, not by removing triggers but by increasing tolerance.
  • Exposure helps clarify which judgments and relationships truly matter.

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How to Conduct Exposure to Emotions (18:35–24:39)

• Identifying Triggers:

  • Focus is less on the exact trigger and more on eliciting the intolerable emotion (shame, disgust, sadness, helplessness, etc.).
  • Work is highly individualized and creative: "It's about them learning to increase their tolerance of it so that…they can get that learning that we can't just get from just talking about it." (19:18)

• Practical Examples and Self-Disclosure:

  • Ethan discusses his own aggressive obsessions related to upsetting others, and how exposure has reduced his need for reassurance:

    "As I've learned to tolerate people being upset more, even potentially at me, I just, I do a lot less of reassurance seeking and checking for myself." (20:37)

• Functional Avoidance:

  • Avoiding emotions like sadness can lead to anger/resentment; exposure fosters acceptance, making real-world navigation easier.

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DBT Skills for Emotion Exposure (29:30–34:43)

• DBT Skills Used:

  1. Willing Hands: (30:02–32:45)

     • Simple body posture technique: palms up, hands open.
     • Symbolizes acceptance, exposes wrists (a vulnerable gesture), signals safety to the brain.
     • Helps disrupt protective, “closed” postures during exposure.

     "We're exposing our wrists to the environment…that tells our brain that basically we’re not in an environment of danger." (30:18)

  2. Mindfulness of Emotions:

     • Consciously observe and label emotional experience during exposure.
     • Encourages full immersion in the difficult feeling, not avoidance or immediate self-compassion (“go right into the deep end”).

• Reflection and Self-Compassion:

  • Post-exposure, process and affirm survival; over time, self-compassion comes more naturally.
  • Recognizing helplessness and powerlessness as core emotions often masked by guilt or shame.

• Why Guilt?

  "The reason why we feel guilt is because it gives us a greater sense of control…It’s really hard to shift people away from feeling guilty when they can’t really tolerate feeling that lack of control, which…is a shitty emotion." (34:56)

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Memorable Quotes & Moments

• On the Root of Compulsive Guilt:

  “When we are feeling that level of guilt, it can almost actually make things a lot of times worse in that moment and increase our sense of guilt too.” (36:58)

• Metaphor for Willing Hands and Emotional Vulnerability:

  “…Dropping guilt is almost like a symbolic version of exposing your wrists because you’re making yourself vulnerable, which is terrifying to someone who’s got sort of guilt obsessions.” — Stuart (38:09)

• Empowerment through Exposure:

  “Ultimately I find exposure to be a very empowering thing because it helps us to better act in ways that feel aligned with our values.” — Ethan (39:43)

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Addressing Dissociation in Emotion Exposure (42:58–45:11)

• Dissociation as a Barrier:
  • “Shutting down,” spacing out, or depersonalizing is a natural but problematic way the brain avoids overwhelming emotions.
  • Solution: Incorporate physical activity (balancing board, stationary bike, bouncing ball, even just standing) into exposures to keep grounded and present.

“By being physically active, it really prevents ourselves from getting more dissociative and shut down, which then allows us to continue to engage in the exposure.” (44:26)

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Integrating DBT-PTSD Protocol with OCD Practice (45:26–46:27)

• Ethan adapts the DBT-PTSD approach (emotion-focused exposure) to treat all his clients, regardless of diagnosis.
• Emphasizes emotional identification and acceptance as central—“We don’t want to fear our emotions; they’re just a part of our experience.”

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Personal Reflections & Advice (46:42–49:40)

• Advice to 20-Year-Old Self:

  • “Do more stuff, try more things…Doing more of this stuff’s going to suck initially, but it’s going to feel really good in the long term.” (47:18)
  • Compassion for youthful avoidance; regret as a natural emotion to accept.

• Billboard Message:

  “Live an exposure lifestyle. Face the things that you're afraid of. Life becomes so much more peaceful and enjoyable when we're able to do that.” (48:17)

• Words of Encouragement:

  • If you feel hopeless, remember: hopelessness is often a protective avoidance of future disappointment. Change is possible, and it’s worth holding on and seeking help.

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Notable Timestamps

• Ethan’s background and ERP/DBT training: 02:12–06:11
• Exposure to emotions explained: 06:25–11:20
• Why emotion exposure is essential in OCD/OCD+trauma: 11:20–20:36
• DBT skills for sitting with emotion (willing hands, mindfulness): 29:30–34:43
• Why guilt and shame are so sticky, and how exposure addresses them: 34:43–39:43
• Addressing dissociation during exposure: 42:58–45:11
• Advice and encouragement: 46:42–49:40

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Key Takeaways

• Exposure to emotions (not just feared situations) fosters resilience and reduces avoidance in OCD, trauma, and other conditions.
• Shame, guilt, sadness, helplessness, and disgust are common but functional emotions; the goal is to increase tolerance, not suppress or control them.
• DBT skills like “willing hands” and mindfulness of emotions are simple but powerful tools to physically and mentally support emotion exposure.
• For those who dissociate during exposure, add physical activity to stay grounded.
• Facing fears and living an “exposure lifestyle” can lead to greater self-compassion, agency, and enjoyment of life.
• Hope is an essential ingredient in the healing journey—feeling defeated is temporary, and change is possible.

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For listeners struggling with OCD or emotion regulation, professional help and empirically-supported therapies like ERP and DBT can make a profound difference. As Ethan says: "Things can really change."

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 for interviewing inspired therapists, psychologists and people who have experienced OCD. Welcome to the OCD stories and welcome to episode 527 of the podcast. And in this one I interview Ethan Tuchienza and and Ethan. Apologies if I've just butchered your surname, but I think I may have nailed it. Ethan is a licensed clinical social worker and clinical director of the Behavioral Psych Studios LA office. In this we discuss his therapy story. Dialectical Behavior Therapy or DBT for short Exposure and response prevention Therapy. Exposure to Emotions, the intervention dbt, ptsd, Trauma Shame Tolerating emotions. He shares a couple DBT skills including willing hands and mindfulness of our emotions. We also discuss guilt, shutting down during exposures and what to do and much more. And thanks to our podcast partners, nocd. If OCD is interfering with your life, NOCD can help Their licensed therapists specialize in exposure and response prevention therapy, the most proven therapy for OCD. With NOCD, effective treatment that is 100% virtual is available for children and adults with OCD and most members can get started within seven days on average. No hassle, just real science backed help and support between sessions. Begin your [e-mail] or I'll put the link in the episode description. So thank you so much to Ethan for his time and expertise. It was really nice meeting with him and talking with him and thank you to you guys for listening. As always and without further ado, here is Ethan. Welcome to the podcast, Ethan.

[B]

Hi, thanks for having me, I really appreciate it.

[A]

Yeah, it's good to have you on. So before we get into today's topic, it'd be good to hear about your story if you have one. Why become a therapist and specifically for ocd?

[B]

Yeah, totally. I did not initially intend to become a therapist in my life. I actually originally wanted to be a movie critic. I grew up really loving just film in general, my house, my dad raised me on watching a lot of westerns, read a lot of Roger Ebert when I was in like middle and high school and I just like kind of realized it wasn't for me. When I was in college I really tried my best at it and just for a number of reasons, reasons it didn't feel right. One of the big ones was I kind of what I now would say from an act lens, you know, wasn't values aligned. I really like to feel like I am. I'm affecting some change for people still love criticism, but I just didn't feel like I was. I was doing that. So I decided to become a therapist and I went to social work school. I went to Columbia in New York City. And while I was there, I found out about. They have a training program in DBT which I could. I know you've had some folks come on and talk about before, but I could explain in some more detail if you'd like. And I got into that. I just heard great things about it. I didn't really know a lot about different kinds of therapy at the time. I was just in talk therapy myself, seeing a guy who was pretty Jungian with his background. And so I got trained in dbt, started learning more about behavioral therapies, had a supervisor who really liked erp, and I was like, oh, this sounds kind of cool. After I graduated, I got trained in it and I realized after I was trained in ERP that I was like, oh, I have ocd. Just a lot of things clicked. I always knew I was a fairly anxious person. I thought it more so had to do with some level of social anxiety, maybe from certainly childhood experiences and whatnot that have definitely contributed still to the things that I have my worries about. But there was a lot of other things where I was like, oh, this makes a lot more sense for me now. So I enjoyed learning ERP just inherently and then the fact that it has become such a life changing thing for me personally, knowing what it is, doing it for myself, seeing just the really dramatic benefits of exposure. I really, really love doing ERP with folks and generally exposure. The team that I work with, I joke that I'm a broken record that I think exposure is the answer for most things.

[A]

Yeah, yeah, I know the feeling. Okay. So, yeah, maybe just briefly describe DBT just for anyone that isn't familiar with it.

[B]

Sure. Yeah. So it's. It's probably most known as the. The treatment that's best for folks with borderline personality disorder.

[A]

Right.

[B]

These are individuals who we now understand struggle a lot with. We call motion dysregulation, which is something what everyone experiences, where our emotions just kind of kick our ass. Right. But these are people who it's more chronic and pervasive, so they can have really up and down emotions, changes in mood, engage in self harms, you know, might be suicidal, have lots of difficulties in interpersonal relationships. And specifically I do what's called comprehensive dbt, which is the formal name for the treatment I Know, comprehensive. A lot of times when I tell people about it sounds like some fun adjective. I'm tagging on to be like, it's comprehensive, but it's actually literally the name. And there's a couple of parts to the therapy where you do individual sessions, there's a skills group, people do phone coaching where they reach out to the therapists and then there's a team meeting where for the therapists, we call it like the therapy for the therapists where we all just kind of support each other, help us help, help make sure everyone's doing kind of the best job that we can because, you know, we're fallible, we make mistakes, we lose sight of things, we forget things, we get frustrated, what have you.

[A]

So, yeah, good point. Absolutely. Now that's interesting. So today we're going to talk about exposure to emotions. What do you mean by that? Why is it important? Just any way you want to start with that.

[B]

Yeah, of course. So I think this is really where my background in DBT and then my love of ERP kind of, I think really combine. I don't, I don't think you need me to talk about why exposure is so important. I don't think anyone listening to this necessarily needs to hear that. I'm sure folks are aware, have heard it many a times on this podcast. But in terms of the emotional piece. So DBT is a therapy that's really focused on our emotions. A lot of the skills that we teach people are about regulating our emotions. So basically just fundamentally understanding what our emotions are, what they do for us when we experience them and what we can do. Right. Classically, people a lot of times think of we have distress tolerance skills. So these are skills that when we're in a crisis, we feel really, really bad. It's hard to think clearly, what can we do to help ourselves get through it and then get to kind of a more clear state of mind. In dbt, we like to say our wise minded state. And then skills that when we're not in a crisis for emotion regulation, like basically, okay, I'm feeling this way. What can I do? I'm sad. What's going on with my sadness? Does it make sense? How can I best deal with it? I'm feeling anxious, I'm feeling avoidant. Does it make sense for me to be avoidant? Should I actually be doing something the opposite of my avoidance urges? It's really great. It's a really, really wonderful therapy that I think a lot of these skills are just beneficial for most folks because they're just about learning how to deal with our emotions, which everybody's got. But the thing that some research has shown is that while DBT is really, really effective for folks, a lot of times clients come in with trauma histories for DBT and progress doesn't always stick in the way that we might want over the long term. And where we see that progress can really be effective for people in the longer term is when we tap back on trauma work, particularly in exposure components to the treatment. So traditionally we think of prolonged exposure is the treatment that's exposure based for trauma. But the thing that I really love that is it's still based in prolonged exposures. I got trained in this treatment that's called DBT ptsd. It's got a hyphen between the two. It's made by this German guy named Martin Bohus who he was actually, he was a student under Marsha Linehan, who is the woman who made dbt. And apparently he said that they would talk. And in DBT you kind of have this strict rule of you don't talk about trauma when you're doing the thing with people because it's going to be too triggering. You need people to learn their skills first. And she apparently was like, do we have research on that? Is that true? Can we really not talk about trauma? And so he kind of, my understanding made that a bit of his mission and he developed this alternate protocol that's really, really amazing. He talked a little bit about how being in Germany really helped because they were able to kind of give people who are really chronically suicidal and self harming and really dealing with a lot of support that unfortunately my home country of the US that doesn't really exist. So they were able to kind of, hey, let's do this research study on people who are really suicidal and self harming and let's give them a lot of free support basically and try it out. So fortunately, thanks to Germany's more universal healthcare there that was able to come about. But basically what he found in the treatment, what's the theory that he's proposing that my understanding there's a lot of research backing it, is that the thing that really helps people change in this study at least of people who are suicidal, who are self harming, who are highly dissociative, who might struggle with disordered eating, is when they get more exposure to emotions that they find aversive, that that actually is really what affects change for them. And in fact one of the really big differences between traditional DBT and this therapy, DBT PTSD is that you really aren't nearly as focused on trying to get people to necessarily change their behaviors. You definitely want people to try to reduce perfect, particularly life threatening stuff in terms of self harm, suicide, severe substance use. Obviously we want people to be staying alive throughout the course of treatment. Of course that's always going to be the number one focus. And you really don't get too hung up on, hey, stop self harming that you might in traditional DBT and instead you're just like, let's get these people to do exposure. Really, that's the biggest thing that we're really pushing people towards.

[A]

Yeah, yeah, that's interesting. And I wasn't aware of that adaptation to dbt. So yeah, in the con because obviously in OCD there can be a big trauma overlap as well. So are you thinking of this, this, this sort of approach more for that, that population or just sort of everyone vocd? Because we know, you know, when I think about my clients, the, the biggest challenge is really the, when we do exposure is it's them trying to ride out these strong feel and sometimes that just feels impossible to ride it out. You know, others can for whatever reason and sometimes people can't and then it becomes a real block or barrier to therapy and sometimes it's the thoughts more, they can't get past. But I think more often than not I experience it as the emotion that's the toughest bit to work through.

[B]

Absolutely, yes, totally. And I can personally living with OCD and doing exposures myself, I definitely think that is, it's the physiological discomfort for me that's tied to my emotions that is really the most challenging bit. And yeah, I do, I do. I'm bringing this up because I think it's really, I frankly think it's honestly like really helpful for kind of everybody not to be a little too reductive, but especially for folks struggling with ocd. Yeah. Because it's frankly this sort of, this thought of exposure to emotions is really what has grounded a lot of the clinical work that I now do with people where a lot of folks I'll see are coming in who have OCD or more sort of, they might say generalized kind of anxiety or depressive symptoms or coming in for DBT and deal with some more acute stuff. And for everybody, I'm trying to help them learn some ways of coping so that they can better function day in and day out if that's particularly a struggle for them. Because obviously if we're having a hard time functioning, it's hard to do much else in therapy. And then ultimately I'm really wanting to push people towards some level of exposure. So for folks with ocd, I might see I'm definitely doing your traditional run of the mill of we do the Y box. We identify what are people's primary fears, what are those fears kind of like ultimately about for them if they're a bad person, Certain things they just generally can't tolerate, what have you creating those exposure hierarchies. But for everybody I'm working with is I really am trying to ultimately impress upon them that their emotions, all of them, are functional. This is true for all of us, right? Even the ones that really, really suck, to feel, you know, feeling disgust, shame, sadness, grief, helpless. I don't like feeling any of those. I'm imagining you probably don't either. And if you do, I have a lot of questions for you about that. But yeah, that all of them are functional, even though they might feel really painful. And that better understanding that when we can tolerate these emotions, that there's a lot of other really, really excellent stuff that, that we can see. For example, to your point, I think a lot of the folks, I'll say more anecdotally that I see who have OCD also usually have a component of being really invalidated by their environment. Just because a lot of times OCD presents as pretty odd or strange or people just get frustrated. Why aren't you listening to me? I'm telling you it's going to be okay. What's wrong with you? Or why would you even think that? That's crazy. These might be things that we can hear when we have. We're really stuck in an obsessive spiral. I know, I certainly have heard those. And when we're invalidated, which is when people kind of communicate that something is wrong or doesn't make sense about our experience, it can make us feel shame. Shame is the emotion that we see as tied to social rejection. And it's an emotion that is really actually like, if you think about it on an evolutionary sort of lens, it's actually really threatening. A lot of times I have people who come in who have trauma histories that are not your typical ones that you might think of. Right. They haven't been in a life threatening situation. They didn't experience like severe neglect in childhood or physical or sexual abuse. Right. They've just had lots of experiences where people were invalidated towards them, didn't understand them, their family was seemingly dismissive of their experiences. Again, this is definitely particularly the case for folks with ocd and I think feeling chronic and prolonged shame is like, is really a life threatening thing because, you know, a while back we used to live, you know, out in the wilderness, right? We really depended upon our tribe to survive. And if you didn't fit in with your tribe, that wasn't good, you know, they might kick you out, they might kill you, right? So shame is a really, actually, it's a very, very powerful emotion that there's still a part of us, I think, that really recognizes it as being part of our survival. And so what happens when we do exposure to shame, which we can do through in vivo exposures? Think of going to places where we're purposefully acting kind of foolish and people might be judgmental toward us and rejecting of us. We can do this through imaginal exposures. Whether we're writing about something that's going to happen in the future potentially, or for memories that we can do imaginal exposures around sort of reliving these negative experiences from our past. What happens, we see is that a lot of our shame can really reduce actually as we get more exposure to it. Think of someone with contamination obsessions and compulsions when they do more contamination exposures. It's not like they're necessarily going to encounter less dirty stuff in the world. It's just like they kind of think about it less, bothers them less, they encounter it. They're much more able to be like, you know, is this serious? Do I really need to go wash my hands and just touch something that's like absolutely horrendous and you know, if it comes into contact with me, it's going to kill me, or is it more of just something that's like, it's a little gross, but I'll be fine, right? So with shame, you know, it's like people are going to shame us. People are going to judge us. And it actually really helps us learn that people's judgments, it really gives us the ability to kind of discern more of like, whose judgments do I really care about, right? Is this my most cherished loved one who's telling me, hey, I think the thing that you're doing or the joke that you just made, I don't love that. Is this a random stranger who I probably will never see again and whose thoughts about me probably don't matter too, too much? And it really helps us, I think, to act in a way that feels much more aligned with who we really are and who we really want to be. Does that make sense?

[A]

It does, it does. So, so from an exposure lens, you're, you're finding out what triggers them, but more so you're trying to trigger the emotion itself. That's.

[B]

Yes, yeah, exactly. Yeah. It's, you know, it's really just a matter of identifying as what I say with all my clients and with colleagues who we ever talked about exposure. So I'm just like, it's kind of whatever works. Right? It's like whatever gets your distress up, frankly speaking. Like I, you know, that's, it's always, you know, function over form. Right. I don't know if again, someone with contamination ocd, if they're like doing something that I wouldn't traditionally, I'm like trying to think like what would be a non traditional exposure for that? I don't know. But it's just a matter of like whatever gets them feeling contaminated and feeling disgust, feeling like there's stuff on them that they want to get off, whatever it might be and like, you know, whatever works. Right. It's about the exposure. It's about them learning to increase their tolerance of it so that, you know, through that experience they can get that learning, you know, that we can't just get from just talking about it. Right. And so for. In terms of whatever emotions we're needing more exposure around, it's really just a matter of what, what gets you feeling that way. Right. You know, and it's really person to person. You can. One of the fun things I think about being an exposure therapist is you can be very collaborative, you can be very creative, especially when people are willing. Right. If they're not willing, that's, that's a little harder. They don't want to do the exposure, which, which happens. And I can understand. But yeah, it's really just a matter of what gets them feeling that emotion in a very sort of prolonged state so that they can see over time and through repeated practice that that emotion is something they can tolerate and will dissipate. And it's through that lens is where the intolerance of our emotions in the way that when we can't tolerate obsessional fears. For me, I'll speak. A lot of my fears are around it's, we would say aggressive obsessions. Right. Particularly emotion, emotional stuff. Which has made my job as a therapist a little complicated at times.

[A]

Yeah.

[B]

Because I'm worried about upsetting people. You know, when, when I found it way less tolerable if someone might be upset around me, I would, I would want to reassure and seek a lot reassure myself, check with the other person, what have you Go back over the events in my head. And as I've learned to tolerate people being upset more, even potentially at me, I just, I do a lot less of reassurance seeking and checking for myself. And I'm able to. I find I'm able to like be a lot more better at handling those situations also. And so in that same kind of way, what I see a lot for, for folks is that the emotion they find intolerable is usually what's related to a lot of the things that they really struggle with, right? So a lot of times when we feel intense shame, for example, that we find intolerable, we're going to engage in a lot of self criticism. We're going to say a lot of really negative stuff to ourselves. We're probably going to ruminate a lot about people's judgments towards us and why, like what's the function of that? It's seen as, it's kind of protective, right? If I'm worried about going out into the world and people judging me, if I criticize myself, if I ruminate about these things, I'm going to probably isolate and withdraw and disconnect from others. I'm not going to take risks. I'm not going to put myself out there potentially risking more shaming from others. If I find sadness a really intolerable emotion. I've experienced a lot of sadness, a lot of grief too, let's say. A lot of times folks might engage in getting more angry, bitter, resentful. Things shouldn't be this way. Why the fuck are things like this? This is bullshit. I realized I should ask, is it okay if I curse?

[A]

Sorry. That's good. It's good. Okay.

[B]

Okay. Just wanted to check, you know, it's like we're trying to fight the state of something right in the world, which makes sense because there's a lot that can happen in our lives, in the world that we don't like now in particular, I would say in the save the world. But the problem a lot of times with that, especially when it's really chronic, is it doesn't change things, instead keeps us really stuck. And what we see through a very DBT kind of lens is that the anger is functionally related as sort of blocking ourselves from feeling sadness and grief. A lot of times when we shift ourselves more to a place of acceptance, of saying, well, this is how things are right now, not for the future. Who knows the future. We're not going to ever say that this is how things are. You know, this, this job that I wanted didn't work out. This friend who I really cared about, you know, has let me down. You know, this thing that's happening within the world is really, you know, there's not too much that I can do about it today. Right. Or affect the change that I might want it. It leads us usually towards these emotions of feeling really sad, feeling a lot of grief, and. And when we're able to feel more of these things, it's not that we then care less about this stuff, but that it becomes a lot easier for us to deal with disappointment, sadness. It becomes easier to navigate the world. It becomes easier for us to figure out what we can control and what we can't and where we can kind of put our focus and attention. Because I think particularly with that sort of anger, bitter thing, we're so often focusing on things that aren't within our control. Same as for me when I was compulsively reassurance seeking and checking. I was worried about what people might think of me or be upset with me around. And I can't control that. I can't control. I could say something completely harmless to you, for example, and you could find it to be. Or in my opinion, it would be harmless. I shouldn't say it entirely. You might find it to be quite offensive or I might strike a chord.

[A]

I don't know.

[B]

Right. And I would hate that. I hope not. I hope I haven't yet. Please tell me if I have or maybe don't. Good for my exposure. But unfortunately, there's just not a lot I can do about it if I, like, if I do make that misstep, let's say. Right.

[A]

Yeah.

[B]

Does that make sense?

[A]

It does. It does. Yeah. Yeah. And, yeah, no, I can relate because. So, yeah, my OCD over the years, or more. More recent years has been about. Yeah. Offending people, writing the wrong thing, you know, and doing the podcast. I inevitably offend people sometimes and, you know, that's not my intention, but everyone has their own histories and everyone has, you know, my something I say is harmless, but to them, it gets filtered through their lens and isn't harmless, you know, so. Yeah, but that's. Yeah, in those six you, like, you're saying you have to. Over the years, I've learned that's not about me. That's, you know, in the same way other people have said stuff to me that's been harmless, but it's pressed my button and, you know, and then. Yeah. So, yeah, now all of that makes sense. And. And obviously in. In ocd, the. The more you Deal with the feelings, the easier you can dismiss the thoughts. Because the thoughts, I always say, is the thoughts. It's not my thing. But the thoughts are only really potent because of the emotion. If you remove the emotion, we all have weird thoughts, but if the emotion's not there, we don't really care. We can dismiss them, you know, which is why most people have intrusive thoughts, the general public, but they're not anxious, stressed, ashamed, whatever, so they're not sticky, they're not sticking around. They can just go, that's a weird thought, and let it go. Whereas we can't, because it's like, oh, no, did I offend him? And now I feel this doom or guilt or shame in my gut. I have to check. And the cycle begins.

[B]

Yes. Yeah, there's. From dbt, ptsd. There's. There's a section of the treatment where we. Where we talk about the experience of an emotion. And the way it's sort of conceptualized is it's like, okay, we have an emotion that we're feeling, and then there are kind of these five things that all happen that are part of the experience that are all kind of interacting with each other. And the stronger they are, the more they're impacting each other. And these five things are thoughts, they're action urges, they're the physiological sensations. There's the posture of our physical body, and then there is our perceptions. So think of, like, the way that the world starts to look for us, right? And so to your exact point, right, let's say for someone with contamination ocd, they're probably an emotion that's coming up. A lot is disgust, right? And so when disgust is really, really powerful for them and really intolerable, to your point, those are going to. They're going to have some really intense thoughts of, I can't tolerate this, I can't deal with this. This is going to get me sick. This might get someone else sick. I just can't deal, whatever it might be, right? And they're going to have really intense urges as well that are going to then interact with their thoughts that are about cleaning, washing your hands, not touching the thing, avoiding whatever it might be in whatever situation that person is in. And so what I see is really beneficial. So I'm kind of saying for all folks is whether you have OCD or not, though of course, I'm really speaking to my fellow obsessives and compulsives is learning that we can better experience and expose ourselves to these emotions and tolerate them is going to Then lead to less of those thoughts of I can't tolerate this, or is this dirty or am I sick now? Or whatever it might be. Right. And less of those urges that we need to immediately get away from this or wash our hands or get clean or what have you. Disgust is an emotion that particular for folks with certain trauma histories can also really come up and be really difficult, especially if they've experienced physical or sexual abuse. And that's where folks with those histories can look a lot like they have ocd. And they might also have comorbid ocd. That can also be the case, but where they're very routinely cleaning themselves, having these very ritualized bathing practices that they're engaging in. And it really just has to do with the fact that they experience disgust in a traumatic experience that is now feeling dangerous to them. And so then reminders of that experience or re. Experiencing some level of disgust really makes them feel contaminated and bad in this way, leading to a lot more of, you know, of those. Those kind of more compulsive behaviors. Yeah, we think ocd.

[A]

Yeah, that's interesting. Yeah. And so when doing exposures to emotions, thinking in DBT terms, what are like. Or one, do you bring in. But two, what are some of the skills that help to, quote, unquote, sit with those feelings, work through them, allow them, like I use, obviously, acceptance, commitment therapy to make space for the feelings and all of that, and compassion focused therapy to how are we talking to ourselves right now? And all of that. But from a DBT lens, what would you be doing?

[B]

Yeah, yeah. Well, in terms of what are the exposure. It's again, whatever kind of is effective for people. And then in the moment, the only skill. It's funny, I sort of say there's only really two skills that I usually encourage people to do. And neither of them, they're both just kind of around having to feel the thing. The first is a skill that we call willing hands in dbt, which. Have you heard of that one?

[A]

No, I haven't. No. So it's this.

[B]

It's. It's a. It comes from distress tolerance, and it's part of. We have a group of acceptance skills and distress tolerance, and it's an acceptance skill that all you do is you just. You flip your palms up like this. So for folks who can see I'm holding my. Holding my hands up, I just do this for the camera. You can. You can rest your hands on your thighs if you want. And what we're doing, it's kind of symbolic. It's Kind of nice, right? We're willing, our hands are open. But really the reason why we do this is because we are exposing our wrists to the environment around us. And that really serves a very powerful thing on our brain, which is it tells our brain that basically we are not in an environment of danger. We're actually safe physically where we are. Because exposing your wrists shows to those around you you're not holding a weapon. We call it willing hands. Because if we are willful, usually our hands are pretty clenched up, right? Think of our fists are up, like we need to fight somebody. So it's kind of the opposite of that. So it's in the moment when people, let's say, are doing an imaginal exposure for an experience where they felt a lot of disgust. I might have them do some willing hands with it if they can. And the other one is a skill from emotion regulation that's called mindfulness of our emotions, where all we're doing is we're just being aware of the emotion that we're experiencing. Because, you know, while, yes, ultimately I do really want people to become more compassionate towards themselves, more accepting of their emotions, at least in the way that I often practice this with people. And what, you know, in DBT we usually are doing, we're really in the moment during the exposure. We're just kind of want to like, you know, go right into the deep end with those emotions, you know, really feel. Feel all the shitty aspects of it, frankly speaking, all the nooks and crannies of how, you know, gross we are or, you know, how everyone judges us and no one likes us and et cetera, et cetera. And the reason for that is because again, once we. We tolerate, you know, it's like, you know, you. The contamination, exposure of sitting on the floor of a public bathroom and rubbing our hands on the floor in the toilet and really just sitting there and, you know, rubbing your hands on yourself, right? Doing the. Really, the. Some of the worst bits, you know, you could probably even do even worse is that that is what's going to help us then to ultimately, the day in and day out, experiences that aren't nearly obviously as intense as that, just deal with and not feel as bad about it. And ultimately then, you know, when we're able to be more tolerant of these things, of these experiences, of these emotions, um, it's a lot easier than to be compassionate towards ourselves, understanding towards ourselves. Right. A big part of any exposure work in ERP and prolonged exposure is. Is afterwards sort of like reflecting on the experience Kind of reprocessing it in a way of like, you know, looking back and like, you know what? I. I got through that thing and I'm okay and actually it wasn't my fault. Once we learn to tolerate, you know, at least in this lines, the emotions, it becomes a lot easier for us to have more of that kind of self compassion. Right. You know, in my childhood when I was abused, it really actually wasn't my fault for that one. Is it okay if I talk specifically what the emotion is there? Would that be all right? Yeah. Why that happens? Because that's another thing that I really feel a lot of passion about that I want. I think that's the thing a lot of people can struggle with is particularly why I see, you know, it can be hard to be self compassionate about, you know, things that we find intolerable is because a lot of times the emotion we're experiencing during these negative experiences, for me, right, with my aggressive obsessions, as well as maybe for you a bit too, is we're often feeling a sense of helplessness and powerlessness. And those are two emotions that I would argue are probably the most threatening that we can experience in a given moment in time because it means we truly don't have control over a situation. You know, imagine you're in a cave and a bear shows up. Really not good. Right. It's pretty bad. I'm gonna be honest, hope that never happens. You know, we're probably gonna feel a level of helplessness and powerlessness because our brain's like, holy, I'm gonna die. So we can experience that, though, interpersonally in situations, if from childhood abuse, it's very. It's a very common emotion for us to experience. But even in experiences of being bullied or dismissed or people being upset with us, right. We. We have a lack of control and there's something we do to cope with it. There's another emotion we often feel as a way to cope with feeling helpless and powerless. Any idea what the emotion is?

[A]

No, I don't. And I don't want to make an idiot of myself.

[B]

I'm sorry, I. More so I was probably saying that because I'm cognizant of how much I'm talking. Don't worry. It's guilt.

[A]

Yeah, okay.

[B]

Guilt. And the reason why we feel guilt is because it gives us a greater sense of control. We're focused on our actions, the things that we've done. Right. If I just hadn't have said this thing, if I just hadn't have done this thing, If I just hadn't have waved to that person, if I just hadn't been in that location. Right. And it's really hard to shift people away from feeling guilty when they can't really tolerate feeling that lack of control, which again is a frankly feeling a lack of control. Feeling helpless is a shitty emotion. I'm sure. I always say to people as therapists, right, we experience that a lot with the people that we work with because there's only so much we can always do. And the more we tolerate it though, the easier it is for us to feel, to have less of this invalid unjustified self blame. Right. Of course, if there are things we've done that we're responsible for, guilt is good, it's helpful. But for a lot of this stuff, it's like I said a thing, I didn't realize it was going to push this person's button. What can I do, right? Or that thing that happened to me in the past, I was seven years old, I was a little kid. What am I going to do about that? Unfortunately, it really reduces a lot of that self blame and makes it a lot easier for us to be compassionate and accepting of ourselves and also really better identify too. Well, what can I then do? What actually is within my control? Because the thing that really frustrates me a lot of times about that guilt or the compulsions associated with these kinds of fears is that again, it's like can't really control it. And usually the things that we do, like for me, when I reassurance, I was reassurance seeking with people, there were certainly times where I was reassurance seeking with someone who wasn't upset with me. But boy, oh boy, by me continuing to reassurance seek, they got upset with me actually. And so it can almost like when we are feeling that level of guilt, it can almost actually make things a lot of times worse in that moment and increase our sense of guilt too.

[A]

Yeah, yeah, exactly that. Yeah, you're right. Guilt comes up so much and most of the time it's the no reason to feel guilty. And the few times I understand, maybe there's a bit more rational reason, there's guilt. It's like you human, you made a mistake. Not that deep. The brain's still amplifying it more than your, your guilt is not. So I guess even when the guilt is somewhat justified, it's out of proportion to the event. Yeah.

[B]

And what I would, what I usually find for people is that's because there's a level that they, the lack of control that they feel that they don't want to experience, which I can't. I can't fault anyone for that. It is not. It's. It's really unpleasant to. To identify what's out of our control. Like, that is. That is some really hard and scary stuff. And unfortunately, though, the guilt really, you know, it avoids that. That powerlessness in the moment, but really, it's just making things worse in the long term, unfortunately.

[A]

Yeah. It reminds me of the. The. Was it Willful Hands, did you say? Is that the name? Willing Hands? Sorry, yeah. Willing Hands.

[B]

That's okay. That's okay.

[A]

Because. Yeah, when you flip your wrists, you're physically vulnerable in that you're exposing a part of your body that if someone attacked your wrists would be dire. Right. In terms of a physical fight, you would hide your wrists and your organs and all of exactly like you're doing. You're crossing your arms. You're not going to expose your wrists to someone trying to hurt you. So you. That could be quite vulnerable sitting there like that. In the same way, dropping guilt is almost like a symbolic version of exposing your wrists because you're. You're. You're making yourself vulnerable, which is terrifying to someone who's got sort of guilt obsessions.

[B]

Yes, yes, It's. It. It's really. Yeah, exactly. That's a. That's a. That's a great analogy. It is. It is like we're. We're. We're accepting and allowing ourselves to be vulnerable to kind of open ourselves up almost for attack. Right. Whether it's physically, with willing hands, someone can, you know, I don't have my arms up, so I can't protect myself from someone punching me in the face, in the chest, what have you. Or with guilt, it's like, well, I'm. I'm like, well, I may not be able to stop this sort of negative experience that's happening. I may not be able to go on a podcast and say, wrong thing that upsets the host. And what can I do about that? Right. Or for someone leaving us in a relationship. I talk about this a lot, especially with people with fears in their relationships, which can come up, obviously, for sure, with ocd, like relationship ocd, but also for other folks as well, where it's. It's learning that someone can leave us kind of at any time. I'm married. I hope my wife doesn't decide to just suddenly leave me. And the frank fact of the matter is she could at any time. Right. And learning to tolerate that fact helps me actually to better tend to the relationship day in and day out and be kind of my best version of myself. Right. So it's very vulnerable to your point. And also ultimately I find exposure to be a very empowering thing because it helps us to better act in ways that feel aligned with our values. We're better able to be self compassionate and we're better able to do the things that actually can affect the kind of change in our lives that we want.

[A]

Yeah, yeah, I like that. And just one last question on willing hands. So. So while they're doing the exposure, you might say, right, can you put your palms up, you know, rest your arms on your legs. You're kind of exposing your palms and your wrists and all of that. Forearms.

[B]

Yes.

[A]

And is that so? Because what I stopped doing it, but I used to do it a fair amount is like when if I was doing exposure with someone and I'd see their body starts to close in, you know, they hunch over and I might be like, no, just relax. Like, you know, lean back, open your posture, put your arms out, almost like exaggerated, like you're fully like on holiday, you know, like. And, and that worked because you then see their posture change and then it would calm. Is that partly the reason for this as well?

[B]

Yeah, yeah. And there's. Yes, yes. There's a couple of things that I think that does. One is it is, to your point, right. A lot of times when we're feeling things that are threatening, whether we're feeling ashamed, we're feeling afraid, we're feeling angry, all emotions tied to some sense of threat, we're usually curling up, getting tense, trying to hide ourselves or trying to prepare ourselves for some kind of danger. And when we open our bodies up, it's absolutely. We're making ourselves more vulnerable, like kicking back on the couch or on vacation for shame in particular, that can be really helpful because usually we're trying to like hide when we feel really ashamed. But the other thing it does too is it kind of signals. Again, it's like our brain, we can have this kind of feedback thing where it's like our brain can obviously identify stuff and tell our body how to act. But then how our body is can also sort of give information to our brain. And so one of these things too can, you know, if we're feeling really curled up, if we're feeling in danger, and we then open ourselves up more, you know, it actually can feel initially quite, you know, alarming because it's that inherent element of exposure. We're cutting off the safety Seeking thing of curling up. But ultimately then, like by doing that, our brain can be like, oh, wait, oh, I'm more open. I'm making eye contact with this person. You know, I'm relaxing the tension in my body. I'm okay, nothing's happening. I might be safe.

[A]

Yeah, yeah, good point, good point. Is there anything else you wish you could have said on this topic before we move on?

[B]

Oh, it's a good question. One thing I would say is, I guess a lot of what I'm talking about is more of like the sort of like the, the. The idea of this exposure to emotions. What I would say is in the treatment itself of dbt, ptsd, just in case, like this, what I'm talking about resonates for folks. It's a treatment that's really been developed for folks who are. It's been found to be effective for a wide range of people, but like, especially for people who have a history of physical or sexual abuse. And one of the things that can happen for people with that, but also can be the case for people who just generally are struggling with experiencing their emotions for whatever reason, is there's a lot of dissociation that these folks can experience. And so dissociation is kind of like our brain shutting down and sort of feeling out of the situation. Right. Like, we're derealized where things feel surreal, we're depersonalized where we feel outside of ourselves. And that can be a real problem for exposure because it's like our brain's natural way of trying to escape the thing that we're experiencing in that moment. It's like our brain's trying to be like, ah, this emotion. I can't run away from it. But what I can do is try to like, you know, psych, you know, psychologically get out of it, right. And for the exposure, for it to really be effective for people. And again, if this resonates, I'm just sort of saying this. If anyone feels like they shut down a lot during exposure, and it's like it's making it hard, is you actually want to do something more physically active while you're doing it. So for example, in the treatment itself, a lot of times what you have people do is you have them stand on a balancing board. You know, one of these things that, you know, it's like sort of like you have to stand on and really focus on balancing. It takes a lot of exertion. And then you usually hold people's hands to help them sort of stabilize themselves or they can hold onto A wall. You can also have people be on a stationary bike or bouncing on a bouncing ball or doing wall sits or even just standing up can also be a bit more of an activating thing. And what that does is by being physically active, it really prevents ourselves from getting more dissociative and shut down, which then allows us to continue to engage in the exposure. So that's just like one additional little thing I just wanted to throw out for people.

[A]

Yeah, no, that's really interesting and just a clarifying question. So on DBT ptsd, is the exposure element you're talking about within that or is this more of just an adaptation you've made for acd?

[B]

Oh, no, this is part of the treatment protocol and the exposure. And I've, I've really been inspired by it. And so I use that framework of exposing to emotions for all my clients, including especially my clients with ocd of really, as we're doing the exposure, trying to really properly identify what are the emotions a lot of times that people are experiencing. And increasing encouragement of my clients for contamination, disgust for my like making indecision and making the wrong choice and making mistakes. Right. Like the sense of helplessness and the sense of grief, of loss, of making the wrong decision, for aggressive fears of helplessness, of feeling shame. Right. Like really trying to hone in on these emotions with folks so that they can really start to better identify that like they can tolerate these things. When these things happen, they're not as bad that actually our emotions are functional. Right. We don't want to fear our emotions, we don't want to hate our emotions. They're just a part of our experience.

[A]

Yeah.

[B]

Yeah.

[A]

Okay, that makes sense. Thank you. And slight change of direction. So pick up the phone and call the 20 year old. You what you tell her?

[B]

Well, it's funny, before we started recording, I was just asking you Stu, for recommendations from London and we were talking about like, you know, sort of feeling like not taking advantage of certain places. So when I was 20, I was living in New York City still and I feel like I did not take advantage enough of things and people. So I would call him and be like, go out and do more stuff. When I was 20, that was a time where I had a lot, a lot more fears around how I affected people. And I would try to be, you know, really kind to my 20 year old self and be like, I get it and it's scary. And also be like, and by the way, you have ocd, I promise. And like, you know, doing more of this stuff's going to suck initially, but it's going to feel really good in the long term. Because something that I've had to contend with a little bit as I've really improved in my life is some sense of regret looking on the past of, you know, feeling like when I was younger, I could have put myself out there more experienced more things, you know, had more experimentation in my life, met more people, and, you know, it's something that I try to find peace with and, like, it's okay, and what am I going to do? But, I mean, if you gave me that power, I would certainly be like, yeah, go, go do more stuff. Go, please, come on, try more things. Because I think it would really. It would just feel really nice and help me earlier and also kind of be nice to look back on that time in my life and be like, yeah, I really. You know what? I took full advantage of that experience.

[A]

Yeah, exactly. Yeah. Good words. And you got a billboard. What do you want written on that billboard?

[B]

Oh, live an exposure lifestyle. Yeah, that's something that I really. I like to talk with everybody is like, face the things that you're afraid of. Life becomes so much more peaceful and enjoyable when we're able to do that.

[A]

Yeah, yeah, exactly. And lastly, anything else you wish you could have said or shared today?

[B]

You know, if anyone's listening and is really struggling, whether they have ocd, trauma history, both just sort of more amorphous, generally kind of anxiety, depressive symptoms, what have you is like, you know, there's good help out there. There's good stuff out there. It might take some work and it might take some time, and things can really change. The thing that I really. It saddens me a lot of times is when people can get hopeless in treatment, which I understand. I actually view that as an avoidance thing, too. It's usually avoiding future potential disappointment. If I take a risk, you know, I could get disappointed. If I'm hopeless, I won't take risks. So it makes sense. And also, I just. I don't. I hate when people feel defeated. And so I hope if anyone's feeling defeated, that if there's a part of them that can hear me and just know that things can change to. Please, hopefully just hold on to that.

[A]

Yeah, Nice. Good words. Well, thank you for coming on, talking about this topic. Yeah, it's really interesting. Thanks.

[B]

Thank you for having me. I really appreciate it. Thanks for entertaining my ramblings. Thank you.

[A]

That's good. Good. Thank you. Thank you for listening to this week's podcast and thank you to our Patreons who helped make this episode possible. And if you would like to find out more about Patreon and the rewards and benefits, 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.