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The OCD Stories
Jonny Say: OCD and the therapeutic relationship (#485)
00:50:29
In episode 485 I chat with Jonny Say. Jonny is a UK based therapist and co-director at The Integrative Centre for OCD Therapy. We discuss the importance of the therapeutic relationship, the benefits of it to outcomes, functional analytic...
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- [00:00]
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 485 of the podcast. And in this one I got back on Johnny say, who is a UK based therapist and co director at the Intricate Centre for OCD Therapy. In this episode we discuss the importance of the therapeutic relationship, the benefits of it to outcomes functional analytic psychotherapy how compulsions can get in the way of the therapeutic relationship how a good therapeutic relationship can help acceptance, commitment therapy and exposure and response prevention therapy the therapeutic relationship as a way of dealing with shame, rupture and repair and Jonny and I share our own experiences from therapeutic relationships. 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, NOCD makes getting the right treatment easier than ever. Start your journey today@nocd.com or or the link will be in the episode description. So thank you to Johnny for coming on talking about this topic and also for any therapists listening. In about five, six days we've got a training on the 16th of May on functional analytics psychotherapy for OCD. So I'll put the link in the show notes. But thank you all for listening. I hope it helps inspires you in some way or gives you some insight. And thank you as always for listening. I deeply appreciate it. About further ado, here is Johnny. Welcome back to the podcast Johnny.
- [01:59]
B
It's good to be here. Sue, Great to talk to you as always.
- [02:03]
A
Yeah, it's good to have you on. And today's topic OCD and the therapeutic relationship. When we met up last week for our sort of semi regular business meeting to talk about the center, we were talking about podcast topics and episodes and we were discussing the training we got coming up with Nate and Megan on FAP functional analytics psychotherapy for OCD and we thought maybe it'd be good to do a general sort of episode looking at OCD and the therapeutic relationship more generally outside of fat. But I'm sure we'll, we'll mention that to summary.
- [02:44]
B
Yeah, I think it's something we both feel is really important in therapy. I think both in our own recovery journeys and how important strong therapeutic relationships have been and then what we see in Clients. And that, yeah, you know, as always, ERP is the focus and ACT and compassion, Focus, therapy and other things we've talked about before. But not wanting to underestimate how important the therapeutic relationship is and you know, how that can determine how effective those other components are, to be honest. Often.
- [03:24]
A
Yeah. And of course, the three therapies you mentioned, erp, ACT, and cft, all have the therapeutic relationship within them because it's just the bedrock of psychotherapy is the relationship between client and therapist or patient and therapist, depending on the terms we use. And that goes back many, many decades and years of research on looking at how important the therapeutic relationship is or the alliance within successful outcomes in therapy. So, yeah, but I guess we're going to highlight it more and, and focus on it more in this episode as a kind of sub. As an individual thing of its own. But I guess I just wanted to highlight that for the listeners, non therapist listeners. It's in every therapist, with every therapist, the relationship is there. The question is just, is a good relationship or a not so good one or an okay one?
- [04:23]
B
And how much attention are we paying to that? You know, how much are we assuming it's a good relationship and yet haven't checked that out and explored that with the client versus how much are we talking about those factors and checking in with people and seeing, you know, how that side of therapy is going?
- [04:42]
A
Yeah, I think. And look, whenever I. I don't say whenever I've had, you know, successful cases or clients I've worked with, we've made really good progress, that it's always been a wonderful relationship, but I think I have to have had developed some connection and bond with them in the work for change to have occurred. Otherwise, the clients that I've really struggled to connect with on some level doesn't mean I don't care for them. I've just struggled to connect in that way or they've struggled with me. I don't know. I don't know quite where it's at. You know, you then get clients that don't stick around as long. Therefore, I can't help if they're not sticking around or you just find that the sessions aren't flowing, you're not getting to the, the deeper levels or you're not putting in the work, maybe because they don't trust me or whatever it is. So I guess I just wanted to highlight that that when there is. That we're both connected in some way, the work gets done much more effectively.
- [05:48]
B
Yeah, completely. Yeah. I mean, I'd Be interested in what are the things you see in the clients that it's harder to connect with, that they're themes you see there, would you say?
- [06:03]
A
Yeah, I haven't planned this. I mean, the first thing that comes to my head is because obviously I work with children, young people and sometimes young people, especially that sort of primary age, elementary school age, they, sometimes they come in, they really want to like use the sessions, get involved, connect. And other times they're very hesitant and reserved and it's not always shyness. Sometimes they just don't want to open up and you know, and sometimes I work on that with them and we make progress and we develop a good relationship and sometimes I just, maybe it's my flaws I just can't get through. And, and, and I feel that even if they're happy with me as a therapist, I feel that we haven't, we haven't or I haven't done enough to cut through and, and truly help in the best possible way. Even if there has been shifts and things have changed, I don't leave the relationship when it ends feeling satisfied with the work I've done, if that makes sense. So, so that's kind of putting it on the client there about, you know, and they may be picking up on me and my character and maybe they don't like my personality or my jokes or whatever it is.
- [07:17]
B
I can't believe that for a minute.
- [07:19]
A
I know, exactly.
- [07:21]
B
But, but it's true though. You know, we've got to be humble and honest as clinicians. We're not going to be the right fit for everyone. And any thera therapist that thinks they are, you know, is, is not really looking at an honest appraisal of their personality and how it lands with everyone. Yeah, I mean, I, I notice in clients sometimes you've got the kind of anxious attachment where the client doesn't feel empowered within themselves. Self efficacy, trust, and they are reaching out for that reassurance. Essentially. I see it correlate with reassurance seeking and that impacts the therapeutic relationship because, you know, on the one hand the compassionate part of you wants to relieve their suffering. On the other hand, you know that it's not going to help unless we establish that personal strength and self efficacy in the client to accept uncertainty and to, you know, move forward in their life. And then on the other hand, I see other clients with the more avoidant attachment style where they don't want any connection really. They carry in shame. They almost don't want to share a lot of what's going on the compulsions are internal in their mind. They're maybe not fully honest with quite how bad things are at times, or they're sort of, you know, they're not quite connecting with you enough to either internalize some of the compassion that comes through the therapeutic relationship, or they. They. They're not telling you the barriers. So this is another thing. I think with clients, sometimes you, you know, at a surface level, you'd think the therapeutic relationship is good, but it's just the person isn't telling you the difficulties they're facing, the barriers they're having. And I think that's why fap, Functional analytics, psychotherapy, in sort of allowing us to focus on the relationship a bit more directly and what's happening between oneself as the therapist and the client. You can open some of that stuff up and, you know, you can name that dependence on others and the sort of insecure attachment, or you can name the avoidance. And then that might open up, like, how is the therapy really going?
- [09:51]
A
Yeah, yeah, that's a really, really good point. And yeah, so, I mean, you know, talking about, like, confessing and stuff, when the clients come in, asking for reassurance a lot, confessing a lot, it does put a barrier between you and them because you can't really connect with them because they're just desperately seeking an answer. And, you know, we've got to wonder. That's probably happening in their own life with their partners, their kids, their parents, their whatever. And that's getting in the way of true connection, which is a key thing in humanity, is we. We're social beings and we need to connect and it fends off loneliness and all of this. And I remember going back to the training, we mentioned Nate. Nate's co running the training with Megan. And both you and I had supervision with Nate around fat for OCD a couple of years ago. And I remember Nate saying to me once about how I. Where I felt connected to a client. And I can't quite remember the context, but he. He mentioned that he sometimes says to clients of, you know, because of what the OCD is getting in the way, I feel like I don't actually know you. I don't know, you know, your hobbies, your interests, what really makes you tick or you ever share with me is the ocd. And obviously that's okay because that's what you're there to work on. But it goes where there's not any of the human coming in. It's all the ocd and it's not even. We're talking about the OCD in a recovery way. We're just compulsing in session. And so now what I do, since he, he said that is I will. Some clients of, you know, we work together for like eight weeks, three months, whatever it is. I, I feel like I don't know you yet. I feel, and sometimes that they look at me blankly, but other times they were like, it will, it will open it up and then I get to know them more and that strengthens the relationship. And then I feel we do better work.
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B
Yeah.
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A
And I get access to their values, what matters to them.
- [11:54]
B
I was just going to say that. And it opens up areas for erp, Right. Because you start to see things that are important, that might be blocked, aspects of social connection that offer opportunities for erp, which I think is another part of fat. You know, you can use the therapeutic relationship to practice things that are difficult in, in relationship and then take that out into someone's life and their actual connections. And that's scary. And that's a form of ERP in of itself. And, and yeah, I mean, I, I like the example you, you give. I mean, I, I reached out for supervision to Nate because, you know, I, I was having a cat, A group of, of clients that, you know, weren't responding so well to erp, weren't responding that well to act, weren't responding so well to compassion, and you know, you might say, well, was I not applying those things in the right way for this client? Maybe, but they'd had a lot of ERP before with very well known places, and, you know, wasn't like I was the only one hitting these sorts of barriers. And I like this idea that we could actually switch onto how people are showing up in their relationships, how they're connecting, how that manifests in therapy. And that could open a way of helping people that were stuck with those other approaches. And I think some of those people I saw that were really stuck with those other approaches had difficult histories with attachment, difficult, you know, traumatic or invalidating histories that made them vulnerable to more intense emotions, you know, less self belief that enabled them to treat the intrusive thoughts as intrusive thoughts. Like there was a history to their attachment that explained why some of the symptoms were harder to work with. And so I liked the idea of using the therapeutic relationship is another way of trying to work on that and actually get into erp, getting to skills, you know, modeling skills through connection in the therapeutic relationship as another way to help people. And so that's what drew me to getting that help from Nate and I learned so much from him and I continue to. And you know, I'm excited for people to learn that too in the training. And I think you're right. Sometimes when I'm stuck with someone and we might have tried a typical pathway that I would do in terms of building up ACT skills and then starting to do ERP and then we're hitting barriers and people are struggling to apply what I'm talking about to those barriers, then I might start switching on to, well, you know, what's going on between us here now. Because invariably person's going to get frustrated or upset when that's happening and difficulties are going to start showing up in the relationship and then they're going to be windows into that person's connections outside of therapy. And they call it functional classes. I think they call it functional classes or something like that. In fact, where it's. The behaviors might not be exactly the same in the therapeutic relationship, but they save this. They, they serve the same function as the behaviors in the person's life. So they might be more, I don't want to use the word traumatic, but they might be more sort of intense and confrontational or more higher emotion outside of the therapeutic relationship. You see similar subtle aversions there and, and sort of attending to that stuff to me helped open up ways of doing erp. People started dating that hadn't been dating people went to groups that hadn't been doing any social connection. People. People actually put up boundaries to people that were difficult in their life, that were stressors and you know, they were being too people pleasing and you know, being too forgiving of these difficult characters. So I saw some real behavioral impacts of that work. Now I wouldn't sell it as a miracle. It's not like this is the new miracle way is like attending to people's relationships is somehow going to be the magic cure for ocd. But I think it opens up options when people are really stuck on some of the other methods. And because it's so universally powerful to us. I mean I was looking up the Harvard Study of Adult Development which is this 86 year running study on a cohort study of men whose many have died now and some are still alive. And the biggest finding of the predictor of happiness was strong positive relationships. And it is the most, you know, the biggest factor for fulfilling and healthy life. So it is so universally important to all of us the nature of our relationships. And OCD is going to block them in different ways. And so switching the focus onto that in therapy I found really helpful when I'm stuck with other things.
- [17:28]
A
Yeah, that study is really interesting. Yeah. And I guess what else comes to my mind, I agree, when we're not doing this episode, to say this is some kind of missing factor. It's just a known important thing in all therapy is you get on with your therapist, you believe your therapist cares about you, you like seeing your therapist and. And then obviously you can have all that and the therapist not have a clue in terms of the strategies and tools and interventions for ocd. And you'll have a great time with them, you know, and they will help you in many areas, but they may not help you in the ocd. So you need. You need.
- [18:06]
B
But it could be negative, even. It could, you know, you could be having a good relational experience, but, you know, reinforcing habits that are very bad for the ocd.
- [18:16]
A
Yeah, exactly. And I think I want to add, like, you know, when I think I've had clients, it's less common, but I feel we've had a really good relationship. But they've used the relationship, like I've been the container for their anger. So in session they'll come and I'm the one who gets it. Now, you could look at that and be like, this client hates you. And. And I've definitely had that, Rob. I've come away thinking, oh, my God, this client despises me. Like, and then I speak to their mum and their mom's like, no, they love coming to see you. Like, you know, and I don't. It doesn't feel like that when I'm in the room. But that's because, you know, negative transference, you know, they're using is the. The projection they're putting all their anger that maybe a parent or someone else. The client I have in mind didn't have ocd. It's something else. But that client, we had a good relationship that he could come in and use that and be angry and. And aim it at me and we could work through that and then I could highlight the anger and explore it and, and eventually we worked through it. But that's maybe, yeah, the. The. There needed to be a good, strong relationship there for him to use it in that way and then us to highlight what's going on between me and him and work through it. So then he isn't doing that in the rest of his relationships in the world.
- [19:38]
B
Yeah, yeah. Which I really like. It's a very concrete and simple example of. Of functional analytics, psychotherapy, but also other relational therapies. And, yeah, I mean, I think, you know, the relationship, when it's secure, you're right. In some ways, it's kind of obvious. And sometimes it gets overplayed. You know, there's the research on common factors, and sometimes people will make the claim that, you know, everything is the relationship, where really that finding isn't as simple as it's, you know, I think most therapists will read that research and go, yes, that shows how important the therapeutic relationship is. But it isn't, you know, the only factors we just said before. But I think with ocd, that secure attachment, you know, validating relationship number one, it helps people do ERP because, you know, we need to trust, we need to believe and feel the rationale makes sense from the person. And you're not going to get that if you don't feel conn. You have to, you know, you get courage from other people. So if our therapist feels courageous, we're more likely to be courageous. I think Stanley Rachman, who. Who developed one of the developers of ERP, he studied World War II veterans and what led to courage in that context? And they said a lot it was feeling connected. You know, I would do these very frightening, scary things if I felt connected to my, you know, my other people in my battalion or whatever. And I think there is an element of that, that the courage is contagious. But I think the shaming is something I see a lot in the OCD clients I work with with, you know, taboo OCD and these types of, you know, sexual obsessions and violent obsessions, things like that. Just that sense that, you know, I can tell this person all of my thoughts and feelings and actually they feel very supportive. And you could say, well, is that reassuring? But actually, you know, that is the assurance clients need to then engage in ERP and other things. They need that sense of, you know, this person thinks I'm worthy and lovable and deserving of a good life. And, you know, I have a spreadsheet that I fill in after I've finished with any client and not anonymous. And, you know, I'm not keeping people's details in it or anything, but I asked what was helpful from the client, and I compare it to what I think was helpful. And the thing, the two things that people always say of the hundreds and hundreds of people now, they always say the relationship. And they actually say that before the treatment. More often than not, they say, you know, to have someone who is understanding and compassionate, supportive and got me and listened and, you know, validate and all of that, and then they often say skills because that's, you know, act skills is a big part of what I'm doing. And they might, you know, they might put exposure in there. But it is so often the therapeutic relationship that clients feel has been most helpful. And I think it deshames, I think it shapes the skills. So if, if I'm modeling being present, diffused, accepting, you know, not engaging in compulsions, then that, that kind of is contagious through the relationship. Bit like with your anger client, where you were able to observe their anger and stay with them and, you know, be with them. And then that models what they need to do inside with the anger to not let it, you know, ruin their relationships. I think self compassion, I mean, compassion is so shaped by a relationship that is supportive and unconditional in its positive regard. And, you know, it's very validating and that gets internalized over time. And people are sometimes very receptive to that. And sometimes people are very scared and frightened of that secure attachment. If they've had trauma and no sense about in their life. It can feel dangerous to start to trust and rely on someone. So that can be such a healing thing when there's trauma. And then, you know, I think when we talked about this before, you talked about the sort of corrective experiences where that therapeutic relationship can kind of heal some of those attachment wounds, like if I was neglected emotionally can be hard to be the focus of attention and for someone to really be interested in me and care about me. So that can, you know, if I was shamed and criticized all my life, to be offered compassion and loving support, you know, can correct that. You know, the. Sometimes it's. People have been overly, you know, they've accommodated too much and they haven't reinforced our strength and courage. So they've been very kind and supportive parents and attachments, but no one's really gone. Actually, you've got more strength than you realize you have, and you can tolerate a lot more distress than you think you can. And you are courageous even though you don't feel it. And then, you know, so you sometimes need that more positive sort of, sort of, you know, actually reinforcing the strength rather than the, you know, empathizing the pet with the pain side of it. So I think there's. And I wonder about for you, you know, those sort of proactive experiences of relationship, what you've seen.
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A
Yeah, I can answer that. I mean, just before that, going back to your spreadsheet about what you were saying before they even mentioned the treatment, they Say what. What they liked most was the relationship. You know, I just googled Maya Angelou's quote of. You know, she said, I've learned that people will forget what you said, they'll forget what you did, but they will never forget how you made them feel. And I think that's such a great example of the therapeutic relationship. You know, when I think of my therapist of many years, I think the reason that relationship was so healing for me was just. Yeah. How I felt in her presence, how she made me feel, how over and over again she showed that she cared, even when there were ruptures between us, which is, I think, worth highlighting that it's natural there's ruptures between therapist and client. What's. As there are in every single relationship of any kind on this planet. All that matters is how do we repair those ruptures? Can they be repaired? And a good therapist should help repair them with you.
- [26:29]
B
And what can we learn from it as well?
- [26:32]
A
Yeah, the client also has to want to be willing to repair it, I should add, because, you know, it could tap into stuff for the client that really. I just can't face the therapist. And I understand that. But, yeah, even when there were ruptures with my therapist, we worked on it, and that actually made us closer and stronger. And I don't see her anymore, but if I ever needed to, I wouldn't hesitate. If I need her, I know she's there, and I know I would feel the same way when I saw her.
- [27:00]
B
Again, you know, so, yeah, that bond is. Is deep and.
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A
Yeah.
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B
And you've carried it in you, right? You've carried that.
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A
She's always there. Yeah, that. That love, that connection, that belief in me. If I'm being hard on myself, you know, I can think of her and it's there. It's internalized now. So in some way, I embodied her natural, compassionate way of being. We didn't do CFT together, just her natural, compassionate way of being. I think maybe took longer than if we did directive cft, but, um, I. I've internalized that, you know. Yeah. That grace, that compassion, that belief that I'm not a bad person is all there.
- [27:46]
B
Yeah, I just. While we're on personal experiences, I may have shared this before, and forgive me if I have, but the one I always think about with Therapeutic alliance was I worked with an ERP therapist early on when I was really struggling. And if I'm honest, the ERP within that bit of treatment wasn't so helpful as much because I was approaching it. As like, this is the thing I'm going to do to get rid of the symptoms. Right. Why are the symptoms not gone? You know, let's keep doing it. You know, I was. There wasn't that acceptance, you know, agenda and framing for me. But what did stick with me was, you know, I was really struggling with so much shame at that point. I was so isolated and, you know, I read a study that said 76% or something like that, that people with OCD will report high levels of loneliness. And I was totally in that place. You know, I was more and more isolated, seeing less and less people and, you know, really just feeling like no one would want to be friends or connected with me because of what I was experiencing inside. And I had a lot of social anxiety blended in with the ocd and some of the symptoms were manifesting in different way. And I had this wonderful therapist who was from southern Ireland and had one of those really gentle, relaxed Southern Irish voices that are quite soothing in of itself. And he said to me, and it stuck with me more than a lot of other things I've heard in therapy. He said, sure, Johnny, everyone gets up in the morning and does a shit. And the way he said it at that time, you know, it's a simple thing. It's something other people may say, you know, people may have heard that in your life, but you know, he was really saying, like there was so much communicated in what he was saying. At least that's what I took from. It was like a real acceptance, a real sense of like, everyone's going through their shit. Yes. Some people hide it and you look at them, you think they're not doing a big shit in the morning because they're polished. And they present in this way that they feel like they've got everything together, but they are actually going through their shit both literally and metaphorically, and you're okay, you know. And that was all kind of communicated in one phrase and one sort of playful moment. And it really stuck with me and it really shifted something in beginning to open up a bit more self acceptance and a bit more like, it doesn't matter what happens here. I'm going to connect. Yeah. So, yeah, that one always stuck with me. With the power of the relationship.
- [30:35]
A
Oh, yeah, the image and the Irish are good at it. Yeah. Shout out to my Irish listeners. Yeah, no, good example, good example. They do have a good way with words, so it's nice.
- [30:46]
B
I hope people will forgive my terrible impression, but it was so powerful.
- [30:53]
A
Yeah, exactly. That's what I mean. That shows you sometimes one sentence, one word, one timed phrase can really resonate. I remember I had a supervisor years ago where. Clinical supervisor. And she. I was. I was struggling a bit. I was having a bit of a relapse. Not a bit. I was having a relapse. And. And I kind of hidden it, that I was struggling at work and all this. And. And then I told her, and she said it was like, you know, why didn't you tell me? Not in a bad way, but just. And then I think a week or so later I said something about being bad at communicating or opening up and sharing with others. I'm struggling, or something like that, which someone I worked on in therapy. And she just said to me, yeah, but we're not doing that anymore. As if to say, we're trying something new.
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B
Yeah.
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A
Like. And it was that kind of cut through. Yeah. Really, Your story.
- [31:54]
B
It cut through your story, didn't it? Your sense of self and who you thought you were. That wasn't helping you. And.
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A
Yeah, it's the same now. If I feel like I'm bottling stuff up, it's like, I'm not doing this anymore. I'm doing something new.
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B
Yeah.
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A
So, yeah. Yeah. Again, we. I had the. The good relationship with that, you know, and again, that relationship. I still like her, but, you know, we had our issues towards the end that we maybe haven't quite repaired yet. But even so, that still remains a very special statement in my mind.
- [32:28]
B
Yeah, well, and that's important too. No, no one is perfect. Everyone's flawed and fallible in relationship. And. And that can be another thing that OCD clients like. If you've had very difficult relationships, you can then put so much pressure on the therapeutic relationship. It can't let you down in any way. This person can't be fallible. And then the therapist may do a small. Well, I mean, I hear big invalidations too, so I'm not trying to minimize anyone out listening that's. Have big invalidations. I hear that all the time. You know, when therapists have been patronizing or invalidating or have been angry at the client for not doing what they're saying and all kinds of, you know, force them into exposures and all these sorts of things. So I'm not talking about that. But sometimes therapists who really genuinely care about their clients can make mistakes or be fallible. And like you said before, the rupture and repair is the important thing about, you know, the therapy and learning from that. But you know, what you're saying about your Supervisor. We're all flawed humans. None of us have got this perfect good enough. You know, Winnicott's phrase good enough is so useful for relationships now. It doesn't excus use people who have been abusive and traumatic, and we're not talking about that yet. But, you know, we're all flawed. And so sometimes that becomes the barrier, I think a little bit. You know, when the therapist is put on the pedestal and has to be this perfect thing, and when they're not, then everything falls to pieces. Whereas actually, you know, that should be the opportunity to learn and explore something that's supportive for relationships outside of therapy and helps moving forward in recovery.
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A
Well, that's it. It's a good point. So, like, and I imagine this is more of adults. I don't see this as much with. Well, I don't really see it at all with kids. But I'm not saying it can't be there, but, you know, if someone has had, you know, various things, whether it was partners, whether it was parents, that, yeah, there were. There was a lot of pain relationally there, you know, and then stuff was never repaired or seen or heard, and then the therapist makes one little mistake and suddenly that. That little mistake feels huge to the person.
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B
It activates that history and all those other. Yeah, yeah.
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A
But that in that as long as it was a small mistake, in that there is an opportunity to repair and heal and learn a new way of being. Like my supervisor said, learn a new way of being that then that client can take out to the rest of their relationships. And. And because they might meet someone romantically that is a really fit for them, is a generally good person, but it's human. Is going to make mistakes.
- [35:19]
B
Yeah.
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A
And. And they could prevent it being volatile. If the person has been able to have this restorative relationship with someone such as a therapist.
- [35:29]
B
Yeah, yeah, yeah, definitely.
- [35:34]
A
Just looking at my notes, one other thing that comes up to mind with kids of like, when the therapeutic relationship doesn't land, sometimes it's because mum or dad or both or caregiver has basically forced them into therapy. You need to go, you need to be there, blah, blah, blah, blah. And sometimes, yeah, they might need to be there and they might need to go. But if they're not willing, they're not. They might be polite to me, but they're not. They have no interest in working and developing any kind of relationship or connection. And then you just battling with them, which. And then sometimes I'll say it's not the right time. I don't Want them to have an awful experience of therapy and when they finally ready, never want to go. Because, you know, I was a real bad example of a therapist. So that can happen sometimes and that.
- [36:22]
B
Can happen with adults. And certainly at times when I worked more with the NHS in the past, I would see that a lot because, you know, doctors had sort of pushed people that way or family members or other, other, you know, systemic reasons for going down that pathway. And yeah, it's very tough. But then that's a classic example where the ideas from functional analytics, psychotherapy are so helpful because we can directly call out what seems to be happening and talk about it different with kids because, you know, they may not be ready yet there, but with adults to sort of talk through, is that what's going on? You know, what, what are the barriers here? And, and, and to sort of look at that workability wise, like, what will happen if we just come to therapy and I tell you a load of ideas and you sit in your head thinking this is a load of bullshit and why am I here versus let's build an authentic connection that could be helpful, that's honest and, you know, maybe that will move us towards the ERP and ACT and other things, or maybe it'll just be a useful relational experience that helps, you know, with, with other relationships in life.
- [37:41]
A
Well, I see we've talked a lot about that. But yeah, going back to ERP and ACT and whatever else, or even icbt, I think, yeah, having that good therapeutic relationship or alliance, you're more likely, as you said, want to do exposures. You're more likely to, you know, practice ACT skills and, you know, whatever else, especially with erp, because you've got someone next to you who, you know, has your best interests at heart, that believes in you, that supports you, and you're gonna go into battle, so to speak, with someone you care about. Speaking of courage, you know that WAR example you gave versus there's someone next to me, a therapist that I don't like, I'm not connected with, doesn't get me as impatient or as whatever it.
- [38:26]
B
Is telling me I should just do this thing and don't do it. I'm treatment resistant or, you know, it's my fault, I'm not recovering or. Yeah, yeah, it's completely different. And then on the other side of it as well, a lot of OCD clients will not tell us what is going wrong for them. You know, they'll have heard how effective these treatments are and they're good, compliant people who want to do a good job and want to be liked as I was. And they might not report all the tangling up that's going on, you know, and even to the point where they might report good stuff at the end, but they're not able to be truly honest about the barriers they're hitting because they don't want to upset you and they don't want to let you down, don't want to disappoint you, and they. They don't want to, you know, all kinds of things that can be playing out there. So I think it really helps with being able to honestly talk about when things are going well and when they're not and when they're going well. Actually, that's another side of it. I mean, to have that genuinely praised by a therapist who really wants the best of you and is incredibly proud of your courage and thinks you're doing the most awesome job, facing OCD and doing exposure and facing down your mind and doing skills like, that's so reinforcing. When it's genuine. When, you know, when, like, when you really feel it coming off the therapist and it's genuine, that's.
- [39:55]
A
That's so, so powerful 100%. And that, you know, that goes back to FAP. That's what they do.
- [40:00]
B
Right.
- [40:01]
A
Is naturally reinforce clinically relevant behaviors that are helpful to the client. And yeah, going back, you know, you just using my. My story as an example with my therapist, as far as I'm aware, she wasn't trained in fap, but when I had made change and I'd come back the first, you know, another week and something had shifted or moved in my life or I'd stood up for myself, which was one of the things I worked on. She could see in her face like you couldn't hold the smile back. She was deeply proud. And, And. And that. That reinforced my behavior to want to go and do it a hell of a lot more.
- [40:38]
B
Yeah.
- [40:39]
A
You know, and imagine in the ERP if that's happening, and I try and do that with my clients when they do something that either shocks me that we didn't plan or. Or even if they see the homework through, I'm generally happy and I'm generally proud of them and let that. And one, because I'm just being a human and sharing my joy. But two, I know that that is going to reinforce them to do it more.
- [41:01]
B
Yeah, yeah, yeah. I'll be welling up with them often. You know, I'm feeling that moved, you know, tears of joy. When you see someone really getting their Life back and people feel connected to you, and they, you know, they are more likely to continue with the treatment and to keep working at it, living ERP and act as a lifestyle. And I think, you know, for me, I was so disconnected in the experience of ocd, and I had some good therapeutic relationships, but I would say, you know, a lot of my recovery work I did on my own. And then it was. It was then going back into relationship was the exposure and having to do that, and it's so tough. And to have a therapeutic relationship, to talk. I mean, it would have been so helpful for me to be talking through that with someone who got it, because, you know, people will say simple things like, you know, even hinted at it in this podcast, like, you know, relationships are the thing that make us most happy. And then when you've got OCD and you start trying to connect with people and you can't because your mind's just throwing you intrusive thoughts the whole time, or you're feeling depressed or you feel in shame, or like me, my existential OCD would latch onto relationship and, you know, deconstruct all of it and say, what's the point? And do you really love people and what is love? And all this sort of stuff, you know, when you've got that going on, you're trying to do the exposure to connect with people and diffuse from all of that, it's so tough. And to have someone who gets that and you can practice it. You can practice connecting with your therapist and build it up there, and then, like, FAP does, take that out into the world, you know, it's such a powerful place to practice that. And I think that would have helped me a lot. I had to sort of get out there, try and reconnect, feel immense pain and suffering, and it didn't feel helpful at all. But commit and trust the process and go for it. And then after a period of months of doing that, yeah, I started to feel awesome and, you know, have joy connecting with people and start laughing again and, you know, having fun and not. My mind wasn't trying to unpick and unravel social connection the whole time, but it's hard to do that. And if you have a therapeutic relationship that helps you reconnect out in the world after the impact of OCD on relationships, I think it's. That's so helpful, you know, in the therapeutic relationship.
- [43:37]
A
Absolutely. Good way of putting it, I think. Lastly, I just want to add, maybe there's also the risk that we can idolize our Therapists as we can idolize anyone and actually we want to. It's okay to really like my therapist who I mentioned I deeply respect, you know, and value and. But I don't idolize her. I probably did at one point in my life, but very much I humanize her now and. And in my mind that just makes her better because she's just a human that's trying to be caring and doing her best. But she's real.
- [44:11]
B
Like it's not fantasy. Good point.
- [44:14]
A
Yeah. 100. And that's why I think I just want to highlight that that's why I like act because in actual said act for anyone doesn't know, acceptance of commitment therapy should have been act. Act is, is for self disclosure if it's in service of the client. And I think when you share that, you know, the other week this happened to me and then I use this skill that we're practicing together and this is how I used it. You're showing that I struggle too. I have emotions too. I'm not perfect. You know, maybe I got angry when I was driving into work today when I'm working with a client with anger and I'm using that as an example or. And it shatters that.
- [44:55]
B
Yeah, yeah. There's power dynamics that can really be not so helpful and can kid us into. We're really helping people we don't even know because of the power dynamic. Yeah, I love that part of ACT and the metaphor of, you know, I'm on my mountain. The clients on their mountain. From where I am, I can see their route better than them. I've got a zoomed out position and I can see, oh, there's some dangerous features up there. And they'd be better off dangerous, but you know what I mean? Like the route would be better off to the right and curve around. But equally actually my client can see my mountain and they potentially could see stuff I'm not doing that is so helpful and workable in my life. And yeah, I think people do idolize you. And I always try to push back on that when I hear that. And you know, if someone puts me on a pedestal saying, oh, you've done this and that, I'll smash it down as quick as I can and say, you know, talk to my wife. This other area I'm struggling in, I mean, I'm proud of my recovery. I mean, I own that. I'm proud of what I've achieved, you know, in terms of OCD and where I've got to. But I, you know, we're all flawed humans. So I'll talk, you know, I'll be honest about what's been helpful, and I'm happy to celebrate, you know, the wins I've had that I'm proud of. But I'll smash down any sense that I'm not a struggling human and having difficulties, too. And I think we should all do that as therapists. And that's. ACT does that in a beautiful way. Functional analytics, psychotherapy does that in a beautiful way. Compassion focused therapy, all these modalities are really in favor of that. And, you know, I think, you know, it helps us, as Paul Gilbert, thinking of cft, would say, to think with our clients, not for our clients. Yeah, that's so important.
- [46:53]
A
Yeah. Yeah. Awesome. Is there anything else you want to bring up on the therapeutic relationship and ocd?
- [47:02]
B
I think the therapeutic side, I think we've covered a lot of things. I think there's so much we could say about OCD and relationships, but, no, I think we've covered all the sort of key stuff that feels most pertinent in my mind. Yeah. I'll maybe end with a Yolom quote, because we both like Irving Yalom, as many people do. And again, I'm not saying he's got the answer to ocd, but I think he's got a lot of really good ideas about relationships and therapy. He said the act of revealing oneself fully to another and still being accepted may be the major vehicle of therapeutic.
- [47:46]
A
Help, which is so true for ocd.
- [47:49]
B
Right.
- [47:50]
A
Like you're saying earlier, you share in these. These horrible thoughts we have and the compulsions we do that can be embarrassing. And for someone to receive that and still like us and care about us is.
- [48:03]
B
Yeah. So healing and. And also that might be the reason people do the erp, you know, Is that that foundation, then? Okay, I can go for it.
- [48:14]
A
True. I know. Being attacked by my cat, by his tail.
- [48:19]
B
Talking about relationships. Pets count, too, right? There's three.
- [48:23]
A
This guy loves me regardless, as long as I keep feeding him.
- [48:27]
B
And my dog helped me. You know, my old dog that I had helped me through many a tough time with ocd. So I think relationships with pets are another. A big source of unconditional positive regard and unconditional love.
- [48:42]
A
Yeah. And I've done an episode on ICDM Pets not too long ago with Emily Hemmending. So anyone interested in that? And ages ago, I did an episode on the therapeutic relationship with Steve Phillipson. I think it was called. Just call me Steve or something like that. Anyway, I'll put links in the show. Notes to both of those. Be any therapists listening that want to learn more about FAP. The training is in about five days on Friday the 16th, so link in the show notes. Cool. Thank you Johnny as always for coming on talking about this. Like you said, we could have covered it a lot more. There's tons we missed, no doubt. But I think, yeah, it's good occasionally to check in on therapeutic relationships.
- [49:21]
B
Yeah, definitely, definitely. And I appreciate our ongoing relationship as a source of support and, and you know all the good stuff we talk about here today.
- [49:31]
A
Good way of learning rupture and repair. 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, 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.