← The OCD Whisperer Podcast with Kristina Orlova
The OCD Whisperer Podcast with Kristina Orlova
179. Can DBT Help OCD? What Actually Works (ERP, ICBT & Emotional Regulation Explained)
00:32:58
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- [00:00]
A
Welcome to OCD Whisper Podcast, guys. If you find these episodes useful and helpful, please remember to subscribe and hit that notification bell on today. With me, I have Maggie Duray and we're going to be talking a little bit about her personal story and something called dbt Dialectical Behavioral Therapy. Does it even have any space or place for OCD and OCD treatment? So let's welcome Maggie to the show and please tell us a little bit about yourself.
- [00:24]
B
Hi, Christina. I'm so glad to be here. A little bit about me. So I am an LPCC in St. Paul, Minnesota. So I'm licensed in Minnesota, as well as Counseling Compact Privileges in Arizona. And I'm specialized in treating OCD and anxiety disorders using erp, icbt, and act. But as we'll talk about today, I also integrate DBT skills into the work. So that's me.
- [00:54]
A
Hi, I'm Kristina Orlova, host of the OCD Whisperer podcast. As someone who lives with ocd, I understand the struggles firsthand. If you're here, you're not alone. Before we start, grab your free OCD survival kit at www.corresults.com to help you take control. That's K O R results.com now let's dive into today's episode. Awesome. Well, so Maggie, let's. Let's dive into a little bit of your story. I love to hear a little bit about what got you into this work. I've seen that in some places you're kind of openly talking about also your own experience with ocd. So maybe we can start there.
- [01:41]
B
Yeah, so, I mean, like a lot of other folks, I am someone who was diagnosed with generalized anxiety disorder for years and years and years. Maybe misdiagnosed, maybe I have a dual diagnosis. But the OCD behaviors didn't become recognizable to a therapist until I was about 20, 21 years old in college. And it presented for me as a moral or religious career scrupulosity. And I really just thought actually I was just a person who was trying to be a very, very good person and a very good Catholic at that point. And I luckily had a therapist educate me on OCD and how it can present and recognizing that the behaviors and the thought patterns I was having were OCD behaviors and not just simply intense anxiety really clicked for me, something that I had never put together before. And then lots of different behaviors and thoughts made sense after that as well. But then doing some ERP treatment was really a game changer for me. And I've been in recovery since, which is such a Beautiful thing. So that's kind of how I got into the world of ocd and passionate about ocd. Although I didn't start there, started in dbt, working with personality disorders, mood disorders, depression. But then it was a really natural transition for me to start to specialize in OCD and anxiety disorders from there.
- [03:17]
A
Awesome. Okay, so can we talk for a second about, like, if I could like jump in your head and. And we can time travel back to when these things were all going on. Like, what are some of the things that I would hear? What would be the things that are going on in your mind that now looking back, you're like, oh, yeah, this was clearly ocd. Um, but I just didn't know it then.
- [03:38]
B
Yeah. And I think the thing that made it so challenging to see was that it was all mental. Right. And so that's just part of. I feel like part of my work in the world is just educating people that you could have literally no physical compulsions and still meet full criteria for ocd. So my mental compulsions were a lot of self reassurance seeking, checking list making, excessive prayer, excessive confession due to me growing up Catholic. And. Well, I mean, what. The things that were going on in my head, I at the time thought they were just simply real problems that needed me to solve them. Right.
- [04:22]
A
So
- [04:24]
B
like, what, what even. What college should I go to? What is the right path for me? What would. In this language that I was using in my head at the time, what would God want me to do? What is the right step to take here or here? And then what are all the potential consequences of every single avenue? And this feeling that it was my responsibility to somehow guess what God or some higher power or some cosmic energy required of me and it would be my fault I had strayed from the right path. And so it was just all sorts of things like that. Sometimes here or there, a little bit of, what if I go to hell? Or what if I'm a bad person? Come in. Honestly, not to rap about it, but. But honestly, it was more of like a just right. Manifestation of scrupulosity that had ties to this idea that magically there was a right path and that I should know because should have certainty about that. Which is something that, of course, there's just no certainty to be found about. So it was really powerful. I'm so grateful for that therapist at the time that recognized what I was going through.
- [05:45]
A
Yeah, well, like, I mean, if you're talking about faith, right. In religion, I mean, a big piece of it, right. Is Faith, it's. It's hope, it's belief. Right. So just, just that alone is. Is difficult to have some absolute certainty. You can have resolve, you can have a strong belief, but, you know, you're not always necessarily maybe. But then you have add the OCD layer to it, of course. Right. And now it's just like everything's up in arms. And I love that you named that, which is exactly what it is. We're trying to analyze and figure something out. Like we're trying to get to the bottom of something to get an answer to, kind of. Because it feels like there's this problem, this thing, it's happening internally, and I, I should get, get an answer somewhere somehow, because normally we do. Right. Except when you have OCD brain, then it's like, what's happening here?
- [06:32]
B
Right. It was so deeply distressing for me to not be able to come to some sort of answer or right answer about what I should do. And, you know, it was, it was ultimately not a faith issue. And whenever I talk about scrupulosity or religious, moral ocd, I always want to just spread the good word that if you are suffering with scrupulosity, it's not a faith issue. This is a medical or a mental health issue. Right. That's attacking the faith component. So for me, that was so powerful. I mean, my faith and my belief system has changed just naturally over time. But I have such a big heart for people now who OCD attacks their faith system, whatever that may be, just because it's so distressing and it is not an issue of their faith or their, you know, trust in God or any of those, like, values, true values that they want to live by. It's just a manifestation of this mental health disorder that's attacking this really important thing. So, yeah, I always have a big heart for that. Although I do treat, you know, every manifestation of OCD at this point.
- [07:41]
A
I mean, yeah, this is like when I see people sometimes talking about things like superstitious stuff, Right. And I know we can start to separate out and say, oh, there's superstitious ocd. I mean, if we start to get into the weeds, we can start to come up with infinite sub themes and topics. But, you know, ocd. Exactly. OCD is ocd. It's like, let's learn how this thing is dysfunctional a bit in how we're looking at things, how we're doubting things, and you know. Yeah.
- [08:10]
B
Like, it's so transformative about icbt, right? Is that it? Like out that it's the same sequence every single time. And so it doesn't matter what it is targeting, doesn't matter the content. Right. It's laid out in that sequence and that's how it plays out every single time, whether it be germs or religion or harm. I mean, it's just, it's kind of amazing to me that it does play out the same every single time. There's a pattern which makes it nice to treat because no matter the content, there's a ground, groundwork for us.
- [08:46]
A
Well, okay, so you mentioned that you did ERP and now you mentioned icbt. So I have to ask the question, right? Because you said you did. ARP was really great, especially at the beginning, but now sounds like you also know and learn icbt and you're like, oh my gosh, all of it, no matter what the topic is, follows the same sequence. So what, what did you experience for yourself? Different. Similar. Right, because they're different therapies. I know people still have a lot of questions about the stuff and asking, oh, can you just do two together or you know, how does this work? So just want to hear your own personal experience with this.
- [09:19]
B
Yeah, I think on this topic I want to hold a lot of nuance and I don't have, I don't have any absolutes, which I find it a little funny that in the OCD and anxiety world, us clinicians are looking for absolute answers. I'm like, oh no, the call is coming from within the house. But I just, I just think that there are thankfully, I would say three big treatments, three evidence based treatments, icbt, ERP and act. Right. That can target different processes through which OCD it manifests. And I think our job as clinicians, or at least this is how I see it, is to see the client in front of us and ask ourselves which form of treatment is going to best fit for how they think, how they see the world, how their OCD presents. So I mean, sometimes it's just an exploration for me with a client of do I think ERP would work best? Do I think ICBT would work best? ACT is kind of always in there for me just because values based work is so important. And then even like we may talk about here, DBT skills, right? Emotional regulation, distress tolerance, interpersonal effectiveness, they're all intertwined underneath. But as we have discussed, exposures versus targeting, the mechanism of inferential confusion are pretty much two different paths. Right? And so I think the question for me is always what will connect more and what will be most effective for the Client because they have both proven to be evidence based. From my personal experience, I'm not really sure that I fully went through structured ERP at the time. I don't think I was seeing a specialist, but I think we did some. Some of that. I know we did some of that and that it was helpful, just even a small understanding of exposure and response prevention. I would say, though, that an extra layer of healing happened for me when I learned to teach and practice ICBT with folks. It was like another layer clicked for me of, okay, not only can I just tolerate this uncertainty, but perhaps there isn't even uncertainty to be had, and perhaps I know I can know more and I can trust more. The idea of the real self versus the feared self really connects with me. So for me, it just kind of took it to a little bit of a next level for me. And I really just find both treatments to be quite helpful in their own ways. And I let the client guide me on what's going to be best for them, what they connect to most totally.
- [12:18]
A
I mean, as you're talking, when I've shared this before and I'll share it again, like, I started with ERP training myself and personally, like, I loved imaginals. They really. I don't know why, but I just really like them. It doesn't work for everybody, but for me, they were great. And like, I was one of those that did a lot of mental rituals. So response prevention for mental compulsions and even learning, well, what is compulsions? Like, rumination and then compulsively ruminating and all the different ways that we're trying to figure stuff out. Like, that was really a game changer to really get that difference. But then. And so that worked for a long time and it was wonderful. And still though, I would get caught in certain things and still think a certain way. And so, you know, took like a little while. But learning icbt, I similarly, at first I'm like, I think I get this. I do some of this. And then, you know, I realized later, oh, my God, I. I sound like a fool because I don't actually get it and kind of had to do it, you know, with. And thank God several clients said yes to me, you know, working with them. And we learned together over time, right? And now I, you know, understanding and suddenly seeing like my own internal process of, oh, I'm not just like, when
- [13:27]
C
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- [13:56]
A
I don't know, having some funky distortion around something, but like you said, it's like, wait a minute, I'm. I'm acting like I'm completely disconnected and don't know something when I do know things, or if I don't know stuff, realizing, wait a minute, this is an area where I don't know. I truly don't know something or maybe I don't know it yet and I need to wait. And it's like, wow, what am I doing with that space that feels tense and weird? And you know, we start to of course fill in the blanks from our own head. So it's such an interesting pivot and similarly took, it took my recovery to a different place. But then you also mentioned dbt. Right. So let's pivot to that for a minute.
- [14:33]
B
Sure.
- [14:34]
A
I mean I've certainly had people reach out, say, oh my gosh, can I just do DBT for ocd, like DBT by itself? Or I mean, I hear also, I'm sure you do too. A lot of folks hear things like can I just do hypnotherapy or can I do, you know, just EMDR or can I do art therapy or basically any other therapy, but some of the things that are there. So I know I put a lot of things out there. But since you did mention DBT and like you said, you have a, you know, great experience with it beforehand, what have you found and seen in terms of, you know, where, where is there space for that? Is there space for that in OCD treatment? Like how, how would that help somebody?
- [15:16]
B
Yeah, I mean my clinical experience has just taught me that there is so space for it. And I think my conceptualization of DBT and this is, this is what I was trained to, to believe as well, is like, it's a very foundational therapy. So it's, you know, just for, for the listener that may not know. It's an evidence based therapy created by Marshall Line derived from cognitive behavioral therapy. But basically she saw that there were things lacking in, in CBT that she wanted to include, I believe first. Her first thought was it was for folks with borderline personality disorder. So the intention was large, variable, volatile emotions and how do we help the, the individual with those experiences to manage the intense emotions to reduce self harm and to build what she calls a life worth living. I think that those things are so connected to the experience of ocd. I mean, managing intense emotions. Hello. Like OCD filled with distress, right? Filled with this emotional experience, reducing self harming behaviors. I mean, there's a certain way to look at it that compulsive behaviors are ultimately self harming, right? Maybe not in the very direct way that we think of self harm, but there's behaviors that contribute to our distress. And so in many ways that's a tie. And then building a life worth living, right? I mean, how many times do our clients with OCD just say, like, I just want to feel okay. I just want to be able to do this or that. I want to be able to live by my values or to focus on things that bring me joy and, and be in relationship or whatever it is that OCD is attempting to take from them. So I think there's a huge amount of overlap there. And it's so important to say that DBT is not an evidence based treatment for ocd. So how I think about it is that if we need to, oftentimes we need to do some baseline DBT skill work in order so that targeted evidence based OCD treatment can be done. Because as you know, depending on the treatment, but I mean, a lot of the different treatments can have some real distress associated with them, especially erp, which, you know, is, is exposures. And sometimes they can be extremely challenging to do. Often they are because the goal is to increase the distress and then habituate or inhibitory learning, depending on which you. You drive to. But all to say that OCD sufferers often describe this nervous system that feels completely hijacked. And a lot of my clients will say, maggie, I know this doesn't make sense, right? I know I'm thinking in OCD reasoning, but what do I do about this feeling? I can't tolerate this feeling and the emotional experience I'm having. And that is where DBT comes in. And I often have that answer for them of, okay, I actually do have this bag of skills that we can use to tolerate uncomfortable.
- [18:44]
A
Yeah, so let's get into that, right? Because people want to. Of course. Anybody listening ever to anything, any podcast, any show, I mean, we usually listen for a couple of reasons, right? Either A, I'm trying to just get some entertainment or something fun and silly and kind of, you know, because sometimes I, I need to do that, you know, and I'm sure everybody else does, right? But then sometimes you listen because you're trying to get education or something relevant for you, right? So when you're listening, then you're thinking, okay, just tell me what's the skill? What are the skills? What's the skill? What's the thing I can do? Because I need it now. So, you know, we explained a little bit of some of that. So let's dive into that a little bit, if you don't mind. Like what, what's something. Just give us an example that. Let's say I'm sitting with you and I'm like, oh, my gosh, I. I'm feeling this insane amount of guilt and this feeling of anxiety. And it's just, I feel like almost panicky. Like it's like really high. It's up there. I can't handle this. What do I do? What would you. What would you do with me?
- [19:36]
B
Yeah, absolutely. So, you know, there's four modules to dbt. Mindfulness, distress tolerance, emotion regulation, and interpersonal effectiveness. But I would say that distress tolerance is the module where DBT can really shine in that moment. Right. So client is feeling a lot of distress. Perhaps they're trying to resist seeking reassurance or compulsion or sitting with very uncomfortable uncertainty. My first instinct would be to talk about the TIP skill, right? So tipp, temperature, intense exercise, paced breathing, progressive muscle relaxation. This is my favorite to suggest, and it's the one that I find. People come back and say, oh my gosh, it worked. It worked. Okay, so my favorite would be using both temperature and paced breathing. So when we think temperature, we're going to want to go towards some intense and sudden cold shift. So here in Minnesota, where we have the great outdoors, so if it's cold enough, right. Going out in light clothing and having a sudden cold temperature shift can really kickstart the nervous system. It does that by stimulating the vagus nerve, that parasympathetic nervous system response that rest and digest, that connects the brain to all those other organs. Now, if you don't have access to the freezing cold and often even just when we're inside, right. I mean, as simple as an ice pack on the neck, on the under, eyes on like the bridge of the nose or the chest, anywhere in kind of this area can connect to that vagus nerve. And then it sends signals to the amygdala saying, we're safe, we're safe. And the reason for this is because of the. What's called the divers response, where this cold takes energies away from what isn't needed in our body, decreases the heart rate rapidly, and everything calms down into that rest and digest phase. Now I like to pair that temperature with paced breathing, right? So calm, deep belly breaths. And those two together. I come. I have people come back and just say, like, wow, I was way over my window of tolerance. And this helped me get back within that window of tolerance so that I could resist the compulsion, so that I could do something like distract. Like a healthy distract, where we're focusing on other activities, we're using some containment so that we're not obsessing about one particular thing.
- [22:33]
A
So I gotta jump in here for a second because, okay, so when I hear this, right, and I'm sure, sure you've seen this on the Internet, because I think this is where there's confusion and I just want. I want to hear from you because people will say things like, oh, my gosh, stop it with the iPad, ice packs when you're dealing with OCD or panicky, right? Or, oh my gosh, like, this isn't gonna. Because we know with ocd, it's so easy to start to. Or to want to really latch onto anything you can. It's like, this is gonna be the thing, the one thing that's gonna now save me. This is gonna be the thing I'm gonna grab. It's gonna make me feel better. But that's not what you're saying. And I just really want to kind of point this out and take a moment here because I. When I hear you, I. I think I understand what you're saying. But, you know, any. Any other person listening, you know, they're not in this world. They might go, okay, so I'll just go do that. When I feel intense emotions, and it's like, no, that's not what we're saying. So if I got you right and understood what you mean, you're saying basically, like, look, when your feeling is like you're 10 out of 10, you're. It's really high. You're just completely overwhelmed. You can't even fathom doing something. This is when a skill like this from dbt dialectical Behavioral Therapy can come to. Can be useful essentially, to apply. Just to help bring it down enough so that you can get back into that place where you can just kind of be in your body and the. In the experience of that discomfort, whatever that is going to bring. Breathe a little bit. So you can now kind of step in and do some of the work. If we're using ERP that you can do some of the work to do the exposure, to resist the compulsion and to take the next steps.
- [24:11]
B
You're exactly right. Yep. And so, and, and we do, all of us struggle, you know, looking for the next magic. Magic pill or magic button. Right. Easy button, like, okay, just tell me what I'm going to do that will make intrusive thoughts go away or make my OCD stop. Right. And. And that is never really the treatment goal of ocd. Like, intrusive thoughts are by nature intrusive and uncontrollable. But exactly what you said. This is the first line of defense. These are like crisis survival skills. Right. So this wouldn't necessarily be helpful if you were already in a regulated place place, but if you are in that so dysregulated place where you can hardly even form a sentence. Right. Hardly even get. Get a, A, A string of words together to describe your experience to a therapist even. Right. We've all had that client where they're so disregulated and so in their head that there's. There's really no therapy to be done until there's some regulation happening. This is where that comes in. So, no, unfortunately, ice packs do not solve ocd. Wish I had something as simple as that. But these are the first line defense skills, and they do come in. They do really come in handy so much, so many of us feel kind of like, oh, that's too easy, that's too simple. But, you know, we're. We're human. We need some of those kind of hacks to our nervous system to regulate ourselves. Especially when ocd, intrusive thoughts, obsessional doubts can be very, very distressing. I mean, the level of distress is unlike. Unlike anything I've seen really, in any other disorder. It's a very specific level of pain that people experience when it really floods the body.
- [26:01]
A
Absolutely. I love that, that we're clarifying this. And just for me, and I think this is definitely one of the last questions I want to ask. But when you're doing, when you're using icbt, do you find that you also sometimes need to use a DBT skill there or something like this?
- [26:17]
B
Yeah, absolutely. So this is where it comes in where someone will say, okay, I know I'm in the OCD bubble, or I know that I have a choice. Right. Between going into normal reasoning versus obsessional reasoning and the distress and the pain and the emotional intensity is so low loud that I don't feel like I can be skillful in this moment. Right. So all of that learning from ICBT is out the window because the prefrontal cortex is just simply not online. So if we can use DBT skills, whatever they may be, to regulate ourselves. There's going to be a way higher chance that you're going to remember any skills, any lessons, any sensory type of like, like reality sensing from icbt. And I know I, I consult regularly, regularly with Bronwyn Schroyer, who is so great with icbt, and she taught me to ask clients, did you listen to your nervous system alarms over what your senses are telling you? So if the nervous system alarms are going off so loud and your body is just screaming at you, red alert, red alert, red alert. There's not a lot of space for you to really ask yourself, what were my. What are my senses telling me this moment? What information are my senses telling me in this moment, which is a key part of icbt? And so that's kind of how I see DBT skills being helpful in that moment.
- [27:53]
A
I mean, yeah, this has been great and I really appreciate you sharing kind of your insights and your experience because, you know, I've certainly, when I've heard dbt, and I'll be honest, I don't, I'm not trained in it. I know of it. I know pieces about it. I know distress tolerance is something that historically in my ERP training was part of the training, but it was kind of put more together as kind of part of ERP to kind of, I guess, more holistic approach, you could say, but not discussed where, oh, this is specifically a DBT skill we're pulling from and putting it in a ERP process. Just like of course with erp, right? Like as, as it has evolved with acceptance, commitment, therapy, we started including more values or willingness, you know, anybody listening now, some of this might be like, what are they talking about? But I think all I'm trying to say is that, you know, we have different therapies and we have different things that have been studied enough to show that, hey, this helps. Basically, that's really what we're talking about, is that this helps. So it's great to hear that there are some tools and strategies we can take from other places and at least put it together and combine it with especially those really intense emotional moments. Because I certainly know, you know, with folks with just anxiety, even in general OCD or anxiety, any anxiety issues, right. The, the, the feelings are just of that anxiety and distress are so high. Right. Whatever it is, it could be guilt, panic, any of those. Right. It's, it's just so intense sometimes that it feels overbearing. And so it's great to know that while you can bring something like DBT and say, hey, let's practice learning to kind of regulate a little bit. I love that there's a mindfulness module. Right. I'm a big fan of that. I think it's so important to learn to slow down and kind of breathe and kind of inhabit your body again and, you know, feel like it's okay to do that.
- [29:46]
B
And there's so much to the mindful model. You know, we often have this idea of what mindfulness is, but you know, even just labeling thoughts as thoughts. Right. I'm having a thought in. Within. Mindfulness is kind of that cognitive diffusion. So in so many ways, OCD treatment is already. We're already talking about these DBT skills in different ways. And I think it's just a great moment to say, hey, these skills are kind of what we're talking about in these other therapies as well. And perhaps how it's laid out in DBT is. Is effective for someone. It's important to say that the. The DBT model that Marsha Linehan intended is a very structured, very specific model with individual therapy, with group therapy, with skills tracking and phone calls in between. And that is not what I do. Right. So I think it's important that we say DBT skills. I use DBT skills because the full model of DBT that has been shown effective for certain disorders is a full model that is not what I do with ocd. But some of those skills are always in my back pocket and are really helpful for folks.
- [31:02]
A
And. Yeah. And I think that's great. Right. Just like erp, we can either do more ACT based ERP or take some pieces from ACT and put into erp. I mean, I think at this point we're just kind of getting more into like, look, there's really. Right. I think there's just a couple of different ways right now that we know for sure that we can work with that really have a different approach. And I think it's more just with experience and training, you know, being able to weave in different pieces to essentially just help the person still get to the same outcome, which is to help you reduce the intensity idea of the whole OCD experience. That that's the bottom line. Right. We want you to get your life back and, you know, living.
- [31:41]
B
Yep.
- [31:42]
A
Yeah. Exactly. Exactly.
- [31:44]
B
There it is. Right. That's the. That was the whole point of Linhan's model of DBT is to get to that life worth living. And is that not what we want for ourselves and for every single client? Right. To be able to be in their lives and not let OCD boss them around 100%. That's kind of what we're doing.
- [32:04]
A
Yeah. Well, Maggie, thank you so much for coming on the show. And if people would like to find you, how can they find you?
- [32:10]
B
Right? So thank you so much for having me. They can find me at northlightcounseling.org or I have a Psychology Today page under Maggie Duray. As I said, I'm licensed in Minnesota, but I have privileges in Arizona as well through the counseling conference. So it's just such a joy to be talking to you about OCD and it's such an honor to be with you. You do such great work in this space and I've been listening for a long time. So it's really a pleasure.
- [32:41]
A
I appreciate that. Thank you, Maggie.
- [32:43]
B
You're welcome.
- [32:47]
A
Thanks for listening to the OCD Whisperer podcast. Remember, freedom from OCD is a journey and you're not alone. Visit www.coraresults.com to explore self help masterclasses like Sneaky Rituals with Jenna Overbaugh or ICBT Masterclass with Christina Inabe. Don't forget to grab your OCD CBT journal tracker and planner while you're there. If you found this episode helpful, please subscribe, share and leave a five star review to help others find the podcast. Together we can make a difference. Keep keep going and I'll see you in the next episode.
- [33:28]
C
When it's time to scale your business. It's time for Shopify. Get everything you need to grow the way you want. Like all the way. Stack more sales with the best converting checkout on the planet. Track your cha chings from every channel right in one spot and turn real time reporting into big time opportunities. Take your business to a whole new level. Switch to Shopify. Start your free trial today.