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Your Anxiety Toolkit - Practical Skills for Anxiety, Panic & Depression
454 Suicidal OCD vs. Real Suicidal Thoughts: How to Tell the Difference (with Taboo Tracie)
00:52:30
This episode dives into the crucial differences between suicidal OCD and suicidal ideation—how to spot them, how to respond, and how to support yourself or a loved one with skill, compassion, and evidence-based care.
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- [00:03]
A
Suicidal thoughts are among the most terrifying and taboo experiences a person can have. For some, they stem from a deep emotional pain and the desire to end their suffering. And for others, they're intrusive, unwanted, deeply ego dystonic hallmarks of suicidal ocd. But how can you tell the difference? And how can you respond with compassion, skill and care when it's happening?
- [00:30]
B
Take care.
- [00:30]
A
Today I'm joined by the incredibly brave and insightful Tracy Ibrahim, also known as Taboo Tracy, an advocate and survivor who has lived experience with both suicidal OCD and real suicidal ideation. Together we're peeling back the stigma and breaking down the critical differences, because some lives truly depend on it. Welcome to your anxiety toolkit. I'm your host, Kimberly Quindlen.
- [00:57]
B
Thank you.
- [00:58]
A
This podcast is for all things anxiety, OCD, BFRBs, a space to give you mindfulness based skills and science backed resources that you can bring into your recovery journey. So let's get started. Thank you, Tracy, for being here.
- [01:13]
B
Thank you for having me. This is like my most favorite stuff to talk about, so I'm really glad that we're talking about it.
- [01:20]
A
Yeah. So I first want to just like say this is a touchy topic. It's a really difficult topic for even me to even address because there is so much suffering around this topic and I want to do it with care. I know people want to do it with care and people are really, really suffering. So just for us to get like, what can we set as an intention, you and I, for our listeners to help them navigate this episode as we go into it?
- [01:52]
B
That's a great question. I think probably the most important thing is understanding the nuance and differences between when things are something that you need to pay attention to and take action on, towards safety versus understanding that it's part of depression versus understanding it's part of ocd. So really parsing out those things and then the overarching goal is to not let OCD get you stuck trying to figure it out because it's pretty cut and dry when you know the difference.
- [02:33]
A
It's refreshing for me to hear you say it is pretty cut and dry because I think people with OCD or clinicians who are treating people with depression, it's scary, right? And we want it to be cut and dry and it often feels like it's not. So let's go straight to like, understanding. So can you describe for me and we can chat back and forth on like, what is the experience of someone with suicidal OCD or suicidal obsessions?
- [03:04]
B
Sure. So suicidal OCD and Suicidal obsessions, which is one of my ride or die themes Since I was 10, 10 years old, is really this intrusive thought process. These maybe even intrusive urges, intrusive images that are telling you that you want to harm yourself or end your life or that maybe you're that way or maybe you're going to do that. And it can come up in so many, so many different ways. And I like to mention urges and feelings because a lot of people say, yeah, but, you know, sure, I have intrusive thoughts, but I really felt like I was going to do something. And so really highlighting that it can show up in all the different ways and that it's not always going to show up as maybe I'm going to do this. Sometimes it also shows up like, you're going to do this, you want to do this. This is how you're going to do this. You can't stop yourself. So. So I think those are important highlights.
- [04:08]
A
And I love that you bring that up because that's actually a lot of the questions that I have received from students or clients or even strangers on social media is they'll say, I hear that OCD is a condition where they have intrusive thoughts, what if thoughts? But mine don't sound like that. Mine sound like a command, like, you have to do this or you want to do this. And that can take them off guard because they're thinking, you know, I think that there is some unplanned reassurance that an intrusive thought is an intrusive thought. And when it shows up as a command or it shows up as an urge, and I think we all understand that urge feeling. You know, I do. I remember, and I use this as a simpler example, is I remember holding my daughter on a balcony and having the urge that I was going to throw her. Like, I felt this energy in my arms. Now, I would not never throw my child, but it did feel like my arms wanted to do something. And so that urge can be equally as concerning and perplexing.
- [05:13]
B
Absolutely. No, absolutely. I had this come up a couple of weeks ago. I'll just give you a really good example of an urge with suicidal ocd. My, actually, my daughter was in Australia for three months visiting her boyfriend, and my husband was in California visiting his family. So I was home alone. It was just me and the cat and the chickens. So of course, all my harm ocd, my suicidal OCD went to, well, you're home alone and they're going to find you dead. You know, there's no one else except the animals that I can harm. And I have had, really had this under control for a long time. It still comes up every day, but in terms of having it well managed and not distressing. And I was eating breakfast one morning, and all of a sudden my body just went into this extreme urge. Like you're going to run into the street and run in front of a car and you're not going to be able to stop yourself. And I was like, oh, I haven't had an intrusive urge in a while. And it felt like you said like this. I could feel the energy in my body was like, you're just going to run out the door. And so what I did was I faced my fear, actually. I was like, yeah, I know what this is about. And so I went and put on some running shoes. I was still in my pajamas. And I ran toward the street. And obviously I stopped before I went into the street with the cars, because I already know that this is. This is just one of my intrusions. And then I ran back in and finished my coffee and called it a day. But that's what living with suicidal and cd, that's very well controlled looks like. But it felt like for a second it was like, wait, this feels super real. Like, are you going to do it? And I was like, you know how this goes. You know what?
- [06:53]
A
You recently posted on social media, you were at a train station and you sort of was just standing there. And then in the video you go, well. And you shrugged and you said, I guess not this time. Which I thought was a really interesting approach or a beautiful approach using what we always talk about here on your anxiety toolkit, which is sort of like sort of a shrug it off or that's cool, bro, kind of nonchalant response. Do you want to share what that experience was like and maybe give, like, a real life example of how OCD impacted you in that situation?
- [07:29]
B
Sure. So my friend was coming up to visit me because I was alone at home. And so she was coming through the train station and I was like, all right, gonna go visit her. I knew in advance every time I go to this stinking train station that I get suicidal OCD whether I'm getting on the train or I'm picking someone up, because it seems odd. Maybe all trace stations are this way. I don't know. I don't take a lot of trains. But there's no guard rails or warning signs. They're sort of a different color strip where you could just. If you're Standing there, the train like. And you're really like, you put your arm out, the train would hit your arm. There's not really. There's like a little sign, like, back up, don't really be here kind of thing. Like, you know, little warning. And so of course I go up there and it's like, hey, you're gonna just actually throw yourself onto the tracks. And then it was like this whole conversation starts going on in my head and I'm not ruminating. This is just happening without me. Oh, well, you can't throw yourself too early because then somebody will come take you off the tracks. And then before the train comes, you have to wait till the train is really close so it doesn't have time to hit the brakes. So I was like, oh, yeah, you're right. That makes the most sense. You, you do definitely have to wait till the train's close enough that there's no time to job. So it definitely runs you over. So I was like. Went into my ERP mode. And I was like, all right, this is happening. And I felt my body. So I was like, what if you stand in the little area where I'm pretty sure you're not supposed to stand. Cause it's too close, but also the train doesn't hit you. And I was like, okay, I'm going to do that. So I felt my anxiety go up a bit, like medium amount. And I went and stood there and the train still wasn't coming yet. And it was like, what if the wind blows and pushes you in? And what if this happens? What if you get vertigo? What if you just. I don't even know why, but you just fall over? What if the train creates a win that pushes you over? What if somebody comes close to you and you get startled? What if you cough too hard? I mean, the most ridiculous things are coming up. And I was like, yeah, that's all possible. That's exactly why I'm going to stand here. Because I'm hoping that. I hope I cough so hard I fall on the tracks. Yeah, that's going to happen. And so that's exactly what I did. And I thought, well, let me share this experience, exposure with other people who are trying to maybe do lower level exposures to their suicidal STD to see if I can get through a really high level exposure. You can certainly do something less than this, if not the same thing.
- [09:53]
A
Yeah.
- [09:53]
B
And so that's exactly what I did. Sort of held that up there. The train was coming. And of course, the closer the train gets, the more My anxiety is going up, like, you're gonna jump. And I got the intrusive urge, see, you're just gonna flip yourself over. And I just waited. And again it went by me. And I was like, maybe next time. Because so far I've done this exposure about four times, and I haven't thrown myself in the tracks yet. But maybe another day.
- [10:20]
A
Yeah. I think it's so great that you. And thank you. I know it's vulnerable stuff, but it's so great that you can explain that minute by minute, because I think that really does give a deep understanding of what it's like for someone with suicidal obsessions or OCD in general. Like, it. It just is so dang creative and dramatic, and it can find its way into the every little corner of the potential problem and the potential consequences. Like that is just so typical of ocd. And so thank you for sharing that. For contrast, I mean, we can talk about treatment in a little bit, but for contrast, what is the experience of someone who has real suicidal ideation? What does that look like for folks who are experiencing it?
- [11:12]
B
Yeah, well, I think suicidal ideation or passive suicidal ideation, you know, for people that don't know, it's thinking about not wanting to be here anymore, thinking about not wanting to be alive. But maybe you're not quite at the part where you're like, and for sure I don't want to be alive. And for sure I'm going to do something about it. So it's sort of of the precursor or just a different space. So what I like to think of it as, and this is how I always describe it to people, and when I'm training therapists or talking to my own clients, I say, you know, humans don't get a pause button. If we had a remote control where we could just hit pause, fast forward, stop. I feel like sometimes suicidal ideation is that we're asking for a break. Can I just catch a break? And most of us can't take breaks from our life. There's no just, can I go sit in a. You know, on an island alone and not think about my problems? Nobody can do that. That I know maybe somebody. And so the thought that I don't want to be here anymore, a lot of times goes with that. So it's depressing. You're very stressed out and you're just like, I want to break. So that's what I think about passive suicidal ideation. I have that on and off. I don't know, at least a couple times a month, sometimes several Months in a row where I'm just like, yeah, it would just feel so much easier if I wasn't here anymore. I wouldn't have to do the following hard things. I wouldn't have to get through this tough situation I'm in. So that's what that's about. And maybe you've thought of ways that you want to do it. And I feel like that's sort of sometimes, especially for clinicians and sometimes also for people suffering, go, oh, no. But I thought of a way. And isn't that a problem then? I always say, doesn't everybody have a way? I mean, maybe I'm completely lost, but I feel like everybody who's ever thought of this thought of a way. I have a way. I'm not using it, but I have a way. That doesn't make it more dangerous. It just means that I've thought it out. Yeah.
- [13:10]
A
And so when do we then go into active suicidal ideation? What would that look like?
- [13:16]
B
You know, that's going to look like, first of all, that you recognize that you have given up. You recognize that this is too much for you, and you recognize that you would like to start making steps toward researching and moving toward that plan or a plan. Maybe you're looking online for ways to do it. Maybe you're looking around your house, Maybe you started collecting pills or looking up dangerous combinations or, you know, giving your stuff away, saying goodbye to people. Like, really, you're actually an active planning to go toward ending your life, not wondering if you're going toward it, not wondering if maybe that's what this is about. It's. And as somebody who has had that type of suicidal. Active suicidal ideation, and I've had a couple of obviously failed suicide attempts, it doesn't feel. It didn't feel anything like my suicidal ocd. This felt like the true bottom, hopeless. I'm done. I don't have the energy to go on, and I'm going to do something about this.
- [14:27]
A
Thank you for sharing that. And so you've beautifully outlined the difference between these three. So there's suicidal ocd, there's passive ideation, which you've talked about it being like, it's not that you want to die by suicide. It's more of just like this, too hard. And I wish there was an easy way to just eject, you know, what's so difficult? And then that more active suicidal ideation, which is the plan, the intent, the moving towards that plan, there's action involved. Is it possible for folks to swing between these three areas. And if that was the case, what would you suggest they do?
- [15:11]
B
Yeah, definitely. Because I'm somebody who definitely has switched between the three over time. I have a depressive, persistent depressive disorder on top of my ocd. And I would say, yes, first of all, yes, you can be on any given day in any of those places. And if you have suicidal ocd, it's probably going to latch on anytime that you happen to be depressed. That's just one of the triggers. Tends to be for people with suicidal ocd. Now I'm depressed. Now it's more likely that I'm going to have this thing happen, which is true. So I think it's about staying in contact with. If you're in treatment, letting your therapist know if you're at that hopeless place or you believe you're really close to it, or you really feel like, I don't want to be here anymore, and making sure that they know that and that they get you somewhere to be safe. If you're not in treatment, recognizing that for yourself. So that you do go to a crisis center, you call your local crisis number, go to the emergency room, you get evaluated so that you can be kept safe while people help you kind of regulate back to a place where maybe it's just passive now and maybe we can get our life back on track. But I would say to me, it really kind of goes more along with the depression. Are you doing something about it? Are you not doing something about it? Because I know a lot of studies show, like, you know, untreated OCD can increase depression, but also depression can get better as you get your OCD treated and vice versa. You can do better treatment for your OCD when you're less depressed?
- [16:50]
A
Yes.
- [16:51]
B
So all these things are really connected. So you can see how they all play with each other over time. Because maybe you're doing better this month and so everything's better, and then maybe the next month something really hard happens. So it's really knowing the difference. Like, I know the difference. Like, if I really was wanting to jump in front of a train, I wouldn't go to the train station and stand that close to the tracks, for instance. I would know that I intended to do that. And I wouldn't go to the train station. I would go get myself some help. Right.
- [17:23]
A
And so what I think you're saying, and you can correct me if I'm misreading this, but if you're having real active suicidal ideation, we don't do exposures for that. We actually go get help that's it. If you're having intrusive thoughts, intrusive urges, intrusive commands, then you would move more towards what we talk about here a lot on your anxiety toolkit, which is using exposure and response prevention. You would engage then on those skills.
- [17:52]
B
That is correct. Exactly. If I had been thinking at breakfast, if I was crying and just thinking about how I wanted to end my life and I was going to run in front of a truck, I wouldn't have put on running shoes and run through the street. I did that because I knew that that did not agree with what my values were in that moment.
- [18:11]
A
Yeah. And you that. So that's a beautiful little nuance piece here, is you're obviously an expert in this area. You know, you've had a lot of experience. You obviously are very good. How would someone who's new to this start to know the difference? Because like we've said, commands can feel intrusive. Commands can feel like active suicidal ideation. So can you talk us through, like, how might somebody identify what is OCD versus what is a real danger to their wellness?
- [18:43]
B
Yes, I love that question. And I talk to therapists about this probably every week because it's dear to my heart. As somebody who had suicidal OCD that was misdiagnosed, it wasn't assessed properly, it wasn't treated properly. And I think one of the biggest errors. It's going to sound nuts, but I'm going to call it an error that people will say, I want to error on the side of safety and put this person in the hospital. And erroring on the side of safety, when you actually. You just don't know how to do this assessment properly can cause clinical harm. So causing one kind of harm instead of a different kind of harm is not better. You know, it's somebody that spent 29 hospitalizations with suicidal and homicidal OCD sitting in seclusion, where people are telling me I'm a harm to myself when I'm not. That's what created me to become suicidal in real life. So I like to point that out because that's probably the number one thing I hear is, yeah, but I want to be careful. You want to be careful. You have to do an excellent assessment. You need to ask a million questions if that's how long it takes you to figure it out.
- [20:00]
A
As a clinician.
- [20:01]
B
As a clinician. So when somebody says, oh, my gosh, I just. I can't stop thinking about harming myself. I'm thinking that I'm going to. Whatever I'm going to, you know, stab myself. I'm hiding all the knives and sharp things. Well, somebody who wants to do that. I wonder why you're hiding them all. Are you hiding them because you're afraid of doing it or you're hiding them because you want to do it and now you're scared and you're going to go to a hospital. Explain this to me. You know, I'm having thoughts about it. Okay. And, well, I have images about it. Okay. But I feel like doing it. Okay, so tell me, what are your reasons for living? Sometimes it's those protective factors, as we call them. What? Why wouldn't you do it? Oh, I want to see my kids grow up. I want to do this, I want to do that. I have all these things. I want to travel. That doesn't sound like somebody that's actively suicidal to me. It sounds like suicidal. When you are not inspired by things anymore, you're not looking forward to the future. I think about that very first hospitalization at age 10. The question was, have you had thoughts about harming yourself or ending your life? Yes. Done. Book closed. We're done. You're going to the hospital. The follow up questions could have been, have you ever thought of a way to do that? Yes. Okay, so now it's getting a little nervous. Okay. Do you intend to do those things? No, it scares the heck out of me. Oh, okay. Done. Hands washed. They could have just put me into some OCD treatment and we would have called it an afternoon. But they were erring on the side of safety, as they call it, and did 10 years of clinical harm instead. So I think really it's asking questions, but also recognizing how somebody, even just their presentation. I think about the difference between when I had untreated suicidal ocd, these thoughts were terrifying to me. When I was truly suicidal, those thoughts were welcome. These were welcome thoughts. These were. Yes, absolutely. These. This is not distressing. It was. I was distressed about life and that's why I wanted to do this. And that's clear line difference. I'm going to do this. Let me go figure out the best way to do it. Not. I'm distressed by all the thoughts coming to me about ways to do it. What if I do this? Oh, no. What if this means something versus I'm done?
- [22:43]
A
Yeah, I know. For me, clinically, I remember when I was younger and greener in my work, I had a client who had suicidal obsessions. And you know, as a new clinician, you're kind of like kind of reading off a script Almost, you know. You know what it's like. It's kind of horrifying to think back, but I was asking her those sort of very good clinical questions, and her answer kept being, I don't know. But I don't know. I don't know. Like, you know. And I think that is also a little gap that a lot of clinicians are like, well, if you don't know, we will err on the side of like. So what are your thoughts on if someone's experiencing that? Well, like, I'm not sure. I think it's ocd, but I don't want to do it, but I feel like I do. And they're sort of like, teeter tottering back and forward. What can you share about that?
- [23:36]
B
Yes, I think that happens a lot. I actually. One of the things I say is don't expect the person to know whether the difference. This is your job. If they're coming at you with confusion. That sounds like OCD to me, because you're not confused when you're suicidal. You're like, this is a terrible life. I'm done. I don't want to be here anymore. What's the point? Yeah, that sounds very different than I don't know, which is how I used to answer all the questions when they would ask me on a weekly basis. Are you still thinking about it? Yes. Do you. Have you thought of some ways? Yes. Do you want to do this? I don't know. Right. I just keep thinking about it, so probably. Right. Seems like it. Why would I be thinking about it constantly if I didn't want to do it? Try saying, you know, confusion isn't the same thing as being suicidal and being done life.
- [24:31]
A
Yeah. And it's so nuanced, isn't it? And I think it does just take the. I know as a clinician, I think the first thing I. What I would say here, and I maybe should have. I apologize. I should have said this at the beginning of the episode. For folks, is. Is it's okay to falter on this conversation? You don't have to say it perfectly. You may need to ask the question. As a clinician, I know I've had to ask the same question in a couple of different ways because it is an uncomfortable conversation. You're not going to clinically present it, like, diagnostically with all the right words. So I think it's a messy conversation, and we have to be okay with it being really messy. And maybe you're. I don't know, Tracy, if you've got it down Pat. But I have to really let it be messy and we both are gentle and slow it down. It isn't just a yes or a no. It might be asking more questions.
- [25:26]
B
Exactly. No. Because everybody sitting in front of you is also a different individual human. So there's not one way to go about it. Everybody presents differently. Maybe you have a history with this person so you know their history. Maybe they're brand new and you don't know a lot about them, so you're still trying to figure it out. But no, absolutely how you ask. You know, again, it just, it's just asking so many questions. I've certainly had to ask and ask and ask and ask. And then usually when I'm sort of like, okay, let me go with this. Do you have any reasons to live? Is I'll shift into. Give me your protective factors. Why do you want to be on earth? What would stop you from hurting yourself right now? And when there's this nice list of things that make sense or at least some really valid things, I'm like, okay, well that, so would those things would you say, keep you from doing it? Kind of like, yeah, like, oh, okay. I think we've arrived at a conclusion.
- [26:27]
A
That, yeah, it's, it's exactly it. Okay, so if you're looking for effective OCD or BFRB treatment that's covered by by insurance, I'm thrilled to announce to you this week's sponsor, nocd. NOCD provides live face to face video sessions with licensed therapists who specialize in OCD and related conditions through exposure and response prevention therapy, a highly effective treatment designed specifically for ocd. Their therapist can can tailor a plan just for you. NOCD's treatment approach is clinically proven to significantly reduce symptoms. With an app that helps you stay connected to therapists and peer communities in between sessions so you'll always feel supported. NOCD is available in all 50 states and even internationally and accepts most insurance plans, making care affordable and accessible. If you think you might have OCD or are struggling to manage symptoms, there is hope. Book a free call@nocd.com you don't have to struggle alone. Big hugs. And now let's get back to the show. Another area I just want to touch on really quickly because it's at the top of my mind is I've had clients who have been consistently having suicidal obsessions but go in and out of depression. And as a clinician, I also often keep a check with myself of don't just assume it's suicidal ocd. Too often, if someone Says, oh, I've been having an increase in suicidal thoughts. There have been a couple times where I went to say, like, oh, that's, you know, we just practice your ERP or. And I had to pause and be like, no, do an assessment. It's not compulsive to do that with a client. It's not create, it's not doing co compulsions in session. Like you're allowed to help them to arrive at how they might respond. So I just wanted to bring that up as well, just because I've fallen into that trap of sometimes we can go the other way and just assume it's all suicidal ocd.
- [28:48]
B
Yes, it's absolutely true. And even further is make sure that every time someone says that they have suicidal obsessions that you're not doing a full suicide suicidal risk assessment. Because then that feeds into, oh no, maybe you're suicidal and I don't know. And I'm doing a suicidal risk assessment every session. It's like knowing the difference between, wait, now you're, you're actually, oh, you're having more depression.
- [29:12]
A
Yes.
- [29:12]
B
That's gonna tweak something in my head. I'm gonna ask some questions. Maybe you just look more depressed, but you're not saying you're more depressed. Then I'm noticing the depression.
- [29:22]
A
Yeah.
- [29:22]
B
And so really going, has anything changed? Do you think about this? Have you started thinking about it differently? Have you started having different considerations when it comes to that being suicidal or having these things? Does it feel different?
- [29:36]
A
I love that. So let's work now backwards so I think we're clear. If you're having active suicidal ideation, go to safety, tell somebody, let them know if you're having passive suicidal ideation, what does the science backed treatment for that? When you're having depression, you're kind of giving up, you're hopeless, you're helpless, you feel worthless. What might be some really helpful skills or strategies someone can use if they're experiencing that, disregarding whether they have OCD or not.
- [30:13]
B
Yeah, just purely just you're having passive suicidal ideation, which can be part of depression. Yeah, I get that separate from my OCD quite frequently. And I use behavioral activation therapy, which is basically, I love to just juice it as easy as possible. All the things that you would normally do if you weren't depressed, that feel really hard and you don't want to do them, do them anyway. That's like the whole therapy in a nutshell. It's pretty easy. Sounds easy, but it feels really hard.
- [30:44]
A
Yeah.
- [30:45]
B
So I do that for myself. So if I wake up sometimes I'm just having like a really stressful situation at home or just in my life. Just being a human is hard sometimes. And I'll wake up and I'm just like, I don't. I'm going to call out of work today. I'm going to cancel all my clients today. I just, I'm going to sleep. I feel like crying. I don't want to do anything. I'm not going to shower. And then I'm like, just kidding. What would you say to somebody else suffering like this? And I'm like, you have to go to work anyway. You have to shower anyway. Go brush your teeth. I'm like, whoops. You know, and even if I have to. And this is real, like sometimes just pulling myself out of bed could be really rough. When I'm in that, I will roll out of bed and fall on the floor. As an interim to getting out of bed, I will crawl a little bit. If I have to, I will like pick myself up and I'll be like, hey, one thing. Just do the first thing you normally do. So, yes, having sunshine. Like, I sleep with blackout curtains, so it's pretty much a depression room until you open them and sunshine comes in. So I'm like, open. I don't want to open it. Too bad. You know, I have to open it. I have to see the sun and I have to take a shower and. And then I always tell people it's not because you will necessarily feel better right away when you're doing these things.
- [32:06]
A
Yeah.
- [32:06]
B
Over time. You do this over and over and over. And there's some chemical alterations that are going to happen in your brain that help cut through that depression and that passive suicidal ideation. Go do the enjoyable things even if you don't enjoy them.
- [32:24]
A
Yep. Yeah, that's what I say. Schedule pleasure. Even if they don't feel pleasurable, Schedule the things that used to make you feel some, even at 1% degree of pleasure. I love that. Excellent. Okay, and then now let's sort of pivot to folks with suicidal ocd. We're going to use exposure and response prevention. Is there any nuanced or subtle adjustments you make to an ERP plan for folks with suicidal ocd?
- [32:58]
B
I do not. So I'm just one of those people that. Well, I guess I'll say a couple things. One is ERP in general. I only use it 60 plus years of scientific based therapy works for everybody. Been using it for 20 years with clients. Been stayed well myself. Using it for 20 years. I happen to be medication resistant, so I only have ERP on board to keep me this well. So all ERP out the door is always safe and legal and ethical and it doesn't go against anybody's morals or values. There's nothing dangerous about it. And so because of that, that goes across all themes I'm treating. I don't make any adjustments because people think. I know, but isn't it scary that, you know, they're afraid that maybe they're going to, you know, do something with a sharp object? Shouldn't we put them away? The answer is no, because that would make it worse. That would make you fear that you'll do something that you're not going to do, which is the same as fear. If I don't wash my hands, I'm going to get whatever germs or illness. It's not different. So, no, actually we go toward it, but we don't ask anyone to do anything that's unsafe. So it wouldn't make sense. Like, I mean, I could show you if you want, but I keep a very large knife next to my computer station at all times because I have suicidal OCD and I have this intrusive thought at all. Let's see it. I'll show you. This is my suicide slash murder knife because I have suicidal and homicidal ideation. I'm just kidding. I actually have the ocd. So this has been there forever. Actually. It's amazing at all.
- [34:41]
A
And the reason next to you all the time.
- [34:43]
B
All the time. This is always. It's actually next to my mouse pad at my computer at all times. And the reason I have such a large knife is because I have had solid for probably the last year the intrusive thoughts and images and urges that I was going to take a knife that's large enough to go in my throat one way out the other way. And then I would always do it while I'm on a zoom call, by the way, either with a client or running a support group where I then also traumatize other people. And they all learn that, just kidding. If you have something sharp next to you, something bad will happen. And so I use this specifically because it fit. It's large enough to fit the bill for what it's saying and I keep it handy and there's nothing dangerous about that. Now. Yeah, of course we're going to work up a hierarchy. I'm not going to just meet somebody and say, put a large knife next to yourself at all times. We have to start an Erp low. Think about what if you were, you know, buttering your toast with the butter knife and your daughter walked by? Would you also butter your daughter? You know, whatever.
- [35:48]
A
And I saw the most awesome reel this morning of a mom who. Who had gotten. Taken her baby's booty off like a little sock and butted the little toes and put it between two croissants and.
- [36:03]
B
Pretended to eat it. And she would.
- [36:05]
A
She posted about how this would be.
- [36:06]
B
An exposure for some people.
- [36:08]
A
And it just cracked me up.
- [36:09]
B
Oh, my gosh. Exactly. See? But somebody who had Hormo CD with their baby, that might be an excellent, excellent exposure, especially if they have cannibalism ocd. I mean, I feel like that one's good for like five things all at once.
- [36:23]
A
Sorry, I didn't mean to cut you off, but it just cracked me up so much.
- [36:27]
B
Yeah, no, I mean, so. So, no, I don't make any adjustments. I'm somebody who does very high level exposures for myself. But also, not everybody has to do really high level exposures. Sometimes you just. It's altering treatment to be appropriate for the person who's right in front of you. And I think that's what's important. Sometimes I have people that are like, listen, we've gone all the way up my hierarchy of exposures, and I'm still a little bothered. I'm like, you want to go next level with me? They're like, sure. Like, all right, train station platform. You know, that's when we start getting into the, like, larger things.
- [37:04]
A
Yeah.
- [37:05]
B
So I almost consider them to be preventative. Not that you can prevent ocd. Preventative in that I'm not waiting for my themes to come haunt me because I'm always haunting them. Yes.
- [37:18]
A
I call it the insurance policy on your ocd. If you're willing to go to the top level, that's your insurance policy on your treatment. It's not that it will prevent it from coming, but it's a really good way to put a long term guarantee on the changing of your brain. So just before we move on, I got another few questions about exposures for suicidal ocd. Do you also implement scripts imaginals? What role does that play in the treatment of suicidal ocd?
- [37:53]
B
Yeah, you know, I find everybody's a little bit different, so I try different things. So, like, on a lower level, we might just be writing down a triggering word like suicide or end my life or draw a picture of a knife or writing a script about it, or writing a goodbye letter or writing. And then I Ended my life and then making a funny ending actually, like, and then my kids had a party with all the money they saved because they didn't have to buy me Christmas gifts. That's a big one I like to do. It adds in a little cognitive diffusion or humor techniques that sort of make it sound silly. I'm a very, very big on humor because nothing about OCD is funny. It never feels funny. It doesn't feel humorous. I tend to keep humor in all of my stuff. Very few people, actually that I work with don't like it. Sometimes someone's like, listen, I don't want to laugh about this. And I'm like, fine, we'll take it seriously. Write a script and make it serious and don't have a funny ending.
- [39:01]
A
I do think that building humor into it is key though.
- [39:06]
B
Right.
- [39:06]
A
Because if you do. Not to say that people who want to keep it serious, that's not that they're doing anything wrong, but when we treat it like it's serious, we're still training our brain to take it serious. And I feel like if we're willing to sing it to the Happy Birthday song, which is one of my favorite things, or to I play a game called one up. Like you. I'll say what I think is scary. You make it worse, I'll make it worse. Even still, you make it worse. We're one ing up each other. I do believe, especially for these, like, scare, like taboo topics that are highly misunderstood. Bringing humor in is almost crucial. Would you agree?
- [39:45]
B
I would 100% agree. I use humor constantly. I wish I still had it here because it's funny. I made myself a suicide bowl the other day, which, like, what is a suicide bowl? I took a lovely glass. Like, I don't know, maybe it's like a fruit bowl or salad, fish bowl or something. Yeah, like some very beautiful. It's like from your kitchen, like something you would serve in. And because my OCD was just. The suicidal OCD was like, maybe you're going to take pills, maybe you're going to stab yourself. Maybe you're going to. So I went around the house and I got a couple different knives, I got a bunch of pills. I put a little bit of mouse poisoning in there. I just. I found several items and I put them in and I put in a beautiful bowl and I put it on my desk. And so that was just, you know. You know, and I was like, I like variety. Yeah, that's just something funny to say about cocktail. Yeah. I was like, you know what I like to keep my options open. And so it's an exposure, but also it's funny. Like it's kind of funny to have a delightful bowl. Why does it have to be in a beautiful glass bowl with like beveled edges? Well, because it's silly, that's why. Yeah, I want it to be beautiful.
- [40:57]
A
I love that you do that. I, I do think I, I have found that in my experience, you know, 15 years of experience, the folks who are willing to take light and be creative in your exposures tend to do better. Let's now talk about what happens or what would you do? How might we modify treatment if someone is having active suicidal ideation and having suicidal ocd? Maybe they're having active suicidal ideation because they're so depressed about how terrible verifying their OCD is. Maybe they have a coexisting condition or they have multiple different obsession subtypes and it's just too much for them. How might we modify treatment for those folks?
- [41:47]
B
You know, I like that question and a lot of people ask me like do you just stop Erp like what do you do? So what I'll do? And there's not like 100% perfect answer. Everybody should always do this exact same thing. This is just what I, I say. We're going to stop exposures right now. We're going to focus on response prevention. So we're going to still focus on not compulsing, but I'm not going to add the distress of exposures to you right now. But we're also not going to ignore this because I don't want your OCD to get worse. So I'm still going to ask you to use non engagement responses and response prevention messages and do the things that keep you from compulsing. We're going to do a lot of behavioral activation, but if you're actively suicidal right now in this moment, I'm also going to actually probably put you inpatient to help you be safe. If you're at that level where you're actively suicidal, I'm not going to keep you on an outpatient basis. Probably let's your light two notches this direction of that. As soon as you're at that, I'm going to help you get somewhere that you can get that, make sure you're safe and then come back out if you're sort of right before that and you're not quite there yet. I'm going to do some behavioral activation is going to be my main focus. We're going to work on building hope and we're going to work on making sure you're not compulsing.
- [43:10]
A
Yeah. Yeah. Thank you for that. Often parents will ask me, let's say that I have a young adult or a teen who have both. And of course, parents are anxious, too, because no one wants to see their child in that situation. The parents want to keep checking on their child. Right. And. And making sure they're okay. How might we help the parents or the loved ones? The partners support the person if they're having both or one of these conditions.
- [43:42]
B
Yeah. I mean, if somebody strictly has suicidal ocd, you're not going to keep checking on them. You're not going to ask them how they are. If they ask you to hide something, you're not going to. If they say, do you think that this means that I'm going to do something? You answer, maybe. I don't know. Could be. Not really sure about that. Maybe you should talk to your therapist. I have two out of my three kids have ocd, so I get to practice this as a parent sometimes. Yeah. I don't know. Sounds like it could be amazing or terrible.
- [44:13]
A
Yeah.
- [44:14]
B
They're like, however, when people are actually depressed, maybe they really are suicidal or passively suicidal, doing regular checks, just sort of paying attention to have their eating patterns changed, have their sleeping patterns changed, Are they isolating more? Kids tend to isolate in their room. Partners too. What it is about bedrooms, I guess, because you could just lay there. Maybe somebody isolates in their living room if you don't have a bunch of kids running around. But Nick's noticing those behaviors and then checking in with somebody. Is there something that I can do? You know, has anything changed? You know, can I get you. Can I help? Can I join? Maybe if you're in therapy. Would you be okay if I joined? Even part of one of your therapy sessions so I can learn more about this or help them understand what's going on. And that goes for the OCD or just depression. I'm a big fan of having family members, loved ones come into a session and ask. I recently did a session with parents who were like, well, you know, they. She's always asking me, you know, do you, mom, can you like, you know, I. I need you to hang on to all my belts. I don't want to hang myself. And I need you to hang on to mom, get rid of all this stuff. And I was like, no, I think you should just pull it all out. Yeah, just pull it all out. That's what I would do, you know, and mom and I actually, we had a loose belt, each of us in session that we wore and the kid didn't want to, that was okay. And we're like, we're gonna wear the belts around like it's a necklace belt. Do you like it? Do you like it? Do you want to wear one as well? So also sort of being. Showing people, whether it's a partner or your child participating can be helpful because you got a ZRP therapist. Sometimes, you know, I'm like, listen, you want to hold the knife? I'll also hold the knife. How about that? You know, you'll do that. I'll do that with you.
- [46:07]
A
Amazing. Amazing. You are amazing. This has been so wonderful and I think really on point in helping people find a very compassionate, rational, effective way to differentiate between these three really difficult experiences. Is there anything left that we haven't said? I mean, that, you know, of course there's a million. We could go on for hours talking about this, but is there something, some point that you feel like we really need to cover here to really hit this home for folks?
- [46:42]
B
I would say from different angles, right? If you're a clinician or you're a provider who treats these things and you're not comfortable in knowing the difference, make sure that you consult with people who do or refer out to somebody who does. Don't try to do something that you don't feel competent in without good oversight, because that's when things go wrong. We don't like mistreated any disorders. If you are somebody who's suffering from a condition and you're being treated and you feel like things are getting worse and not better, it's also okay to tell your provider that it's also okay to switch. I feel like sometimes people get really attached, but I really like so and so I've been seeing them for a long time. Well, that. Okay, but like, are you getting better? Is my question. Ask yourself if you're getting better and if you're not getting better, seek evidence based treatment. Even. Sometimes people will say like, this is evidence based treatment or I am doing something that's helpful. If you don't feel helped, go find help elsewhere, you know, so that you can get that treatment that you deserve. And know that there's always hope because it doesn't matter what your history is, it doesn't matter. You know, like, people are like, oh, it's a miracle you're here. I'm like, it's not a miracle, actually. I'm just here. I'm a person and I have this History. And don't be afraid of people's history, I guess, would be the other big thing. I get that a lot. I'm kind of afraid this person has done this be in the past, it's been like this and this, and now they're saying this. And I'm like, oh, you just described me. Do you want to put me in a hospital today now? Okay. So don't be afraid of a presentation. If you have your own anxieties. Like, get consultation for it. Yeah. Find out so that you can get better at it. If you care to get better at this particular thing. And if you're not comfortable, just don't do it.
- [48:35]
A
Yeah. Amazing. I love that you talked about that too. That as clinicians, we have to check ourselves.
- [48:42]
B
Yeah.
- [48:43]
A
And our own anxiety that shows up. So that's really, really, really wonderful. And I think too, I would add, for folks who have been, let's say, mistreated or misdiagnosed, just continue to look for OCD trained clinicians. A lot of folks have been admitted to a hospital incorrectly. But if you know, again, just make sure you're doing a thorough. Ask the questions before you see them. You know, have you had OCD training? Do you know what ERP is so that you know that these are people that will be able to handle you and your condition?
- [49:17]
B
Yes, exactly. Exactly. And every therapist is not for everyone. Like, I'm not for everyone. There are people who are looking for somebody that's like extremely fluffy and soft and delicate. And I just tend to be like, are you suffering? Yes. Do you want to get better? Yes, I'm very solution focused. Let's get on it. Because you have to get better now. It, you know, and so sometimes you are with somebody who's trained, but it just doesn't feel like a good fit. And that's okay, too. It's okay to go find somebody who feels like a better fit for you.
- [49:49]
A
Yeah. Yeah. Beautiful. Tracy, where can people hear about you more, learn from you more, get in touch with you? You are literally dynamite in this area. So tell us everything.
- [50:01]
B
Thank you. Well, I'm actually very minimally on social media just because I feel it drives me nuts. So I'm only on Instagram at Taboo. Tracy. Tracy's T, R A C I E. Because I'm unique like that. And yeah, it's all about OCD advocacy, Taboo themes, some of my exposures, a lot of stuff about treatment.
- [50:24]
A
So, yeah, it's a really, really good Instagram. I love it's there. There are no other Instagrams like yours, yours. Yours is raw and to the point. It's exactly you. It's so good. I just find it's. I tell all my staff to follow you. It's so good.
- [50:41]
B
Thank you. That's so sweet. I mean, I'm on LinkedIn in case anyone was like, and what. What are her credentials and where has she been doing the last 30 years? You could go to LinkedIn and find that out. It's a little less exciting. I have no exposures on LinkedIn, it turns out, just my credentials.
- [50:59]
A
And where can people work with you?
- [51:01]
B
Well, I have a couple of different areas. I work at NOCD, which you go to NOCD.com and I also have my own private practice, Specialized Psychological Services. I'm not always taking new people in either area. Sometimes I'm full, believe it or not, but always happy to reach out and we can talk about it. Amazing.
- [51:22]
A
Thank you. I truly am on it. This was a beautiful conversation. I feel like you covered a lot in a very short period of time, so you should be very proud.
- [51:31]
B
Thank you. I'm so glad just to be here and have somebody who can talk about these things in an intelligible way to spread real information. I mean, this is like, this is what I live for, actually. I live for a bunch of things, but this is one of the major things that drive. This is my passion inside. This is what gets me out of bed when I'm depressed. You will get up and show people how to do this. I'm like, oh, that's true. You care about it.
- [51:55]
A
Yeah. And it's true. You do. It's a very inspirational.
- [51:58]
B
Truly, it's really, really cool having the space to do it in.
- [52:02]
A
Yeah. Thank you. Please note that this podcast or any other resources from CBTSchool.com should not replace professional mental health care. If you feel you would benefit, please reach out to a provider in your area. Have a wonderful day and thank you for supporting CBTSchool.com.