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Your Anxiety Toolkit - Practical Skills for Anxiety, Panic & Depression
478 OCD Core Fears with Michelle Massi
00:28:32
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- [00:02]
A
Welcome back to your anxiety toolkit. Today we have the amazing Michelle Massey on. We are talking about OCD core fears. This is a topic I don't talk about a lot, and whenever I know I can find someone who can kill a topic way better than I can, I ask them on. And luckily, this is my dear friend Michelle. I love this human being so freaking much. So I'm so happy to have you here with us, Michelle. Thank you for being here.
- [00:33]
B
Thank you for inviting me on. I always love chatting ocd.
- [00:36]
A
I know. Okay, so Michelle and I were actually on our way to vent or spa or something we were doing together, and we were talking about cases. And we're always, of course, trying to get consultation and make sure that we're addressing cases as best as we can. And Michelle started talking about core fears in a way that I don't talk about it. It's not that I don't talk about it. It's just not in the way in which I do. And I loved the way that you were talking about it, and I wanted everyone to come on and understand why understanding your OCD core fear is so important. So, again, thank you for being here. I'm wondering if you could explain those who are new to this idea of what do we mean when we talk about core fears in ocd?
- [01:24]
B
Yeah, so I'll actually back up and start with when I was first trained in treating OCD, like, maybe, like 20 years ago, it was really through the habituation model, right? And so we focused on doing an exposure until a person's anxiety came down halfway at least, and kept, you know, essentially habituated to the anxiety. And we really, like, at that time, really focused on doing exposures to every single obsession or every single compulsion. But then sometimes it didn't quite generalize. And so I think over the last, I don't know, 10 or 15 years, there's been more talk about core fears. And I don't know if it really started with the discussion around inhibitory learning or it came before that or after that. I honestly don't know. But it was really the focus of, like, everything about OCD tends to come down to a handful of core fears. Right. And so rather than doing exposure, I mean, we can do exposures to every single compulsion that a person has or every single obsession, but a lot of times that they have a theme around them. And I don't just mean, like, the subtypes like harm or contamination, because even within those, there's different core fears. So I have come up with a list of Four court fears. Other people have three, other people have five, whatever. I have four that I use with my clients. The first one is something bad is going to happen now, and that means typically, like, I'm going to get sick. Sort of like not in this second. Right. But like, sort of immediate, you know, within a couple hours or a couple days kind of thing. Right. The second one is something is going to happen in the future that's terrible. This is like, I'm going to get cancer. I'm going to go to hell. Something that's sort of far off and, you know, more remote than like, in the next couple of days or weeks. The third one is the anticipation of I can't handle this feeling. We see it a lot with, like, sensory, motor ocd, just. Right, ocd. And that's just like, this feeling is never going to go away. And I feel, like, paralyzed. I feel like I'm going to go insane. I hear my clients say that a lot. And then the fourth one is I'm going to become abandoned and alone. And we see that a lot, especially with, like, harm OCD subtypes of like, I've done this terrible thing, or people will think or find out that I've done this terrible thing, and nobody will want to be around me. You know, my family will abandon me and I will become, you know, be alone, I'll die destitute. All the things, right? And so I've categorized everything down to those four core fears. And it's. When we do exposures, we want to make sure that we're really addressing that, because otherwise we're staying really at the surface level of the exposure.
- [04:06]
A
Okay, so let's. Let's play it out. Let's give some examples. So let's say somebody you've talked about harm obsession. So someone has a subtype of harm ocd, and they. Their fear is that they might harm somebody.
- [04:21]
B
Right?
- [04:21]
A
That's the content of the fear or the obsession. And what you're saying is underneath that fear, it could be that they're afraid, like you said, of being dying alone in a. In a jail cell, or maybe for some, it might be that they won't be able to handle the guilt or shame for the rest of their life, and that they would be sort of stuck in purgatory or whatever it might be with this feeling that they don't want to tolerate. And so that's what you're saying is like the same subtype might have a different core fear.
- [04:54]
B
Right? And it's. There are two things that I think are so important when we're doing exposures, number one, to get to the correct core fear, because otherwise we're really just shooting darts all over the place, and we may not hit the balls. I think the other major piece is making sure we're getting to somebody's values, right? Is like, doing things that align with their values and also move them towards their values. Because, again, like, you know, when I was first trained, I've done exposures where I've had clients hold knives to me, right? And that worked. It was great, fantastic. But it didn't necessarily get to the core fear. And so, you know, like, I don't know if it really hit the, you know, nail on the head with every single one of those clients. And so we want to make sure that then when they walk away from treatment, we've actually addressed the common denominator. And I think we. Where we see this so often, right. Is contamination. Because there's three types of contamination fears, right? As this, I'm gonna get sick or die. I'm gonna cause harm. Gets. Get somebody else sick or kill them. Right? And disgust. And so that's a perfect example of, like, if we don't understand what the purpose is or, like, what the fear is behind their obsessions, I could be doing exposure that's addressing disgust, and it's really a fear of harm or vice versa.
- [06:11]
A
Right. Which you've just led into the next question, which is how does identifying the core fear help with treatment planning for folks with ocd? So you've kind of shared that, but maybe you want to elaborate a little bit more.
- [06:27]
B
Yeah, it's mainly just trying to figure out which exposures would make the most sense. Right. And again, if we're hitting the core fear, then we may not need to break down the exposures as. As, you know, into the very specific pieces. Right? So, like, let's say I had a client years ago who had, like, severe contamination. Everything was contaminated, right? To the point where they were, like, eating potato chips with either a fork or chopsticks, right? Like, they couldn't touch anything. They were using sandals in their own shower, etc. Right? And this is really before I was addressing core fears and knew about inhibitory learning. And so if I were to approach it now, I would think about, like, the bigger issue. If I stood back and asked them, what was. What is your core fear? What's the. What are you most afraid of? And I actually don't know what that client would say at this point because it's been so many years but being able to plan out the correct exposure, then I don't necessarily need to do every single little thing. Right. I had them eating potato chips with their hands, going into their shower and doing all sorts of things within their shower. But there might have been more like grouping of their exposures where we're hitting that core fear and then we're seeing more of a drop or a bigger learning curve.
- [07:43]
A
Yeah, yeah. I think it goes kind of across diagnoses too. Right. So let's say if someone's avoiding food, identifying a core fear might also help us in the assessment process of, oh, is this an eating disorder? Is it arfid? Is it a disgust, you know, thing? Is it a health anxiety thing on why they're avoiding this food item? And so I think that that is a really interesting piece in terms of, you know, understand what's underneath the actual fear. Now what I want to maybe if we could clarify is a lot of folks who aren't trained in the correct science based treatment for OCD often will be spending a lot of time with folks on OCD of like, what's the underlying trauma? Or where did this come from? Or what's the underlying deep dark. And can you help us differentiate the difference between identifying a core fear and just doing a whole bunch of therapy, digging and stuff? That's not necessary.
- [08:46]
B
Yeah. So honestly, when I'm doing this core fear thing with clients, I just label my four core fears and I ask them, you know, and we usually will ask clients, like, okay, what would happen if you didn't do your compulsion? So. Right. Like, what would happen if you didn't check the door lock? Or what would happen if you didn't hand wash? Or what would happen if you changed your baby's diaper and nobody else was around? Right. What are you most afraid of if you didn't do that compulsion? And that's how I get to that core fear. Right. As opposed to like with, you know, if we think it's trauma based is like, tell me about your childhood or tell me about when this first started. Right. Which is if we look at, you know, ERP is a CBT model. Right. And it's really sticking with right now you're not functional. What is going on that will help you become more functional? And I think, like, if there truly is a trauma piece to the ocd. Right. Which for some of our patients. There are not. All my patients have ocd. I mean, have trauma. But some do. Right. I think having. Addressing the trauma is important. And I think also for some People they're interested to know and go down that route. Right. But we don't necessarily need to do that all the time in order to treat the ocd. And not everybody with OCD has trauma. Yep, agreed.
- [10:04]
A
The reason I love asking clients about their core fear is often this is particularly for those folks who have whack a mole obsessions is, you know, one obsession shows up and it feels all real and true and they start to do compulsions and they're doing a lot and they're spending a lot of time focusing or avoiding this obsession. And then let's say they work on that and then their OCD just comes in a different form. Right? Like it's a different, it's got, it's, let's say it's, it's jumped from religious OCD to relationship ocd or it's jumped from contamination to existential or whatever, Right. Sometimes when that's happening, it's hard in the moment because it feels so real to catch that. It's. This is a very similar cycle of ocd, but often we can find that the core fear is the same. It's just changing content, it's changing subtype. Do you use it in that way as well?
- [11:02]
B
Yeah, exactly. Because there's often this underlying theme, right. And we can even figure that out, people are always asking, especially newer clinicians, is how do you build your exposure list or your hierarchy? And we often will group by subtype, but then we can kind of look at it and be like, oh, well, these are actually all the same core fear. So what are we getting at in terms of the core fear? Right. And I think too, as we've changed over the years from the exposures that I was taught to do, right. The, the ones that are not very justice based or justice informed. Right. Is that I think, also addressing the core fear, Right. If you have fear of like related sexual orientation OCD or harm OCD or something like that, rather than going through these visuals and people can still, still do this. There's nothing wrong with it if they want to go through these imaginal exposures of harming somebody or doing something bad. Right. But we can also look at like a more values based exposure that addresses their core fear, right? Because the fear is like, I am this terrible person who could cause harm to these people and then if people knew I would be abandon it alone. Then it's like, okay, let's address that as opposed to you going around and doing all these naughty things, right? Because those also might not align with your values.
- [12:23]
A
Yes, yes. So let's, let's talk about that. And this is particularly for folks who've taken the any of my ERP or OCD courses because I really want to be speaking to those folks because they're going through this and they're doing it on their own. They're not got a therapist who's able. It's sometimes easier when you've got a therapist across from you to identify this stuff.
- [12:48]
B
Exactly.
- [12:49]
A
Is often what will happen in these exposures is you're looking at your fear and you're going, okay, here are all the exposures I could potentially do. And you're really saying like some of them aren't actually addressing this underlying fear.
- [13:07]
B
Right.
- [13:12]
A
Now, as you know, I have a private practice. I have six amazing therapists in Calabasas, California. However, we do not take insurance. Now if you are looking for insurance covered OCD or BFRB treatment, I want to let you know about nocd. NOCD provides face to face live video sessions with specialized licensed OCD therapists. Now their therapists use exposure and response prevention. We know this is the gold standard for ocd. So you can be absolutely confirmed that you're in the right place there. And they have a clinically proven app that helps you stay connected to your therapist and others who have OCD between sessions. So you'll always feel supported. Now the cool thing is no CD is is available in all 50 US states and even internationally and they accept most insurance plans, making it affordable and accessible. We love that. Now if you think you might have OCD or you're struggling to manage your symptoms, you can book a free call. Just click the link in the show notes@nocd.com I am honored to partner with NOCD. I want to remind you that recovery is possible. Please do not forget that. Now big hugs and let's get back to the show. Let's say somebody has the, the fear that I'll be alone. In that case, what exposures might they be doing that? Because they might be on their own thinking, oh, the exposure is just to be alone. But they're like, I don't mind being alone. I'm an introvert, I'm fine. It's just I don't want to die alone.
- [14:52]
B
Right.
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A
My fear is like this thing that I can't create. What type of exposures would you recommend as a clinician to your clients in that circumstance?
- [15:02]
B
So honestly, I would probably first start out with a little bit of like belief system work. Right. Is like this, you know, like, do we have evidence that you'll be alone. And have we seen your, your people around you abandon you in real time, like for like things that you deem mistake worthy or like, you know, and have you seen them abandon other people? Right. You can do exposures to what that looks like, ending up alone. Right. And I think even sometimes, you know, when we have these like narratives that fester in our head, they feel so real. But I've also had clients just say out loud the storyline, like, you know, I would be accused of doing this terrible thing. I would end up in jail and my family would never come visit me. And sometimes just even saying that out loud, like, they can sort of laugh at themselves. I'm sure your patients have done the same thing. Right. And it's like this, like, that's not even realistic. Like, in what world would I actually be, you know, arrested for that? And this isn't reassurance. This is more like making sense of the language that we're rational. Right, right, right, exactly. Right. You can also do like more exposures around like word search games or, you know, like I love to do like mad lib stuff, you know, changing out language. And so it's like, or even like reading stories about people who have been, you know, convicted of and, and are abandoned. Right. Those are one ways that you can do that. Right.
- [16:35]
A
And for those listening, you might want to go back and listen. Recently we did an episode with Kimberly Leonti on ways to make exposures fun, especially those imaginals and scripts and mad Libs and. And so that, that is a. Definitely a resource to connect you to. What about the folks who have the thought that core fear. I can't handle this.
- [17:00]
B
Yeah.
- [17:00]
A
And this goes back to like, and maybe they have no evidence that they can handle it. So what would be an exposure you might encourage in that scenario?
- [17:09]
B
Yeah, So I even like things as simple as like putting a penny in your shoe. Right. And walking around or putting your shoes on the wrong a feet writing wrong. And I know, you know, clients will say, but that doesn't like, you know, like, I, I'm not worried something bad will happen from that, but it's really just noticing like, can I handle discomfort? Right. Can I be mindful of this discomfort? And like, I think I can't handle it. The other thing is to do the thing that they think they can't handle. Right. And, and using language around inhibitory learning is asking themselves, like, how long do I think I can handle this for? Right. Then put a timer and see, see what happens in that point. Right? I had a client, we did a bathroom exposure a couple of weeks ago. At the beginning of session, they did the bathroom exposure and then we were talking about like the weak stuff that we had to talk about and within five minutes they're like, I'm not even thinking about that. And when they first got done with the bathroom exposure, they were like sweating bullets. Right. It was like this and like, you know, OCD hands, as we call them and all the things. And within five minutes we were talking about things and that we weren't using as a distraction, but we were really focused on like living a value based life. Right. And so it was, you know, we kept checking in with it, but it was like, yeah, you know, I was so worried that after touching things in the bathroom, not even the toilet, just things in the bathroom. Right. The faucet, etc. That I wouldn't even be able to concentrate on a conversation. And here he was having a full on conversation with me and clearly it was a non issue. Right. So it's like being able to just prove to ourselves that that thing that we think is going to happen either doesn't happen or does and we can handle it better than we think we can.
- [18:48]
A
Mm. So I think that the main thing for students who are listening is you would still work through the same exposures. It doesn't change the fact that you could rely on imaginals, interoceptives doing the things you've been avoiding, using response prevention like the, the whole strategy stays the same. But, and please, Michelle, correct me if this is not exactly your wording, but identifying the quality core fear can help with really doubling down on making sure your exposure hits the spot and you're getting the best bang for your buck for, you know, ultimately. And also helps you to see the overlap of these subtypes and how they are. The content is different, but yet the core fear is the same. Is there anything that I haven't listed there that is important for them to know about the application of exposures in that case?
- [19:49]
B
I don't think so because it's really, you're doing the exact same things. Like we're not changing what you know, I, I don't have a new term or, you know, way of doing exposure. We're still doing exposure. Right. And it's, it's just more informed. Right. It's like making sure we're addressing all the things again. And the contamination example is the best example. Right. Because if I'm doing, you know, I'm going around touching things and they're not afraid of disgust. Right. Then, like, I may not be hitting the nail on the head. And so it's like, now we've just wasted a bunch of precious time and resources doing something that doesn't make any sense.
- [20:29]
A
Y. Yeah. And I know as a supervisor of. Of my staff, we're on this really beautiful text chain of wonderful therapists, and they will often text me questions. I'm sure you have your own private practice. It's the. And. And I've actually seen this play out in, like, our other groups of supervision and consultation online is a therapist will say, what's a really good exposure for blank obsession? Like relationship obsessions. Right. Or what's a really good exposure? What are. What are some great exposures for? Let's say you said sexual orientation, ocd. And. And back in the day, I think we would have been like, oh, you know, I remember when I was being trained, it's like, you'd be like, oh, you need to wear. If you're a male and you had sexual orientation, here are the ones that you do. Like, there's just like this, this list that you do. Whereas now instead of it being just this cookie cutter treatment, the first question is like, well, wait, what's the core fear? Then we can assign the exposure. And I think that's where ERP has become more personalized, more, like you said, justice based, a little more a gentler approach or even more an effective approach. Do you have any thoughts on that personally, as a. As a supervisor? You're in a clinic as well.
- [22:04]
B
Yeah, no, it's. It's so interesting because you're right. It's like, you know, I. I monitor this Facebook group and like, this question gets asked at least once a day is like, what exposure do? And it's like, it's not a one size fits. All right? And there is a fantastic exposure workbook that people, you know, love to pull out, but it really, like, you know, and I know even newer therapists will say, ooh, what do you have in your experience? Exposure toolbox. Like, in your office? I literally, I was. I was just cleaning out my office because I had dumped things during COVID and was like, re. Re doing everything in the office. And I threw away a bunch of stuff because I literally have a handful of things in there, right? Like, I have some cetaphil, I have some shaving cream. I have some bubbles. Literally, they've never been used. Like, I just throw them away because it's like, I. Every single client gets. I don't use the same thing. I mean, I have a lot of the same exposures I'll do, but I'll have clients bring in things from home or I'll have, like. It's such a personalized thing that I don't have, like this giant basket of exposures. You know, like, yes, at ucla, we had a giant, you know, box of knives. I don't tend to keep knives in the office. That just doesn't seem safe. But, you know, it's like for every single client, it's something different. And so it's like, I really don't utilize a whole lot of stuff. Not to say that we can't have tools, but I think there's just this. No one size fits all. You know, they always say, if you've met a person with ocd, you've met a person with ocd. And so, you know, I can. It's. I definitely. I think the difference between somebody who's just starting treatment, a clinician who's just starting to work with OCD, and somebody who has. It is like, we have these, like, oh, I've seen this. I know what questions to ask. Or like, starting exposures, but we really. It's not this cookie cutter thing. So.
- [23:53]
A
Right. Amazing, amazing. So when you mentioned some people have three or they have. Some people have five. Do you. Do we need to know what those other ones are?
- [24:08]
B
So I always laugh. I always start this out with saying Alec Pollard, and I go head to head. Right. If you don't know Alec Pollard, he's amazing. I love him, but. So he has three and I. He combines two of the ones that I don't ever remember because I teach my own, but he just combines two of the ones. And I think it's. I actually don't know. I don't remember which ones he combines, but his. So it's really the same protocol. It's just more like, yeah, so. And I don't know, I just threw out maybe some people have five. I don't know. But that was just a random number.
- [24:41]
A
No, I just want to make sure because I know a lot of clinicians will be listening and they're going to be emailing me saying, what's the thought?
- [24:47]
B
The fourth one. What's the. What's the difference?
- [24:50]
A
1.
- [24:50]
B
So, okay, no, Alec and I, we joke about this every time we teach together. And it's. He. He just combines two of the ones that I separate out. And so it's just a different way of looking at it, but essentially we say the same thing.
- [25:04]
A
Yeah, Amazing. Okay.
- [25:07]
B
I.
- [25:07]
A
This is really hit the nail on the head. Thank you so much. I feel like it's exactly what people needed to hear. I think that it, it will help a lot of people in understanding what that core fear is. And number two is understanding it in the application of picking helpful exposures. Now, last question. Some people become quite obsessive about picking the right exposures. Right. And that it becomes very scary that what if I do the wrong exposure? What if I'm not doing treatment? Right. Is there any feedback you might give those folks who get stuck having anxiety that they haven't picked the right core fear or that they're doing the wrong exposure? What, what's your genius idea of that?
- [25:53]
B
I'd say what's your core fear of that? Right. Yeah, I can't handle it. It's the, I can't handle the feeling that I picked the wrong thing. Right. And we see this so often. Right. I. What if you're not the right therapist for me? What if I haven't told you all the information and so we're, we're not hitting. What if I really don't have OCD and I'm just making this up? Right?
- [26:11]
A
Yeah.
- [26:12]
B
But again, there's another core fear. There is like I'm, you know, either wasting resources and you're going to be disappointed in me and you're going to abandon me or I won't be able to handle the feeling or you know, there you go.
- [26:24]
A
So there's even the fear that you got your core fear wrong. Has a core fear.
- [26:29]
B
Right.
- [26:30]
A
It's like a cycle. We just get stuck in over them. And I think at the end of the day, for those who would get you like, please do this imperfectly would be my main message. Please let your exposures be a B minus effort. If you are trying to do an A plus effort all the time, it will come back to bite you. You will become a compulsion. So we want to keep an eye on that as well. Oh, Michelle, you're so amazing. Can you tell us where people can learn about you, you know, get in touch with you, hear about your practice?
- [26:57]
B
Yeah. Best place is our website, which is anxietytherapyla.com I post infrequently on Instagram. Yesterday I did a whole dump on a bunch of books because I was like, I need to have these all in one place. But I tend to post during like OCD awareness week and the conference and then I'm like, I don't have, have the energy for this or the capacity for this. Lots of self compassion around that for me and. But best place to get a hold of me is our website.
- [27:24]
A
Amazing. And we'll have all of that in the show notes as well if people want to get in touch with Michelle. Thank you. My love, for being here. It's really, really. I'm grateful. I don't. I mean, while I. Yes, I could have done it, I just feel like you did a better job. And I love when people. I love it. You killed it, like I said you would. Thank you so much.
- [27:41]
B
I was talking about ocd, so it's like, you know, get me started.
- [27:44]
A
And I go, all right, we should just keep recording one after the other. I could batch a couple extra episodes.
- [27:51]
B
I just have to change outfits in between. Yeah.
- [27:53]
A
Oh, no.
- [27:54]
B
It's like Jeopardy.
- [27:57]
A
Okay. Thank you so much. And again, everybody, thank you for being here. Please do follow along, and we're so excited to have you part of this community. 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.