Your Anxiety Toolkit - Practical Skills for Anxiety, Panic & Depression

Welcome back, everybody. Today we are talking about Acceptance Scripts with Dr Jon Grayson.  So happy to be here with you as we tie together our series on imaginals and scripts. Today, we have the amazing Dr. Jon Grayson and he is going to talk about acceptance scripts and the real importance of making sure we use acceptance when we’re talking about scripts and imaginals. I’m so excited to share this episode with you. I think it really does, again, tie together the two other guests that we’ve had on the show in this series.  For those of you who are listening to this and haven’t listened to the other two episodes of the series, go back two weeks. We’ve got the first one with Krista Reed and she’s talking about scripts and the way she uses them. Then we have Shala Nicely and she talks about her own specific way of using scripts. Again, the reason that I didn’t just have one person and leave it at that is I do think for each person, we have to find specific ways in which we do these skills and tools so we can make it specific to your obsessions and your intrusive thoughts. One explanation or one version or variety of this is probably not enough. I want to really deep dive in this series so that you feel, number one, you have a good understanding of what an imaginal and a script is. Number two, you know how to use them, you know the little nuanced pieces of information that you need to help make sure OCD and your OCD-related disorder doesn’t make it a compulsion because it can. I really wanted to get some groundwork so that you feel confident using imaginal and scripts in your own treatment and your own recovery. Again, for those of you who are a little lost and feel like you need a better understanding of OCD, of how OCD works, how it keeps you stuck, the cycle of OCD and you want to make your own individual OCD and ERP plan, you can go to CBTSchool.com. We have a full seven-hour course that will walk you through exactly how I do it with my patients, and you can do that at your own pace. It’s an on-demand course. It is not therapy, but it will help you if you don’t have access to therapy or if you’re really just wanting to understand and do a deep dive and understand what ERP is and how you can use it. That is there for you. But if you are someone who is just wanting to get to the good stuff, let’s go over to the episode with Dr. Jon Grayson. Thank you, Dr. Jon Grayson, for coming on the show again. Always a pleasure to have such amazing people who really know their stuff. I’ll enjoy this episode with you. Let’s go. Kimberley: Welcome, Dr. Jon Grayson. I’m so happy to have you back. Jon: It is always fun to be with you. Kimberley: Okay. It’s funny that you are number three, because I probably need you to be number one. Almost all of the scripting I ever learned was from your book. I think that even Shala Nicely came on and spoke about how a lot of what she does is through your book as well. Let’s just talk about the way in which you walk people through an imaginal or a script. Now do you call it imaginal or script? Do you think they’re synonymous? Do you have a different way of explaining it? Jon: I think jargon-wise, they’re synonymous. I think by definition-- I feel weird saying that by definition because we made it up. I came up with the name “script” because originally, imaginal exposure suggested I’m just dealing with all the horrors and person’s just going to think about it. I changed the name to “script” because I was including both. What are you being exposed to? What might happen and why would you take this risk? Because I feel like the script is not only to get used to the material, but we remind the person, why am I doing this? What am I getting out of taking this horrible risk? Why would I want to live with that?  WHAT IS AN ACCEPTANCE SCRIPTS/IMAGINALS?  Integral to the Acceptance Script is the whole idea of learning acceptance. Because too often, I think the biggest problem I see in most therapists is they just jump into doing exposure without making sure the person has done level 1 acceptance, which is “I want to live with uncertainty,” because to say “I want to live with uncertainty” is to say, “I am willing to cope if the worst things happen.” It’s not just this general idea, it’s like going to the extreme. “I’m willing to live, even if this happens. I’m willing to drive a car knowing that I might get paralyzed and disfigured in a car crash.” I think that’s acceptance because if you’re telling me you’re never going to crash in a car and you know that’s true, I guess that’s a nice comforting thought that you might be in for a shock. We’re willing to take that risk. I think across the board, it’s always willing to live with the worst possible.  Scripts try to encapsulate that. They’re trying to help bring the person not only to confront their fear but remind them of all the ways they want to cope with it. It is not a reassurance thing because let’s face it, the worst thing happening, saying “I’ll cope with the worst” is not really reassuring in a sense because it’s something you really don’t want to happen. But I guess the goal is, first of all, if it happens, you will do something that’s coping or not.  I think non-acceptance-- God bless you. I’m glad we’re live so people can see you were sneezing. I just didn’t go into a religious ecstasy. I think we see non-acceptance insidiously all over the place without realizing it. In the beginning of the pandemic, so many people were going like, “Well, this can’t last all summer. I can’t deal with that.” That is a statement of avoidance and non-acceptance. I was listening to that and in the back of my mind, it’s like, “Let’s see. Everything they’ve told us makes it seem like this is going on for two years because they’re not finding a vaccine.” Seriously, you can’t take it. You’re not going to do it. What are you going to do? In retrospect, everybody would have to admit, “Well, yeah, it was not fun, it was awful, but I lived through it.” Acceptance would’ve been, “Well, how am I going to try to make the best of this?” Making the best of it isn’t wonderful, which I guess brings us to the first point about acceptance because I think in the Western world, we make everything glossy and pretty and beautiful. Acceptance is just this wonderful land of zen happiness. It’s like I’m accepting everything is so good and, in reality, the best way to describe acceptance is that it sucks in the short run. In the short run, acceptance means “I’m going to be willing to embrace what seems to me the second-best life. This is what I want, I can have it, I will embrace this.”  WHY DO WE NEED TO PRACTICE ACCEPTANCE?  The prime reason to do acceptance is you don’t have a choice. The other world doesn’t exist. In the beginning of the pandemic, Kathy and I were doing our pandemic walk, my wife Kathy. We were doing our pandemic walk. I remember because you’re terrified of everybody and you’re walking looking around. Kathy says to me, “God, this would be such a great day if all this wasn’t happening.” I said to her, “You’re wrong, Kathy,” which for all the listeners should immediately cue them into the idea that being married to a psychologist is not necessarily fun. I said to her, “It is a beautiful day. We’re with each other. Here we are. We’re holding hands, taking a walk. It’s really pretty. We’re going to be spending the whole day together.” The truth is, it is a great day AND it’s horrible that all of this is happening. I think acceptance is always AND. We always talk about letting stuff be there as if it’s very passively like, “Oh, I can just let it be there and not bother me.” No, it’s really horrible. Let me tell this really horrible story, which I can’t remember if I’ve told on here, but it’s a more graphic description of what acceptance looks like, if I may. A young girl was brought to me, 17, was really in terrible shape. I mean, she had been hospitalized, she had suicide attempts. So anxious, she couldn’t tolerate being in a counsel’s office for more than one hour when she first came in. Her meds were a mess. Over the next three months, we got her meds in line and she really worked incredibly hard considering where she was. And then in December, they asked, could she be in my support group? I said, “Well, it’s not really for kids.” They talked me into things, “We think she’s mature.” First of all, whenever she spoke up in the group, whatever she said would be brilliantly insightful that would just knock everybody out. She did not look old, but nobody could believe she was only 17.  As the year went on, we were tapering off sessions. The last time I saw her in June, her parents, her and her brother were driving out to the desert outside of LA looking for a vacation getaway place. On their way there, a drunk driver in her third DUI rammed the car and killed my patient Ruby and her 14-year-old brother. I don’t have to tell you how devastated the parents were. I could talk a lot of stories that are amazing about them because I saw them starting about three weeks after their loss. At which point they said, “We want to be more than the parents of dead kids, but we can’t imagine anything else.” I said, “Well, I can tell you what treatment will be like, but it just seems like words.” They agreed it’ll be just words, but it’s just nice to hear there’s something. They coped amazingly well. But the only good thing about coping, in this case, is it’s better than not coping. Maybe that’s true a lot of the time. After a year and a half, they did buy the place where they were going to that they were looking for that day. They bought it because it made them feel closer to the kids. They didn’t push that away at all. After a year and a half, they were at the place. It was one night where there was a meteor shower. They go, “Oh, we’re going to go out and watch the meteor shower.” They go out at midnight, lay down on their backs and both immediately burst into tears because this 17-year-old, 14-year-old were actually the kind of kids they would’ve happily gone out there with their parents and enjoyed the whole time. I said to the dad, “Was it a pretty meteor shower?” He said, “Yeah.”  “Are you sorry you saw it?” “No.” I said the truth, “It was a beautiful meteor shower AND it’s horrible that your kids were murdered.” It’s a dark sense of humor and said, “Well, I thought we’d have at least a few moments. I said, “Yeah, that wasn’t happening.” That’s acceptance. They were living in the present. They could enjoy things and there was a hole in their heart. The alternative to that is comparing life to every second of life to how much better it would be. Whenever I compare life to a fantasy, I ruin the present. I have nothing.  I think the reason for acceptance is to make the best of whatever we can have. I think one of the wonderful things sometimes is that a lot of what we avoid is not something so devastating. It’s maybe more in our head what we’re trying to avoid. But a low probability event is not a no probability event. If that’s what I’m scared of, low odds are comforting because I want no odds. Am I answering your question? Kimberley: You are. I think it’s a really great opportunity for us to segue. You’ve talked about the first step being to familiarize yourself with uncertainty before doing scripts and acceptance. You’ve beautifully explained this idea. For the listeners, you can also go back. Dr. Grayson has been on the show before. You can listen to it. We’ve talked a lot about that, which is so beautiful and I think very much compliments what you’re saying. Let’s talk about the script that you’re speaking of. Once you’ve done that work of acceptance, how would you-- Jon: I may have to call you Ms. Quinlan since you referred to me as Dr. Grayson.  Kimberley: No, call me Kimberley.  HOW CAN WE ACCEPT UNCERTAINTY USING SCRIPTS/IMAGINALS?  Credit: https://www.instagram.com/p/CmZUliJKhQB/ Jon: When considering how to accept uncertainty, that first step, are you willing to learn to live with uncertainty? That step is variable of talking in therapy for the first session. I’ve had some people take three months before they agree like, it’s not like I really have a choice, and that’s really what we’re getting. What are you losing to that? I can’t remember if I just said this before, but one of the biggest things that I end up teaching therapists who have been around the field for years is do not start exposure until the person has actually agreed that they’re willing to learn to do this because obviously, they can just accept uncertainty. Then we’re done with session 1. It takes one session to three months. The loose measure is to accept uncertainty to say if the worst happens, I will try to live with it and I will try to cope with it. If somebody says to me, “If that happens, I’ll kill myself.” No, no. That’s an avoidance. In this scenario, you are condemned to life. You’re going to have to figure out how to cope no matter how awful.  In scripting, the idea of a script is not only to provide the imaginal exposure, which is like this terrible thing might happen. Because a lot of times, people go, if you say X might happen, “I don’t want to think about it.” As I said to you in the beginning of the show, I can get any parent into an immediate statement of denial by saying, “What if your kids die,” the response of almost every parent is, “I don’t want to deal with that. I don’t want to think it through.” But if you’re being tortured by the thought, that normal level of denial, which I don’t think is the ideal way to handle it, but you already can’t do it because you keep going into, “What about no, what about no, what about, no?”  How to write an Acceptance Script The very first step of how to write an  acceptance script is essentially asking the question, “why would I take this risk?” Because within that statement is part of your answer of why I’m going to pursue acceptance. It is not the same as acceptance, but it’s why I’m being motivated to go after this.  Kimberley: What would that look like? How would you word that? Jon: As to why would I take this risk?  Kimberley: Uh-hmm. Jon: I’m trying to think of how horrible to go.  Kimberley: Let’s pick an example because I think examples are helpful. Let’s say someone has relationship OCD and they’re afraid they’re making the wrong choice in their partner. Jon: You picked one, I think, that’s not necessarily the most horribly devastating consequences on one hand compared to like, am I an old child molester?  Kimberley: You go there. Jon: I have a really wonderful acceptance thing I do with that, so we will go there. But with the ROCD, I want to know, am I making this terrible mistake with my spouse? What we’re asking them to accept is never knowing. Kimberley: You’d just say that in the script?  Jon: No, because we’ll talk to them and we’ll talk about why like, why am I willing to never know for sure? Because some of it is like they’re looking into a relationship with the thermometer and taking the measure every minute. What’s the temperature now? What’s the temperature now? There’s this fantasy that I should have no questions. I mean, depending on how deep they’re in, I should find no one else attractive, but every moment should be great and I should have no complaints. Well, that is a fantasy marriage.  Kathy and I took a trip to France and it was an incredible trip. Of course, when you say going to Paris, everybody’s eyes glaze over. We ate at a patisserie every morning, but let’s face it, it’s just a damn croissant. One place had the best café au lait. We were there for two days, but it was great. We saw the Catacombs where we had to wait in line for three hours in the hot sun. Went to a really fine restaurant, but we’re not super foodies, so we’re not necessarily going to like it. The experience can’t just depend on, “This was great food,” or “This is terrible, we just spent a lot of money for what.” We go in knowing that. It was a great vacation. A great vacation. It’s not like every second is great. Three hours in a hot sun, five-hour bus ride to go see the site, but it was still a great vacation. I think a relationship is like that, so I can’t look at that now.  I think for the person with ROCD, we’re going to say they are not perfect. Like any relationship, we want a hundred things and we’re only getting 70 of them. It should be more than 20, but we’re only getting 70. Are you making a mistake? Now, most people with ROCD can say they don’t want to leave right now or sometimes they want to leave because of the anxiety. It’s like, then you have to stay. I don’t want you talking about all your fears and confessing because if you are wrong, you’re just making this person feel bad for no reason.  My thought is, you can leave this relationship when you know for two weeks solid you want to leave with no question. No question. You know it is, sure, as you know you’re sitting there because they generally accept that. We have to point out what are the realities of a relationship. Everyone on their wedding day thinks they’re going to be married forever, but that’s wrong 50% of the time. Whomever we marry, my spouse being an exception, 40 years later, they don’t look as good as you did the day you married them. Technically, you were accepting second best in looks 40 years later. Kimberley: Did you know the rate of divorce is higher in therapists? Jon: Wow. So, Kathy and I are really against the odds. This is a little scary to you probably. We started dating in 1970 and this year, it’ll be our 50th anniversary.  Kimberley: Wow. Congratulations. Jon: Having met at the age of two and started dating then, we don’t really have much significant history before that. You will get angry and there are going to be things they don’t want to do. Yes, you’re going to have to learn to live not knowing that. That’s going to be part of the script, that you don’t get to know. What if you’re making a mistake? Even if you fell wildly happily in love now and you had no question, really nice feeling. If the relationship seems good, no reason to question it. Now of course, if you have ROCD, you’re checking all these reasons. It’s like you’re not ready to leave yet. Yes, when you’re answering your questions, it’s maybe. Even if I feel wonderfully in love with you, it might be that next year or after 20 years ago, I discover you’ve been having a seven-year illicit affair. I discover, “Oh hey, guess what? You’re leaving me.” There are all kinds of things that could go wrong. Or I’ll ask the person in this relationship, if this relationship was good and you felt constant passion affair and next year your spouse suddenly gets a dread disease that’s going to make them really messed up and crippled and sick for the next years, I guess you’re leaving them. Of course, everybody goes like, “No.” But the bottom line is, that’s good, but that’s not going to be what you signed up for.  How do we make the best of it? I did this one thing with one couple that worked like magic. I’m saying that worked like magic because I’d do it with everyone across the board, but usually, it doesn’t work like this. This was the low probability. Oh my god, this was the killer intervention as opposed to, this is a start for most people. It was such a cute couple, but I’d given him the thing. “This weekend, when you’re spending time with her, I want you to notice whenever you’re having fun, and although part of you wants to compare it to what it should be, I want you to consciously just notice whatever it is, like if it’s 5%.” Because a lot of times, you’re comparing your current feeling to what it should be. There could be good things happening and you don’t even notice because it’s like, “I was just thinking about this, I was just thinking about this.” He had that assignment to notice it, whatever. He came back and he was like, “We had a great weekend. I still don’t know if I love her or not, but if it could be like this forever, I’m good.” Now, that was a rarity, but that was the beginning of acceptance for most people, just noticing, oh, I’m not miserable every second. I agree a two-minute 20% joy isn’t like, oh wow, that makes it all worth it. But it’s stuff that you don’t notice all along. We’re trying to notice the good and the other stuff. Acceptance is not a decision; trying to learn it is. But when I talk about that couple who lost two kids, when I say it was more than a year for them to get to acceptance and what acceptance means for them is they didn’t compare every moment to what it would be like if their kids were still alive. In fact, I didn’t know this at the time when I told them that everything goes well after a year. You’ll still have a hole in your heart, but you’ll stop comparing every moment to if they were still alive. They just listened. But the dad wrote a book about mourning and he also did a one-man show called Grief, which I wish I could show everyone. But in one of those places, he said that when I told them that, in his mind, he was saying, “F you! I am never going to stop wishing my kids were alive.” And then he wrote that two years later, he’s come to realize it doesn’t do him or his kids any good to wish they were alive.” He’s in acceptance. He still misses them greatly. He can still cry at them, but he’s no longer making that comparison. I’m mentioning it because that takes time. No one expects a couple, three weeks after their kids are murdered, to be in acceptance. The same with anything I have to accept.  The person with OCD, they have this goal, but getting to that great state where “I’m living with this and it’s okay, I embrace this life” is hard. Luckily, most of the time what they have to accept isn’t devastating in the sense that nobody dies of AIDS. Am I with the wrong person forever? Well, maybe it’s the second-best life, but that’s the life I’m asking you to live for now, because all of us have no choice. Kimberley: Right. Let’s break it down.  Jon: I’m sorry. Kimberley: No, you’re great.  Jon: Okay. You’re good at being back on target. Kimberley: I’m a real visual person too. I don’t know if you know that about me, like if I need to see it visually-- Jon: By the way, that’s fantastic because to say something and show it visually just makes it easier for everyone else around you that you’re talking to. I appreciate what you’re going to do. Kimberley: Okay. Walk me through the visual here. The first step is what?  Jon: Why would you take this risk? Kimberley: Okay, what’s the second? THE SECOND STEP OF ACCEPTANCE SCRIPTS Jon: The second step of acceptance scripts is, if I do X, here’s a list of the things I’m actually scared might happen. I say actually scared because I want to go, what’s their fear? I can always go beyond even more horrible things, but I need to know what is their actual worst fear. Kimberley: Right. Let’s say for two if it was relationship OCD, it would be, “I find out I’m in a terrible relationship and I’m stuck with them.” Or if they were having harm obsessions, it would be, “I harm and kill my wife or my grandparent or so forth.” You would write that down. Jon: Yeah. “Here’s what might happen.” Kimberley: Okay. What’s step number three? Jon: If this happens, how would I try to cope with this in a positive way? Kimberley: That’s key, isn’t it? How would I cope in a positive way? Jon: Right. And that will often be second best. Kimberley: Which is acceptance. Jon: Well, it’s the road to acceptance. Remember, acceptance is not just this logical thing; it’s this emotional thing. I have clients and they appreciate it. It’s like, if we were just doing a therapy test, like say all the right stuff, they could ace therapy right away. They know how to say everything, they can do it. But feeling it takes time and behavior. I not only have to know it; I have to do the work of getting there. I have to go through all this pain. Now, I say, I think going through ERP is as painful as doing rituals. One is just an end of rituals versus endless rituals. I hate to keep going back to this couple, but what I said initially, the only good thing about coping is it was better than not coping. I had told them how well they were coping somewhere in the middle. Again, the dad said, “Wow, I hate to see the other poor bastards,” which was cute. I said, “Yes, but you’ve been in support groups, you’ve seen them.” He suddenly realized, “Whoa, we are coping even though this really sucks.” Kimberley: In this script—and maybe I’m wrong here, please tell me—I always think of the research around athletes and when they have an injury, there’s research to show that while they’re in the hospital bed with their new hip replacement and whatnot, the sports psychologists are coaching them through visual, imaginal, imagery of them doing the layup again and dunking the ball or turning the corner of the sprinting track or whatever. They’re doing that imagery work to help them play out how they would cope, how they would handle the pain, how they would return. Is that what this process is in step 3?  Jon: No. Well, that guy or a woman who’s imagining that, does their injury permit that possibility? Kimberley: Tell me more. Jon: Are they so injured that they will never be able to do a layup? Kimberley: No. In this example-- Jon: Or maybe somebody could say the odds are against them, so here’s what you can try to do, and here’s what to expect of how horrible it is to try.” But they might have to say, “You might not get there.” In a marriage, I don’t care how good the marriage is, I cannot say it will definitely work out. I can’t say you will definitely work out your problems. If I’m married for 20 great years, and then we have these three years at hell and I find out that you’ve been cheating on me the last two years, did I make a mistake? Or should I have left you four years ago, how would I know four years ago and should I have not tried, and all these questions that don’t have an answer. All I know is where I am now.  THE THIRD STEP OF ACCEPTANCE SCRIPTS  I like to say success is not making the right decision. It’s coping with the consequences of whatever decision you have made. I feel regret is cheating because regret is, again, I’m going into denial as soon as I have a regret. I should have done X. X would’ve been different. I don’t know if it would’ve been better. This failed. X being better is one possibility, but there are a whole lot of other ones where maybe it wouldn’t have been as good. All I can ever do is, what is next? That person in the relationship with ROCD, what do I need to do next? What have I learned? Somebody with ROCD did get divorced and gets into a relationship where they have the ROCD, but it’s such a better relationship. It’s not like you should have gotten out sooner because you know what, maybe if you didn’t go into that other relationship, maybe you wouldn’t have been ready for this one. Maybe you needed to go through your ROCD and go through all the crap to have this good one. Dumping that person sooner and getting into another relationship might have been better, or maybe you would’ve picked worse. We don’t get to know. All we know is what is from this moment on.  Part of the exposure is, okay, X might happen. What are the possibilities of coping? Again, I think I said, in my scenarios, the person can’t do suicide. They’re condemned to life and say, why I kill myself? That’s just a way of not thinking in the present. I want you to be stuck thinking about how you would try to cope with this. A lot of times, people have been so distant from it that it just seems like a screaming wall. It is like getting a phone call that somebody you love died. The whole world stops, and that’s where people stop thinking. But in the real world, something happens after you get that information.  Part of the exposure is to go through what happened next, what are some possibilities? I always say to somebody, “I don’t know if I can cope with the worst things that could happen to me, but I know that there are brave people who have. I don’t know if I can be like them, but they’re a model that I hope I will do that.” What if you don’t cope? Well, then I’ll be in deep trouble. My current plan is, the best I can do is I hope I will cope. I don’t want to be paralyzed and disfigured in a car crash. I hope I would cope. I don’t have to know that I’d cope because I’m going to wait till I get there to try to find out. But I might try to imagine it.  We’re going to imagine what would you actually do. In this relationship, how will I live never knowing? I’m taking the ROCD, how will I live? What if this is wrong? It might be wrong. What’s decent right now? What do you like? Because again, no person is perfect. How do I get into the state of that? Do I ever send people to marital counseling? If I see actual problems, I will, but I am not sending them to marital counseling to get rid of the ROCD. I’m sending them to get rid of actual problems. With or without those problems, they still have ROCD. I’m just eliminating, okay, here’s some definite reasons to get out. But once they’re resolved, then you’re still stuck with the ROCD. THE FORTH STEP OF ACCEPTANCE SCRIPTS  Kimberley: Is there a fourth step of acceptance scripts?  Jon: Kind of. It’s embedded in it, which is part of why I would take this risk, is what’s resulting from not taking this risk? What are the graphic horrible things that keep happening to you because you keep avoiding, including the torture you feel, the hours loss, humiliation from doing things? How are you actually hurting the people you think you love? Because a lot of times in ROCD, they can say they care about the person. I’ll always ask somebody, do you love your kids or love your spouse?” They’ll say, “Yeah.” “Will you do anything for them?” They’ll say yes. I’ll say, “I’m sorry, you’re a liar.” How do you hurt your family and loved ones with your ROCD? Not being present, yelling at them because they didn’t do something, and all the other ways that one might, asking for reassurance endlessly being in pain in the neck. I will point out, you have a choice in your relationship. I’m going beyond ROCD. But you get to pick between, are you going to serve your fear or your love? You keep choosing fear over love.  Part of acceptance does have to do with what my values are. Who is the person I want to be? Here’s another reason I need to do acceptance, because here’s life without acceptance. Most people who we see, we can say, the idea of trying to not accept and do avoid, I think you’ve done an amazing experiment of checking out that method. I think the results are clear, it sucks, so it’s time to try this other method. It’s like, why am I doing acceptance? Because I think, again, in our society we just make acceptance sounds so wonderful. But that’s just an idea. Why would acceptance actually be worth it? I have to think about why would it actually be worth it. I have to be motivated to do it. And then I’m stuck with this in-between thing that a lot of the time I’m doing a separate, recognizing I am not there yet, which by the way, there’s this great book that this wonderful person wrote on self-compassion, because I need self-compassion during treatment because I’m not where I want to be. It’s like I’m doing this really hard work and it’s not there yet. The best I get to say is, I’m working hard, I see some improvement, but yes, I’m not there yet and mourning.  Learning to live the second-best life takes time. I keep saying second-best life. I don’t actually mean it in some sense, but that is the feeling that when I’m working towards acceptance, that it is. I think in some cases, it’s not really a second-best life. I think a lot of times, if I overcome a fear, it’s like, this is great. Other times it is. I’ve had some people with a moral OCD about something they’ve done in the past and they’re going through all these contortions to try to convince themself that it’s not really bad even though they actually think it’s bad, but maybe here’s why it’s not bad. Part of the acceptance is, oh yeah, that was a bad shitty thing. You feel guilty about that. What is forgiving yourself mean? Shockingly, almost nobody knows what forgiving yourself means. How are you going to get to that point? But I have to accept, yeah, that was bad. That hurt people or whatever it is by whatever standards. Again, depending on who we’re talking about, it’s like, “Oh, I guess we have to have you accept being as bad as everyone else.” In some other cases, no, that was really bad. WHAT HAPPENS IF I REFUSE TO ACCEPT?  Kimberley: It’s great. The last part of the question is, what happens when I refuse to accept? What is the result of not taking this risk or even not accepting this, which is you have additional pain, right? The pain just keeps going and going and going. Jon: Right. That’s right. End of pain. Endless pain. Kimberley: Yeah. If they’ve used these somewhat prompts and people can go to your book and work through a lot of them, I know on your website there are a lot of worksheets as well. Once they’re writing these prompts, is there anything else you feel is important for them to know about this process or to be aware of or be prepared for in this process? Jon: I am pausing. The next revision of the book might be your inspiration. Well, because I know that it is way, way, way, way easier said than done. The core treatment for all OCD is the same. However, I have a completely different set of things I say depending on the presentation, because they each have their own set of things that the individual has to be focused on working to accept and live with. Although I think in my book I attempt. When I talk about each presentation, I do try to go over those and I’ve seen that for many people as helpful. But I also see for many people who’ve read the book, and even though they’ve read it, it ends up different for them to actually have to discuss it out loud. Sometimes it’s because they haven’t been able to think about it without realizing they avoid thinking about it. Sometimes because I think not all the connections are obvious, which I know is a really vague statement. I think I can go on, but I have to wait for you to ask a question.  Kimberley: Okay. We’re running out of time, so I want to make sure I’m respecting your time. Jon: Don’t respect my time, by the way. I set aside way extra time. This is on you if we end. Kimberley: Once you do those questions, you would then walk them through the four steps that you went through with scripting as well.  Jon: Yes, and some other horrible things because the horrible show, that should have been illegal. Actually, it’s not on anymore. I think you can still find that on YouTube. Toddlers & Tiaras and the crazy mothers who make their little girls try to be in beauty pageants. You know what, if you look at the pictures of the kids, it’s like, oh my God, they’re sexualizing this eight-year-old. But when you say that word, that means you can see what they have done. You recognize the sexual aspect. You know what, if I go and take this picture apart, this horrifies people when I say it. It’s like, if you look at their legs, it’s like, yeah, they have good legs. Now, nobody wants to say that, and it’s like, “Oh.” That’s our first response. But if I have POCD, I see that, “Oh my god, what’s wrong with me?” It’s an acceptance that we can see something and recognize a piece of it.  I think the most difficult POCD is the people who “I don’t want to be attracted to a 15-year-old.” I can say, if I show you this picture and tell you they’re 18, oh, that’s okay. If I show you the same picture and tell you they’re 15, no, that’s okay. It’s like somehow magically, I find that the picture, the attractive is the picture is right or wrong if I tell you the age, which of course makes no sense. The picture is attractive or not independent of that. It’s accepting, yes, I might find a whole lot of things. Again, what we think makes us accept or not do we act on it.  <!-- /wp:paragraph --> <!-- wp:paragraph --> Kimberley: It’s interesting because as you know, we just got a new puppy. It’s taking over all of the Quinlan family and our lives. I had a moment where our puppy loves his belly to be scratched and right there is his genitals. I can see the projection of my mind of like, “What if you just touched that? Or what if you pulled that back?” The imagery, I could see myself doing it. Thankfully I have all these skills where I’m able to go, “Oh, there’s a thought.” I did feel that hot, sticky anxiety flow going through. <!-- /wp:paragraph --> <!-- wp:paragraph --> Jon: If you don’t change diapers regularly, I’m sorry, it’s a weird experience and I don’t care who you are, you’re going to think about that. If you’re changing a little person and there you are, you’re pumping their genitals because you got to clean it up and wipe it, you know what you’re doing and the healthy thing is like, “Okay, weird thoughts. This is normal.” If I have OCD, it’s like, “Why would I even think that?” Well, it’s normal. <!-- /wp:paragraph --> <!-- wp:paragraph --> Kimberley: It’s funny because I was noticing myself going through some of these imaginal scripting steps myself. Instead of going, “No, no, no, no, no, you wouldn’t, you wouldn’t, you couldn’t. That’s terrible.” It was like, “All right.” This is the last question I want because you’ve given some great examples. As I was having this thought, I noticed the choice—I used the word “choice” on purpose—to get really edgy with it and try not to have it. My body language is all tight and I was gritting my teeth, or I was like, “Kimberley, just let it flow. Let the thoughts come.” As you’re doing this with your patients, is there any piece of you where you are bringing their attention to whether their shoulders are all tight and their jaw is all tight and their hands are all tight, or does that not matter? <!-- /wp:paragraph --> <!-- wp:paragraph --> Jon: Nothing not matters, maybe, but that’s not always true. I thought you’d enjoy that. I think it depends on how much that’s part of their conscious fear response. I mean, I think if they’re doing their dog and it’s like, “Oh my God, am I excited by this,” the answer I would be working on is, “I’m not really sure. Maybe I am in some deep way. I’m not going to play with the genitals now and that’s the best I get to know.” <!-- /wp:paragraph --> <!-- wp:paragraph --> Kimberley: Yeah. Agreed. I love this. Thank you. Again, I want you to say, where are the resources that people can go to get your concrete workbooks and your worksheets? <!-- /wp:paragraph --> <!-- wp:paragraph --> Jon: I love how you make me have so many more books and worksheets. All the paperwork that appears in my book appears for free for anybody on the site FreedomFromOCD.com. In the Kindle and audio version, they couldn’t have those, so I was obsessed to have the Kindle version so I made that available. My book has most of my repertoire except about 20 minutes. Those are the main places. I hate to do this, but most of the time, when it comes to OCD books, I will say to people, there are a bunch of books that I would recommend, I think, that are roughly equal. But I think the one that most agrees with me happens to be mine, so I mention a few of the other good books. There is only one other book seriously that I tell people to get because I think it’s different, and that is your book, which is amazing because generally, I hate books that label themselves “self-compassion” because it’s just a version of be nice to yourself in a lot of words. I feel your book gives these not easy-to-do steps that make it work. Although as I said to you last time, it is just you used too many exclamation points. <!-- /wp:paragraph --> <!-- wp:paragraph --> Kimberley: I will forever decline your opinion on my exclamation points and my emojis. If you ever text with me, you’ll know that I over emoji and I over exclamation points. <!-- /wp:paragraph --> <!-- wp:paragraph --> Jon: I’m okay with that in text.  <!-- /wp:paragraph --> <!-- wp:paragraph --> Kimberley: Thank you for that wonderful compliment. I do agree, yes, I have been blamed for the exclamation mark issue before, but I stand up and I stand with it. <!-- /wp:paragraph --> <!-- wp:paragraph --> Jon: I like to warn people because I want them to know, oh no, don’t worry. This isn’t as you would put it all flowers and unicorns. It’s a great book with too many exclamation points. <!-- /wp:paragraph --> <!-- wp:paragraph --> Kimberley: No, it’s funny because my mom helped me edit it while I was in a 14-day quarantine in a Sydney hotel for COVID. She would go through and she would add exclamation marks. She was adding e emojis and hearts and smiley faces and I was like, “Oh, we are going crazy here.” <!-- /wp:paragraph --> <!-- wp:paragraph --> Jon: Now I know where you got it from. <!-- /wp:paragraph --> <!-- wp:paragraph --> Kimberley: We’re all love. Thank you for that. It’s a very huge compliment. Thank you so much for being here and talking about this. Again, I love having you on talking just a little deeper into the topic and a bit more abstract, which I think is helpful too. Is there anything else you want to conclude on here? <!-- /wp:paragraph --> <!-- wp:paragraph --> Jon: I would love to have some really cool, all-summarizing conclusion. The truth is, I can just talk endlessly. I’m just going to thank you for having me on and I am always willing to come talk with you. <!-- /wp:paragraph --> <!-- wp:paragraph --> Kimberley: I would say, the point that I love that you made today, which I will add for you, is the word AND. The word AND is so important in this conversation. <!-- /wp:paragraph --> <!-- wp:paragraph --> Jon: That’s a great summary because I think so many of our ideas, it’s not like they’re new, they get refined with time. In a way, something we’ve been saying all along and suddenly there’s this very slightly different way of saying it, but it summarizes it in a way that makes it more understandable, and AND I think does that for a lot of understanding mindfulness and acceptance. <!-- /wp:paragraph --> <!-- wp:paragraph --> Kimberley: Yeah. Thank you so much.Jon: You take care. <!-- /wp:paragraph -->

Today we are talking all about ERP Scripting with Shala Nicely. Welcome back, everybody. We are on Week 2 of the Imaginals and Script Series. This week, we have the amazing Shala Nicely on the show. She’s been on before. She’s one of my closest friends and I’m so honored to have her on.  For those of you who are listening to this and haven’t listened to any of the previous episodes, I do encourage you to go back to last week’s episode because that is where we introduce the incredible Krista Reed and she talks about how to use scripts and imaginals. I give a more detailed intro to what we’re here talking about if this is new for you. This will be a little bit of a steep learning curve if you’re new to exposure and response prevention. Let me just quickly explain. I myself, I’m an ERP-trained therapist, I am an OCD Specialist, and a part of the treatment of OCD and OCD-related disorders involve exposing yourself to your fear and then practicing response prevention, which is reducing any of the safety behaviors or compulsions you do in effort to reduce or remove whatever discomfort or uncertainty that you feel. Now, often when we go to expose ourselves to certain things, we can’t because they’re not something we can face on a daily basis or they’re often very creative things in our mind. This is where imaginals and scripts can come in and can be incredibly helpful.  If you want a more detailed understanding of the steps that we take regarding ERP, you can go to CBTSchool.com, which is where we have all our online courses. There is a course called ERP School that will really do a lot of the back work in you really understanding today’s session. You don’t have to have taken the course to get the benefits of today’s session because a lot of you I know already have had ERP or are in ERP as we speak, or your clinicians learning about ERP and I love that you’re here. Honestly, it brings me so much joy. But that is there for you if you’re completely lost on what’s going on today, and that will help fill you in on the gold standard treatment for OCD and the evidence-based treatment for OCD and OCD-related disorders.  That being said, let’s get on with the good stuff. We have the amazing Shala Nicely. I am so honored again to have you on. You are going to love how applicable and useful her skills and tools are. Let’s just get straight over to Shala.  Kimberley: Welcome, Shala. I am so happy to have you back. I know we have a pretty direct agenda today to talk about imaginals versus scripting in your way in which you do it. I’d love to hear a little bit about, first, do you call it imaginals or do you call it scripting? Can you give me an example or a definition of what you consider them to be? SHALA’S STORY OF ERP SCRIPTING  Shala: Sure. Well, thank you very much for having me on. Love to be here as always. I’ll go back to how I learned about exposure when I first became a therapist. I learned about exposure being two different things. It was either in vivo exposure, so in life. Meaning, you go out and do the thing that your OCD is afraid of that you want to do, or it was imaginals where you imagine doing the thing that you want to do that your OCD is afraid to do. Research shows us that the in vivo is more effective, but sometimes imaginals is necessary because you can’t go do the thing for whatever reason. But I don’t think about it like that anymore. That’s how I learned it, but it’s not how I practice it.  To help describe what I do, I’ll take you back to when I had untreated OCD or when I was just learning how to do ERP for myself because I think that would help it make sense what I do. When I was doing ERP, I would obviously go out and do all the things that I wanted to do and my OCD didn’t want me to do. What I found was that I could do those things, but my OCD was still in my head, getting me to have a conversation about what we were doing in my mind. I might go pick up a discarded Coke can on the side of the road because it’s “contaminated,” and I would then go either put it in the trash, which would be another exposure because that would be not recycling. There are layers of exposures here. But my OCD could be in my head going, “Well, I don’t think that one is contaminated. It doesn’t look all that contaminated because it’s pretty clean and this looks like a clean area so I’m sure it’s not contaminated. What do you think, Shala?”  “Oh, I agree with you.” “Well, we threw it away, but I bet you, these people, they’re going to get wherever we threw it. They’re actually going to sort it out and it’s going to get recycled anyway.” There was this carnival in my head of information about what was going on.  I determined what I was doing because I was doing the exposure, but I wasn’t really getting all that much better. I was getting somewhat better but not all that much better. What I realized I was doing is that I’m having these conversations in my head, which are compulsive. In my recovery journey, what I was doing was I was going to a lot of trainings, I was reading a ton of books, and I talk about this in Is Fred in the Refrigerator?, my memoir, because this was a pretty pivotal moment for me when I read Dr. Jonathan Grayson’s book, Freedom from Obsessive Compulsive Disorder. I know you’re having him on this series as well. I read his book and he talks so much in there about writing scripts to deal with the OCD—writing scripts about what might happen, the worst-case scenario, living with uncertainty, and all that kind of stuff. That really resonated with me and I thought, “Aha, this is what I need to be doing. I need to be doing ERP scripting instead of having that conversation in my head with the OCD. Because when I’m doing exposure and I’m having a conversation with OCD in my head, I’m doing exposure and partial response prevention. I am preventing the physical response, but I’m not at all preventing the mental response, and this was slowing down my recovery.” The way I like to think of imaginals—you think about imagine like imagination—is that the way I do imaginal exposures, which I just call ERP scripting, is that I’m dealing with OCD’s imagination. People with OCD are exceptionally creative. If you’re listening to this and you think, “Well, not me,” for proof, all you have to do is look at what your OCD comes up with and look how creative it is. You guys share the same brain, therefore, you are creative too. All that creativity. When you have untreated OCD, it goes into coming up with these monstrous scenarios of how you’re harming others or harming yourself. You’re not ever going to be able to handle this anxiety or uncertainty or icky feeling or whatever, and it builds these scary stories that get us stuck.  WHAT IS ERP SCRIPTING?  What I’m trying to do with imaginal exposure or scripting is I’m trying to deal with OCD’s imagination because in the example I gave, I was picking up the Coke can and my OCD was using its imagination to try to reassure me all the ways this Coke can was going to be okay or all the ways this Coke can was going to eventually get recycled. I needed to deal with that. Really, the way I do ERP Scripting for myself and for my clients is I’m helping people deal with OCD’s imagination in a non-compulsive way. For me, it is not a choice of in vivo or imaginal; it is in vivo with imaginal, almost always, because most people that I see anyway are doing what I did. They are doing physical compulsions or avoidance and they’re up in their head having a conversation with their OCD about it. I’m almost always doing in vivo and imaginals together because I’m having people approach the thing that they want to do that OCD doesn’t want them to do, and I’m having them do scripts. The Coke can may or may not be contaminated. The fact that it’s sitting here and it looks pretty clean may or may not mean that it’s got invisible germs on it. I don’t know. The Coke can may or may not get recycled, it may or may not end up in recycling, but somehow contaminate the whole recycling thing that has to throw all that other recycling away because it touched it. I’m trying to use my imagination to make it even worse for the OCD so that we’re really facing these fears.  That’s how I conceptualize imaginal exposure. It’s not an AND/OR it’s an AND for me. Some people don’t need it and if they don’t need it, fine. But I find it’s very helpful to make sure that people are doing full response prevention in that they’re permitting both the physical and the mental compulsive response. DOES EVERYONE NEED ERP SCRIPTING?  Kimberley: Does everyone need ERP scripting? When you say some people don’t need it, what would the presentation of those people be? Shala: That for whatever reason, they are good at not having the conversation with OCD in their heads. This is the minority of people anyway that I work with. Most people are pretty good at having compulsive conversations with OCD because the longer you have untreated OCD, the more you end up taking your physical compulsions and pulling them inward and making the mental compulsion so that you can survive. If you can’t really do all that physical checking at your office because people are going to see you, you do mental checking. That’s certainly what I did. People become good at doing this stuff in their head and it becomes second nature. It can be going on. I talk about this a lot in Fred, I could do compulsions while I was doing anything else because I could do them in my head. Most people are doing that and most people have been doing that for long enough by the time they see somebody like me that if I just say, “Well, stop doing that,” I mean I’m never going to see them again. They’re not going to come back because they can’t stop doing that. That’s the whole reason they called me.  I’m giving them something else to do instead. It’s a competing response to the mental compulsions because they don’t know how to stop that. They’re not aware of what they’re doing, they don’t know how to stop the process, so I’m giving them something to do instead of that until they build the mental muscles to be able to recognize OCD trying to get them to have a conversation and just not answer that question in their head. But it takes a long time to develop that skill. It took me a long time anyway.  Some people, for whatever reason though, are good at that. If they don’t need to do the scripting, great. I think that’s wonderful. They don’t have to do it. The strongest response you can ever have to OCD is to ignore it completely, both physically and mentally. If you can truly ignore it in your head, you don’t even need to do the scripting. It’s a stronger response to just do what you want to do that upsets OCD and just go on with your day. HOW TO DO ERP SCRIPTING?  Kimberley: Amazing. So How do you do ERP Scripting? If you’re not one of those people and OCD loves to come up with creative ideas of all the things, what would be your approach? You talked about imaginals versus scripting. Can you play out and show us how you do it? Shala: I mean, I guess imaginals in the traditional way that it is defined versus scripting. The way I would do it is we would design the client and I would design whatever their first exposure is going to be. Let’s say that it would be touching doorknobs. They’re going to be in their location and I’m going to be in my location. They’re going to be wherever we’ve decided they’re going to touch the doorknobs. Maybe it’s to the outside of their house, for instance. I’m there on video with them and we have them touch the doorknob.  And then I asked them, “Well, what is OCD saying about that?”  “Well, OCD says that I need to go wash my hands.”  I will say, “Well, are you going to go do that?”  “No.”  I’m like, “Well, let’s tell OCD that.”  “Okay, OCD, I’m not going to wash my hands.”  “Now what’s OCD saying?”  “Well, OCD is saying that I’m contaminated.”  “Well, let’s say I may or may not be contaminated.”  So far, we’ve got, “I’m not washing my hands and I may or may not be contaminated.” Okay, now I’ll ask them their anxiety level. When they say, “Gosh, I’m at a four,” I’ll say, “Is that good?” They’ll often say, “No, I wish it were zero.” I’ll be like, “I’m sorry, what? What did you say? You want your anxiety to be zero? I must have misheard that. Is four good?” Finally, they understand, “Oh, well, four is not good because we could be higher.”  “What would be better than four?”  “Anything above a four.”  I’m working with them on that. We might start to throw some things in the script. I want to be anxious because this is how I beat my OCD, so bring it on.  I’ll ask again, “What’s your OCD saying?”  “Well, it’s saying that I’m going to get some terrible disease.”  “Well, you may not get a terrible disease.” I’m questioning back and forth the client as we’re working on this, until we’ve got enough of a dialogue about what’s going on in their head that we can then create a script. A script might look something like, “Well, I may or may not be contaminated. I may or may not get a dread disease, but I’m not washing my hands and I’m going to do this because I want my life back. It makes me anxious and I may or may not get a dread disease.” And then we’ll focus in on what’s bothering OCD most. Maybe it’s, at the beginning, the dread disease. “Well, I may or may not get a drug disease. I may or may not get a dread disease. I may or may not get a dread disease. I may or may not get a dread disease.” We might sing it, we say it over and over and over and over and over again, and look for what the reaction from the OCD is. If the OCD is still upset, then we still go after that. If it starts moving, “Well, what’s OCD saying now?” “Well, OCD is saying now that if I get a dread disease, then I won’t be able to do this thing that I have coming up that I really want to do.” “Well, okay, I may or may not get a dread disease and I may or may not miss this important event as a result.” We add that in.  We do that and do that and do that and do that for whatever the period is that we’ve decided is going to be our exposure period. And then we stop and then we talk about it. What did we learn? What was that like and what did you learn? Really focusing on how we did more than we thought we could do. We withstood more anxiety than we thought we could withstand. What did we learn about what the OCD is doing? I’m not so concerned about what the anxiety is doing. I mean, I want it to go up. That’s my concern. I’m not all that concerned about whether it comes down or not. I do want it to go up. We talk about what we learned about the anxiety that gosh, you can push it up enough and you can handle a lot more than you thought you did. That would be our exposure.  And then we would plan homework and then they would do that daily, hopefully. I have forms on my website that people can then send me their daily experience doing these exposures and I send them feedback on it, and that’s what we’re working on. We’re working on doing the thing that OCD doesn’t want you to do that you want to do, and then working on getting better and better at addressing all of the mental gymnastics in your head.  Now, if somebody touches the doorknob and they’re like, “Okay, I can do this,” and then their anxiety comes up and comes back down and they can do it without saying anything, great, go touch doorknobs. You don’t need to do scripting. Often, I don’t know if somebody needs to do that until we start working on it. If they don’t need to do the scripting, great. We don’t do the scripting. Makes things easier. But often people do need to. That’s generally how I do it. Obviously, lots of variations on that based on what the client is experiencing.  Kimberley: This is all thing, you’re not writing it down. Again, when you go back to our original training, for me, it was a worksheet and you print it out, you’d fill out the prompts. Are you doing any of this written or is this a counter to the mental compulsions in your head? Shala: None of this is written. The only time I would write it out is after that first session. When you’re really anxious, your prefrontal cortex isn’t working all that well, so you may have trouble remembering what we did, remembering the specific things that we said, or pulling it up for yourself. When you’re doing your exposure, you’re so anxious. I might type out some of what we said, the main things, send it to the clients, and have that. But really to me, scripting is an interactive exercise and I want my clients to be listening to what the OCD is saying for the sole purpose of knowing what we’re going to say. Because when we start doing exposure, what we’re often trying to do is keep pace with the OCD because it’s got a little imagination engine running and it’s going to go crazy with all the things that it’s going to come up with. We’re trying to stay on that level and make sure we’re meeting all its imagination with our own imagination. As we get better and better at this, then I’m teaching people how to one-up the OCD and how to get better than the OCD as it goes along. But it’s a dynamic process. I don’t have people read scripts because the script that we wrote was for what was going on whenever we wrote the script. Different things might be going on this time. What we’re trying to do is listen to the OCD in a different way. I don’t want people listening to it in a compulsive way. I want people listening to it in a, “I’ve got to understand my foe here and what my foe is upset about so I can use it against it.” That’s what we’re doing. There might be key things, little pieces we write down, but I’m not having people write and read it over and over. Now, there’s nothing wrong with that. It’s just not what I do. Everybody has a different way to approach this. This is just my way.  Kimberley: Right. I was thinking as you were talking, in ERP School, I talk about the game of one-up and I actually do that game with clients before I do any scripting or imaginals or exposures too. They tell me what their fear is, I try and make it worse. And then I ask them to make it even worse, then I make it even worse, because I’m trying to model to them like, we’re going here. We’re going to go all the way and even beyond. If we can get ahead of OCD and get even more creative, that’s better.  Let’s play it back and forward. You talked about touching a doorknob and all of the catastrophic things that can happen there. What about if someone were to say their thoughts are about harming somebody and they have this feeling of like, I’ve been trained, society has trained me not to have thoughts about harming people or sexual thoughts and so forth? There’s this societal OCD stigmatizing like we don’t think those things. We should be practicing not thinking those things. What would you give as advice to somebody in that situation?  Shala: I would talk a lot about the science about our thoughts, that the more that you try to push a thought away, the more it’s going to be there. Because every time you push a thought away, your brain puts a post-it note on it that says, “Ooh, she pushed this thought away. This must be dangerous. Therefore, I need to bring it up again to make sure we solve it.” Because humans’ competitive advantage—we don’t have fur, we don’t have fangs, we don’t have claws, we don’t run very fast—our competitive advantage is problem-solving. The way we stay alive is for cave people looking out onto savannah and we can see that there are berries here, there, and yawn. But that one berry patch over there, gosh, you saw something waving in the grass by it and you’re like, “I’m going to notice that and I’m going to remember that because that was different, but I also don’t want to go over there.” Your brain is going to remember that like, “Hmm, there was something about that berry patch over there. Grass waving could be a tiger. We need to remember that. Remember that thing, we’re not going to go over there.” We’re interacting with thoughts in that way because that’s what kept us alive.  When we get an intrusive thought nowadays and we go, “Ooh, that was a bad thought. I don’t know. I should stay away from that,” our brain is like, “Oh, post a note on that one. That one is like the scary tiger thought. We’re going to bring that up again just to make sure.” Every time we try to push a thought away, we’re going to make it come back. We talk a lot about that. We talk a lot about society’s norms are whatever they are, but a lot of society’s norms are great in principle, not that awesome in practice. We don’t have any control over what we think about. The TV is filled with sex and gore, and violence. Of course, you’re thinking those things. You can’t get away from those images. I think society has very paradoxically conflicting rules about this stuff. Don’t think about it but also watch our TV show about it.  I would talk about that to try to help people recognize that these standards and rules that we put on ourselves as humans are often unrealistic and shame-inducing and to help people recognize that everybody has these thoughts. We have 40, 60, 80,000 thoughts a day. I got that number at some conference somewhere years ago. We don’t have control over those. I would really help them understand the process of what’s going on in their brain to destigmatize it by helping them understand really thoughts are chemical, neuronal, whatever impulses in our brain. We don’t have a lot of control over that and we need to deal with them in a way that our brain understands and recognizes. We need to have those thoughts be present and have a different reaction to those thoughts so your brain eventually takes the post-it note off of them and just lets them cycle through like all the other thoughts because it recognizes it’s not dangerous.  HOW FAR CAN YOU GO IN ER SCRIPTING?  Kimberley: Right. I agree. But how far can you go in ERP Scripting? Let’s push a little harder then. This just happened recently actually. I was doing a session with a client and he was having some sexual pedophilia OCD obsessions playing up, “I’ll do this to this person,” as you were doing like I may or may not statements and so forth. And then we played with the idea of doing one up. I actually went to use some very graphic words and his face dropped. It wasn’t a drop of shock in terms of like, “Oh my gosh, Kimberley used that naughty word.” It was more of like, “Oh, you are in my brain, you know what I’m thinking.” And then I had to slow down and ask him, “Are there any thoughts you actually aren’t admitting to having?” Because I could see he was going at 80% of where OCD took him, but he was really holding back with the really graphic, very sexual words—words that societally we may actually encourage our children and our men and women not to say. Do you encourage them to be using the graphic language that their OCD is coming up with? Shala: Absolutely. I’m personally a big swearer.  That’s another thing I talk about in-- Kimberley: Potty mouth. Shala: I’ll ask clients, “What’s your favorite swear word? Let’s throw swear words in here.” I want to use the language that their OCD is using. If I can tell that’s the language their OCD is using, well, let’s use that language. Let’s not be afraid of it.  The other thing I do before I start ERP with anyone is I go through what I consider the three risks of ERP so they understand that what happens during our experience together is normal. I explain that it’s likely we’re going to make their anxiety worse in the weeks following exposure because we’re taking away the compulsions bit by bit, and the compulsions are artificially holding back the anxiety. I explained that their OCD is not going to roll over because they’re doing ERP therapy now. Nobody’s OCD is going to go, “Oh gosh, Shala is in ERP. I think I’ll just leave her alone now.” No, the OCD is going to ratchet it up. You’re not doing what you’re supposed to do, you’re not doing your compulsions, so let’s make things scarier. Let’s make things more compelling. Let me be louder. Your OCD can get quite a bit worse once you start doing ERP because it’s trying to get you back in line. When somebody is in an exposure session and their OCD is actually going places, they never even expected them to go, and I’ll say that’s what we’re talking about, “That’s just the OCD getting worse, that’s what we wanted. This is what we knew was going to happen.” We’re going to use that against the OCD to help normalize it. Then I also explain to people that people with OCD don’t like negative emotions more than your average bear, and we tend to press all the negative emotions down under the anxiety. When you start letting the anxiety out and not doing compulsions, then you can also get a lot more emotions than you’re used to experiencing so that people recognize if they cry during the exposures, if it’s a lot scarier than they thought, if they have regret or guilt or other feelings, that’s just a normal part of it. I explain all that. When things inevitably go places where the client isn’t anticipating they’re going to go like in a first exposure, then they feel this is just part of the process. I think it makes it so that it’s easier to go those graphic places because you’re like, “Yeah, we expected OCD to go the graphic place because it’s mad at you.” Kimberley: It normalizes it, doesn’t it?  Shala: Yeah. Then we go to the graphic place too. I tell clients that specifically because this is a game and I really want them to understand this is what your opponent is likely to do so that they feel empowered so we can go there too and trying some to take the shame out of it. When you said the graphic word and your client had a look on their face and it was because how did you even know that was in my head, because you were validating that it’s okay to have this thought because you knew it was going to be there. I think that’s a really important part of exposure too. HOW LONG DO YOU USE ERP SCRIPTING FOR?  Kimberley: So, how long do you do ERP Scripting for? Let’s say they’re doing this in your session or they’re at home doing their assigned homework. Let’s say they do it for a certain amount of time and then they have to get back to work or they’re going to do something. But those voices, the OCD comes back with a vengeance. What would you have them do after that period of time? Would they continue with this action or is there a transition action or activity you would have them do? Shala: That’s a great question. It depends a lot on really the stage of therapy that somebody is in and what is available to them based on what they’re going to be doing. Oftentimes, what I will ask people to do is to try to do the exposure for long enough that you’ve done enough response prevention that you can then leave the exposure environment and not be up in your head compulsively ruminating. Because if you were doing exposure for 20 minutes, you’ve done a great job, but then you leave that exposure and you are at a high enough anxiety level where it feels compelling. Now you have to fix the problem in your head even though you just did this great exposure. Then we’re just going to undo the work you just did. I try to help people plan as much as they can to not get themselves in a situation where they’re going to end up compulsively ruminating or doing other compulsions after they finish. But obviously, we can’t be perfect. Life happens.  I think some of the ways you can deal with that, if you know it’s going to happen, sometimes they’ll ask people to make recordings on their phone and they just put in their earpieces or their earbuds or whatever and they can just listen to a script while they’re doing whatever they’re doing. Nobody has to know what they’re doing because so many people walk around with EarPods in their ears all the time anyway. That’s one way to deal with it.  Another way to deal with it is to try to do the murmuring out in your head as best as you can. That’s really hard because they’re likely to just get mixed up with compulsive thoughts. You can try to focus your attention as much as you possibly can on what you’re doing. That’s going to be the strongest response. It’s hard for people though when they get started to do that. But if you can do that, I think that’s fine, and I think just being compassionate with yourself. “Okay, so I am now sitting here doing some rituals in my head. I’m doing the best I can.” If you’re not in a situation where you can fully implement response prevention in your head because you’re in a meeting and you got to do other stuff and you’ve got this compulsive stuff running in the background, just do the best you can. And then when you’re at a place where you can do some scripting, some more exposure to get yourself back on top of the OCD, then do that. But be really compassionate.  I try to stress this to all my clients. We are not trying to do ERP perfectly because if you try to do it perfectly, you’re doing ERP in an OCD way, which isn’t going to work. Just be kind to yourself and recognize this is hard and nobody is going to do it perfectly. If you end up in a situation where you end up doing some compulsions afterwards, well, that’s good information for us. We’ll try to do it differently or better next time, but don’t beat yourself up.   Kimberley: It’s funny you brought that up because I was just about to ask you that question. Often clients will do their scripting or their imaginal and then they have an obsession, “What if I keep doing compulsions and it’s not good to do compulsions?” Would you do scripting for that? Shala: Oh yeah. I may or may not do more compulsions than I used to be doing. I may or may not get really worse doing this. I may or may not have double the OCD that I had when I started seeing trauma. This may or may not become so bad that they have to create a hospital just to help me all by myself. We try to just create stuff to deal with that. But also, I’m injecting one up in the OCD, I’m injecting some humor, how outlandish can we make these things? I try to have “fun” with it. Now I say “fun” in quotes because I know it’s not necessarily fun when you’re trying to do this, but we’re trying to make this content that OCD is turning into a scary story. We’re trying to make it into a weapon to use against the OCD and to make this into a game as much as we can. Kimberley: I love it. I’m so grateful for you coming on. Is there anything that you want the listeners to know as a final piece for this work that you’re doing? Shala: Sure. I think that there are so many different ways to do exposure therapy. This is the way that I do it. It’s not the only way, it’s not necessarily the right way; it’s just the way I do it and it’s changed over the years. If we were to record this podcast in five years or 10 years, I probably will be doing something slightly different. If your therapist is doing something differently or you’re doing something differently, it’s totally fine. I think that finding ERP in a way that works for you, like finding how it works for you and what works best for you is the most important thing. It’s not going to be the same for everybody. Everybody has a slightly different approach and that’s okay.  One thing that people with OCD can get stuck on, and I know this because I have OCD too, is we can be black and white and say there’s one right way. Well, she does it this way and he does it that way and this is wrong and this is right. No, if you’re doing ERP, there are all sorts of ways to do it, so don’t let your OCD get into the, “Well, I don’t think you’re doing this right because you’re not doing this, that, or the other.” Just work with your therapist to find out what works best for you. If what I’ve described works well for you, great. And if it doesn’t, you don’t have to do it. These are just ideas. Being really kind and being really open to figuring out what works best for you and being very kind to yourself I think is most important. Kimberley: Amazing. Tell us where people can get more information about you. Tell us about your book. I know you’ve been on the podcast before, but tell us where they can get hold of you. Shala: Sure. They can get a hold of me on my website, ShalaNicely.com. I have a newsletter I send out once a month that they can sign up for called Shoulders Back! Tips & Resources for Taming OCD. In it, I feature blogs that I write or podcast episodes, other things that I’m doing. It’s all free where I’m talking about tips and resources for taming OCD. I have two books: Everyday Mindfulness for OCD that I co-wrote with Jon Hershfield and Is Fred in the Refrigerator? Taming OCD and Reclaiming My Life, which is my memoir. It is written somewhat like a suspense novel because as all of you know who have OCD, living with untreated OCD is a bit like living in a suspense novel. My OCD is actually a character in the book. It is the villain, so to speak. The whole book is about me trying to understand exactly what is this villain I’m working against. Then once I figure out what it is, well, how am I going to beat it? And then how am I going to live with it long term? Because it’s not like you’re going to kill the villain in this book. The OCD is going to be there. How do I learn to live in a world of uncertainty and be happy anyway, which is something that I stole from Jon Grayson years ago. I stole a lot from him. That’s what the book is about. Kimberley: It’s a beautiful book and it’s so inspiring. It’s a handbook as much as it is a memoir, so I’m so grateful that you wrote it. It’s such a great resource for people with OCD and for family members I think who don’t really get what it’s like to be in the head of someone with OCD. A lot of my client’s family members said how it was actually the first time it clicked for them of like, “Oh, I get it now. That’s what they’re going through.” I just wanted to share that. Thank you so much for being on the show. I’m so grateful to have you on again. Shala: Thank you so much for having me. It was fun.

Welcome back, everybody. Thank you for joining me again this week. I’m actually really excited to dive into another topic that I really felt was important that we address. For those of you who are new, this actually might be a very steep learning curve because we are specifically talking about a treatment skill or a tool that we commonly use in CBT (Cognitive Behavioral Therapy) and even more specifically, Exposure and Response Prevention. And that is the use of imaginals or what we otherwise call scripts. Some people also use flooding.  We are going to talk about this because there are a couple of reasons. Number one, for those of you who don’t know, I have an online course called ERP School. In ERP School, it’s for people with OCD, and we talk about how to really get an ERP plan for yourself. It’s not therapy; it’s a course that I created for those who don’t have access to therapy or are not yet ready to dive into therapy, where they can really learn how to understand the cycle of OCD, how to get themselves out of it, and gives you a bunch of skills that you can go and try. Very commonly, we have questions about how to use imaginals and scripts, when to use them, how often to use them, when to stop using them, when they become compulsive and so forth.  In addition to that, as many of you may not know, I have nine highly skilled licensed therapists who work for me in the state of California and Arizona, where we treat face-to-face clients. We’re actually in Los Angeles. We treat patients with anxiety disorders. I also notice that during my supervision when I’m with my staff, they have questions about how to use imaginals and scripts with the specific clients. Instead of just teaching them and teaching my students, I thought this was another wonderful opportunity to help teach you as well how to use imaginals and why some people misuse imaginals or how they misuse it. I think even in the OCD community, there has been a little bit of a bad rap on using scripts and imaginals, and I have found using scripts and imaginals to be one of the most helpful tools for clients and give them really great success with their anxiety and uncertainty and their intrusive thoughts.  Here we are today, it is again a start of another very short series. This is just a three-week series, talking about different ways we can approach imaginals and scripts and how you can use it to help manage your intrusive thoughts, and how you can use it to reduce your compulsions.  It is going to be three weeks, as I said. Today, we are starting off with the amazing Krista Reed. She’s been on the show before and she was actually the one who inspired this after we did the last episode together. She said, “I would love to talk more about imaginals and scripts.” I was like, “Actually, I would too, and I actually would love to get some different perspectives.” Today, we’re talking with Krista Reed. Next week, we have the amazing Shala Nicely. You guys already know about Shala Nicely. I’m so happy to have her very individual approach, which I use all the time as well. And then finally, we have Dr. Jon Grayson coming in, talking about acceptance with imaginals and scripts. He does a lot of work with imaginals and scripts using acceptance, and I wanted to make sure we rounded it out with his perspective.  One thing I want you to think about as we move into this series or three-part episode of the podcast is these are approaches that you should try and experiment with and take what you need. I have found that some scripts work really well with some clients and others don’t work so well with other clients. I have found that some scripts do really well with one specific obsession, and that doesn’t do a lot of impact on another obsession that they may have. I want you just to be curious and open and be ready to learn and take what works for you because I think all of these approaches are incredibly powerful.  Again, in ERP School, we have specific training on how to do three different types of scripts. One is an uncertainty script, one is a worst-case scenario script, and the last is an acceptance script. If you’re really wanting to learn a very structured way of doing these, head on over to CBTSchool.com and you can sign up for ERP School there. But I hope this gets you familiar with it and helps really answer any questions that you may have.  Alright, let’s get over to the show. Here is Krista Reed. Kimberley: Welcome back, Krista Reed. I am so happy to have you back on the show. Krista: Thank you. I am elated to be able to chat with you again. This is going to be great. Kimberley: Yeah. The cool thing is you are the inspiration for this series. Krista: Which is so flattering. Thank you.  IMAGINAL OR SCRIPT? Kimberley: After our last episode, Krista and I were having a whole conversation and you were saying how much you love this topic. I was like, “Light bulb, this is what we need to do,” because I think the beautiful piece of this is there are different ways in which you can do imaginals, and I wanted to have some people come on and just share how they’re doing it. You can compare and contrast and see what works for you. That being said, number one, do you call it an imaginal, do you call it a script, do you think they’re the same thing, or do you consider them different? Krista: I do consider them differently because when I think about script, I mean, just the word script is it’s writing, it’s handwriting in my opinion. I mean, scripture is spoken. That’s something a little bit different, but scripting is writing. When I think of an imaginal, that is your imagination. I know that I already shared with you how much I love imaginals because in reality, humans communicate through stories. When we can, using our own imagination, create a story to combat something as challenging as OCD, what a powerful concept. That’s exactly why I just simply love imaginals. Kimberley: I can feel it and I do too. There’s such an important piece of ERP or OCD recovery or anxiety recovery where it fills in some gaps, right? Krista: Yes, because imaginals, the whole point, as we know, it’s to imagine the feared object or situation. It could evoke distress, anxiety, disgust. Yet, by us telling those stories, we’re poking the bear of OCD. We’re getting to some of that nitty gritty. Of course, as we know that, not every obsession we can have a real-life or an in vivo exposure. We just simply can’t because of the laws of science, or let’s be real, it might be illegal. But imaginals are also nice for some people that the real-life exposure maybe is too intense and they need a little bit of a warmup or a buy-in to be able to do the in vivo exposure. Imaginal, man, I freaking love them. They’re great.  Kimberley: They’re the bomb.  Krista: They really are.  HOW TO DO IMAGINALS FOR OCD Kimberley: You inspired this. You had said, “I love to walk your listeners through how to do them effectively. I think I remember you saying, but correct me if I’m wrong, that you had seen some people do them very incorrectly. That you were very passionate because of the fact that some people weren’t being trained well in this. Is that true or did I get that wrong? Krista: No, you absolutely got it right. Correct and incorrect, I think maybe that is opinion. I’ll say that in my way, I don’t do it that way. That’s a preference. But this is an inception. We’re not putting stories into our clients’ minds. The OCD is putting these stories into our clients’ minds. If you already have a written-out idea of a script, of like fill in the blanks, you are working on some kind of inception, in my opinion. You are saying that this is how your story is supposed to be. That’s so silly. I’m not going to tell you how your story is supposed to be. I don’t know how your imagination works. When we think of just imagination, there’s so many different levels of imagination.  Let’s say for instance, if I have somebody who comes into my office who is by trade a creative writer, that imaginal is probably going to be very descriptive, have a lot of heavy adjectives. Just the way it’s going to be put together is going to be probably like an art in itself because this is what that person does. If you have somebody who comes in and creativity is not something that is part of a personality trait, and then I have a written fill-in-the-blank thing for them, it’s not going to be authentic for their experience. They’re going to potentially want to do what I, the therapist, might want them to do. It’s not for me to decide how creative or how deep that person is to go. They need to recognize within themselves, is this the most challenging? Is this the best way that you could actually describe that situation? If that answer is yes, it’s my job as a therapist to just say okay. Kimberley: How would one know if it’s the most descriptive they could be? Is it by just listening to what OCD has to say and letting OCD write the story, but not in a compulsive way? Share with me your thoughts.  Krista: I think that that’s almost like a double-edged sword because that of itself can almost go meta. How do I know that my story is intense enough? Well, on the surface we can say, “Is it a hard thing to say.” They might say yes, and then we can work through. But if I’m really assessing like, “Is it hard enough, is it hard enough,” and almost begging for them to provide some type of self-reassurance, they might get stuck in that cycle of, is this good enough? Is this good enough? Can it be even more challenging?  Another thing I love about imaginals is the limit doesn’t exist, because the limit is just however far your imagination can take you. Let’s say that I have a session with a client today and they’re creating an imaginal. I’m just going to give a totally random obsession. Maybe their obsession is, “I am afraid that I’m going to murder my husband in his sleep,” harm OCD type stuff, pretty common stuff that we do with imaginals. They do the imaginal and they’re able in session to work through it. It sounds like it was good. In the session, what they provided was satisfactory to treatment. And then they come back and say, “I got bored with the story,” which a lot of people think that that’s a bad thing. That’s actually a good thing because that’s letting you know that you’re not in OCD’s control of that feared response and you’re actually doing the work. However, they might still have the obsession. I was like, “Okay, so you were able to work through this habituate or get bored of that. Now, let’s create another imaginal with this obsession.” Because it’s all imagination, the stories, you can create as many as you possibly can or as you possibly want to.  I’m actually going to give you a quote. He’s a current professor right now at Harvard. He is a professor of Cognitive and Educational Studies. If you look this guy up, his name is Dr. Howard Gardner—his work is brilliant. He has this fantastic quote that I think is just a bomb when it comes to imaginal stuff. His quote is: “Stories constitute the single most powerful weapon in a leader’s arsenal.” Think about that. What a powerful statement that is. Isn’t that just fantastic? Because we can hear that as the stories OCD tells us as being hard. Okay, cool story, bro, that is your weapon OCD, but guess what? I’m smarter than you and I brought a way bigger gun and this gun isn’t imaginal and I’m going to go ahead and one up you. If I come back that next week in my therapist’s office and I’m able to get bored with that, I can make a bigger gun. Kimberley: I love that. It’s true, isn’t it? I often will say, “That’s a good story. Let me show you what I’ve got.” It is so powerful. Oh my gosh. Let’s actually do it. Can you walk us through how you would do an imaginal? Krista: This is actually something that I created on my own taken from just multiple trainings and ERP learning about imaginals, because one of the things that I was realizing that a lot of clients were really struggling with is almost over-preparing just to do the imaginal. Sometimes they would write out the imaginal and then we would work through that. But what I was finding is sometimes clients were almost too fixated on words, reading it right, being perfect, that they were almost missing out on the fact that these are supposed to be movies in our mind. Kimberley: Yeah. They intellectualize it. Krista: Exactly. I created a super simple format. I mean, we really don’t have a lot of setup here. It’s basically along the lines of the Five Ws. What is your obsession and what is your compulsion? Who is going to be in your story? Who is involved? Where is your story taking place? When is your story taking place? And when is already one of those that’s already set because I tell people we can’t do anything in the past; the past has already existed. You really need to be as present as possible. But the thing is that you can also think. For instance, if my obsession is I’m going to murder my husband in his sleep tonight, part of that might be tonight, but part of that might also be, what is going to be my consequence? What is that bad thing that’s going to happen? Because maybe the bad thing isn’t necessarily right now. Maybe that bad thing is going to be I’m not going to have a relationship with my children and what if they have grandchildren? Or what if I’m going to go to hell? That might not necessarily exist in the here and now, but you’re able to incorporate that in the story. When is an interesting thing, but again, never in the past, needs to start in the present, and then move forward.  And then also, I ask how. How is where I want people to be as descriptive as possible. For instance, if I say, and this is going to sound gritty, you’re fearful that you’re going to murder your husband tonight. Be specific. How are you going to murder your husband? Because that’s one of the things that OCD might want us to do. Maybe it is just hard enough to say, “I’m going to murder my husband.” But again, we’re packing an arsenal here. Do you want to just say that? Because I can almost guarantee you OCD is already telling you multiple different ways that it might happen. Which one of those seems like it might be the hardest? Well, the hardest one for me is smothering my husband with a pillow. Okay, that’s going to be it. That’s literally my setup. That’s literally my setup, is I say that. Actually, I have one more thing that I have to include. I have all that as a setup and then I say, “Okay, at the very end, you are going to say this line, and it’s, ‘All of this happened because I did not do the compulsion.’” If I were going along with the story of I murdered my husband, I suffocated him with a pillow, and in my mind, the worst thing to happen is I don’t have a relationship with my kids and grandchildren, and the compulsion might be to pray—I’ll just throw that out—the last line might be, “And now, I don’t have a relationship with my children or grandchildren all because I decided to not pray when the thought of murdering my husband came up in my mind.” That is the entire setup.  And then I have my clients get their phones out and push record. They don’t have to do a video, just an audio is perfectly fine. I know some therapists that’ll do it just once, but I actually do it over and over again. Sometimes it could be a five-minute recording, it could be a 20-minute recording, it could be a 40-minute recording. The reason for that being is if we stop just after one, we might be creating accommodation for that client, because I want my clients to be in that experience. That first time they tell that story after that very brief setup, they’re still piecing together the story. Honestly, it’s really not until about the third or fourth time that they’ve repeated that exact same story that they’re really in it. I am just there and every time they finish—I’ll know they finish because they say, “And this happened all because da da da da da”—I say, “Okay, what’s your number?” That means what’s your SUDS? And they tell me they’re SUDS. I might make a little bit, very, very minimal recommendations. For instance, if they say, “I murdered my husband,” I say, “Okay, so this time I want you to tell me how you murdered your husband.” Again, they say the exact same story, closing their eyes all over again, this time adding in the little bit that I asked for. We do that over and over and over again until we reach 50% habituation. Then they stop recording. That is what they use throughout the week as their homework, and you can add it in so many different ways.  Again, keeping along with this obsession of “I’m afraid I’m going to kill my husband tonight,” I want you to listen to that with, as you probably have heard this as well, just one AirPod in, earbud, whatever, keep your other ear outside to the world. This is its way to talk back to OCD. Just something along the lines of that. I want you to the “while you’re getting ready for bed.” Because if the fear exists at night and your compulsions exist at night, I want you to listen to that story before you go to bed. It’s already on your mind. You’re already in it, you’re already poking the bear of OCD. It’s like, “Okay, OCD, you’re going to tell me I’m going to kill my husband tonight? Well, I’m going to hear a story about me killing my husband tonight.” Guess what? The bad thing’s going to happen over and over and over again.  It’s such a powerful, powerful, powerful thing. Because it’s recorded, you can literally listen to it in your car. You can listen to it on a plane. You can listen to it in a waiting room. I mean, there’s no limit.  Kimberley: It’s funny because, for those of you who are on social media, there was this really big trend not long ago where they’re like what they think I’m listening to versus what I’m actually listening to, and they have this audio of like, “And then she stabbed her with the knife.” It’s exactly that. Everyone thinks you’re just listening to Britney Spears, but you’re listening to your exposure and it’s so effective. It’s so, so effective. I love this. Okay, let’s do it again because I want this to be as powerful as possible. You did a harm exposure. In other episodes, we’ve done a relationship one, we’ve done a pedophile one. Let’s pick another one. Do you have any ideas?  Krista: What about scrupulosity? Kimberley: I was just going to say, what about scrupulosity? Krista: That one is such a common one for imaginals. We hear it very frequently, “I’m going to go to hell,” or even thinking about different other religions like, “Maybe I’m not going to be reincarnated into something that has meaning,” or “It’s going to be a bad thing. Maybe I’m insulting my ancestors,” or just whatever that might be. Let’s say the obsession is—I already mentioned praying—maybe if I don’t read the Bible correctly, I’m going to go to hell. I don’t know. Something along the lines of that. If that’s their obsession, chances are, there’s probably somebody that maybe they have a time where they’re reading the Bible or maybe that we have to add in an in vivo where they’re going to be reading or something like that. A setup could potentially be, what is your obsession? “I’m afraid that any time I read my Bible, I’m not reading it correctly and I’m going to go to hell.” What is your compulsion? “Well, my compulsion is I read it over and over and over again and I reassure myself that I understand it, I’m reading it correctly.” Who’s going to be in your story? This one you might hear just, “Oh, it’s just me.” Really, OCD doesn’t necessarily care too much if anybody else is in this story. Where are you? “I’m in my living room. It’s nighttime. That’s when I read my Bible.” When is this taking place? “Oh, we can do it tonight.” Let’s say it’s tonight.  Interestingly enough, when you have stuff that’s going to go to hell, that means, well, how are you getting to hell to begin with? Because that’s not just something that can happen. Sometimes in these imaginals, the person has to die in order to get there, or they have to create some type of fantastical way of them getting to hell.  I actually had a situation, this was several years ago, where the person was like, “Well, death doesn’t scare me, but going to hell scares me,” because, in some cultures and some religions, it’s believed that there are demons living amongst us and so forth. “It’s really scary to think about, what if a demon approaches me and takes me immediately to hell and I don’t get to say goodbye to my family, my family doesn’t know.” Just even like that thought. We were able to incorporate something very similar to that.  Just to make up an imaginal on the spot, it could be, I’m reading my Bible. I’m in my living room, I’m reading my Bible, and the thought pops up in my brain of, did you read that last verse correctly? I decide to just move on and not worry about reading my Bible correctly. Well then, all of a sudden, I get a knock at the door and there’s these strange men that I’ve never seen in my life, and they tell me that they’re all demons, and that because I didn’t review the Bible correctly, I’m going to go to hell. I would go on and on and probably describe a little bit more about my family not missing me, I don’t get to see my kids grow up, I don’t get to experience life, the travel, and the stuff that’s really important to me, incorporate some of those values. I don’t get to live my value-based life. And then at the very end, I was summoned and taken to hell by demons, all because I had the thought of reading my bible correctly and I decided not to.” Kimberley: I love it, and I love what I will point out. I think you use the same model as me. We use a lot of “I” statements like “I did this and I did that, and then this happened and then I died,” and so forth. The other thing that we do is always have it in present tense. Instead of going, “And then this happens, and then that happens,” you’re saying as if it’s happening. Krista: Yeah. Because you want it to feel real to the person. In all honesty, and I wonder what your experience has been, I find some of the most difficult people to do imaginals with our children. Even though you would think, “Oh, they’re so imaginative anyways,” one of the biggest things I really have to remind kids is, I want you to be literally imagining yourself in that moment. Again, I see this with kids more than adults, but I think it just depends on context and perspective. We’ll say, “Well, I know that I’m in my living room,” or “I know that I’m in your office, so this isn’t actually happening to me in this moment.” You almost have to really work them up and figure out, what’s the barrier here? What are you resisting? Kimberley: That’s a good question. I would say 10 to 20% of clients of mine will report, “I don’t feel anything.” I’ll do a Q and A at the end of this series with common questions, but I’m curious to know what your response is to a client who reads like, “I kill my baby,” or “I hurt my mom,” or “I go to hell,” or “I cheat on my husband,” or whatever it is, but it doesn’t land. What are your thoughts on what to do then? Krista: A couple of things pop up. One, it makes me wonder what mental compulsions they’re doing. And then it also makes me wonder, are we going in the right direction with the story? Because again, like I mentioned before, if a client comes back and they’ve habituated to one thing, but they’re still having the obsession, well, guess what? We’re just telling stories. Because the OCD narrative is typically not just laser-focused—I mean, it can be laser-focused, but usually, it has branches—you can pick and choose. I’m going to go ahead and guarantee, that person who is terrified of killing their husband ensure they’re not going to see their grandchildren and children. I’m going to go ahead and waiver that there’s probably other things that they’re afraid of missing.  Kimberley: Yes. That’s what I find too, is maybe we haven’t gotten to the actual consequence that bothers them. I know when I’ve written these for myself, we tend to fall into normal traps of subtypes, like the fear that you’ll harm somebody or so forth. But often clients will reveal like, “I’m actually not so afraid that I’ll harm somebody. I’m really afraid of what my colleagues and family would think of me if I did.” So, we have to include that. Or “I’m afraid of having to make the call to my mom if I did the one thing.” I think that that’s a really important piece to it, is to really double down on the consequence. Do you agree? Krista: Oh, I agree a hundred percent. You got to figure out what is that core fear. What are you really, really trying to avoid? With harming somebody, is it the consequences that might happen afterwards? Is it the feeling of potentially snapping or losing control? Or is it just knowing that you just flat out, took the life of somebody and that that was something that you were capable of? I mean, there’s so many different themes, looking at what does that feared self like, what does that look like, and maybe we didn’t hit it last time. Kimberley: Right. Krista: I know this is going to sound silly and I tell my clients this every once in a while, is I’m not a mind reader. What I’m asking you, is that the most challenging you can go and you’re telling me yes, I’m going to trust you. I tell them, if you are not pushing yourself in therapy to where you can grow, I’m still going to go to bed home and sleep tonight just fine. But I want you to also go home and go to bed and sleep just fine. But if you are not pushing yourself, because we know sleep gets affected super bad, not just sleep, but other areas, you’re probably going to struggle and you might even come back next week with a little bit more guilt or even some shame. I don’t want anybody to have that. I want people to win. I want people to do well in this. I know this stuff is scary, but I’m going to quote somebody. You might know her. Her name is Kimberley Quinlan. She says, “It’s a beautiful day to do hard things.” I like to quote her in my practice every once in a while.  Kimberley: I love her. Yes, I agree with this. The way you explained it is so beautiful and it’s logical the way you’re explaining it too. It makes sense. I have one more question for you. Recently, I was doing some imaginals with a client and they were very embarrassed about the content of their thoughts. Ashamed and guilty, and horrified by their thoughts. I could see that they were having a hard time, so I gave them a little inch and I went first. I was like, “Alright, I’m going to make an assumption about what yours is just to break the ice.” They were like, “Oh yeah, that’s exactly what it is.” There was a relief on their face in that I had covered the bases. We did all of the imaginal and we recorded it and it was all set. And then at the end I said, “Is there anything that we didn’t include?” They reported, “Yeah, my OCD actually uses much more graphic words than what you use.” I think what was so interesting to me in that moment was, okay, I did them the favor by starting the conversation, but I think they felt that that’s as far as we could go. How far do you go? Krista: As far as we need.  Kimberley: Tell me what that means. Krista: Like I mentioned before, the limit does not exist and I mean, the limit does not exist. This is going to sound so silly. I want you to be like a young Stephen King before he wrote his first novel and push it. Push it and then go there. Guess what? If that novel just doesn’t quite hit it, write another one, and then another one, and let’s see how far you can go. Because OCD is essentially a disorder of the imagination, and you get to take back your imagination by creating the stories that OCD is telling us and twisting it. I mean, what an amazing and powerful thing to be able to do. I’m sure you’re the same in that you know that there’s a lot of specialists that don’t believe in imaginals, don’t like imaginals, especially when it comes to issues with pedophilia OCD. I think we also need to not remind our clients because that would be reassurance, but to tell these specialists, we’re not putting anything into our client’s heads that aren’t there to begin with. Just like you said, if your client is thinking like real sick, nasty core, whatever, guess what? We’re going to be going there. Are you cutting off the heads of babies in your head? Well, we’re going to be talking about stories where you’re cutting off the heads of babies. If that’s what’s going on, we’re going to go there. Kimberley: What’s really interesting, and this was the example, is we were talking about genitals and sexual organs and so forth. We’re using the politically correct term for them in the imaginal. Great. Such a great exposure. Vagina and penis, great. Until again, they were like, “But my OCD uses much more graphic words for them.” I’m like, “Well, we need to include those words.” Would you agree your imaginals don’t need to be PC? Krista: I hope my clients watch this, and matter of fact, I’m going to send this to them, just to be like, no, no. Krista’s imaginals with her clients. Well, not my imaginals. Imaginals that are with my clients. Woah, sometimes I’m saying bye to my client. I’m like, “I think I need a shower.” Kimberley: Again, when people say they don’t like imaginals or they think that it’s not a good practice, I feel like, like you said, if OCD is going to come up with it, it gives an opportunity to empower them, to get ahead of the game, to go there before it gets there so that you can go, “Okay, I can handle it.” I would often say to my clients, “Let’s go as far as we can go, as far as you can go, so that you know that there’s nothing it can come up with that you can’t handle.” Krista: I think that where it gets even more complex is when we’re hitting some of the taboo stuff. Not only pedophilia, but something like right now that I’m seeing a lot more of in my office is stuff relating to cancel culture. This fear that what if I don’t use somebody’s pronouns correctly? What if I accidentally say an inappropriate racial slur? I will ask in session and I’ll be super real. It’s hard for me to hear this stuff because this goes outside of my values. Of course, it goes outside of their values. OCD knows that. That’s why it’s messing with them. I’ll say, “Okay, so what is the racial slur?” My clients are always like, “You really want me to say it?” I said, “We’re going to say it in the imaginal.” I realized how hard that is to stomach for therapists. But in my brain, the narrative that OCD is pushing, whether it is what society views as OCD or taboo OCD, it doesn’t matter. We still have to get it out. It is still hard for that client. If that’s hard for that client to think of an imaginal or a racial slur, it is almost the exact same amount of distress for somebody maybe with an imaginal that I’m afraid I’m getting food poisoning.  We, as clinicians, just because we’re very caring and loving people, sometimes we can unintentionally put a hierarchy of distress upon our clients like, okay, I can do this imaginal because this falls with my values, but I don’t know if I can do this imaginal because pedophilia is something that’s hard for me to do and I don’t want to put my client through that. Well, guess what? Your client is already being put through that, whether you like it or not. It’s called OCD. Kimberley: Right. Suppressing it makes it come on stronger anyway. Love that. I think that the beauty of that is there is a respectful value-based way of doing this work, but still getting ahead of OCD. Is that what you’re saying? Krista: Absolutely. OCD tries to mess with us and think, what if you could be this person? Well, like I mentioned before, if a story is like a weapon, well, I’m going to tell a story to attack OCD because it’s already doing it to me. Kimberley: Yeah. Tell us where people can hear more from you, get your resources because this is such great stuff. Krista: Thank you. I’d say probably the best way to find me and my silly videos would be on my Instagram @anxiouslybalance. Kimberley: Amazing. And your private practice? Krista: My private practice, it’s A Peaceful Balance in Wichita, Kansas. The website is apbwichita.com. Kimberley: Thank you so much. I’m very grateful for you for inspiring this whole series and for also being here as a big piece of the puzzle. Krista: Thank you. I’m grateful for you that you don’t mind me just like this. I’m grateful for you for letting me talk even though clearly, I’m not very good at it right now. You’re amazing. Kimberley: No, you’re amazing. Thank you. Really, these are hard topics. Just the fact that you can talk about it with such respect and grace and compassion and education and experience is gold.  Krista: Thank you. At the end of the day, I really truly want people to get better. I know you truly want people to get better. Isn’t that just the goal? Kimberley: Yeah. It’s beautiful. Krista: Thank you. 

Welcome back, everybody. Today, we are going to have a discussion, and yes, I understand that I am here recording on my own in my room by myself, so it’s not really a discussion. But I wanted to give you an inside look into a discussion I had, and include you hopefully, on Instagram about a post I made about being busy.  Now, let me tell you a little bit of the backstory here. What we’re really looking at here is, is being busy a compulsion or an effective behavior? Here’s the backstory. I am an anxious person. Nice to meet you. Everybody knows it, I’m an anxious person. That’s what my natural default is. I have all the tools and practice using all the tools and continue to work on this as a process in my life. Not an end goal, but just a process that I’m always on, and I do feel like I handle it really, really well. In the grand scheme of things, of course, everyone makes mistakes and recovery is an up-and-down climb. We all know that. But one thing I have found over and over and over and over again is my inclination to rely on busyness to manage my anxiety.  The reason I tell you this over and over is it’s a default to me. When I’m struggling with anything, I tend to busy myself. Even when I had the beginning of an eating disorder, that quickly became a compulsive exercise activity because trying to manage my eating disorder created a lot of anxiety, and one way I could avoid that anxiety and check the eating disorder box was to exercise, move my body. Even though I fully recovered from that, and even though I consider myself to be doing really well mentally overall, I still catch myself relying on work and busyness as a compulsion, as a safety behavior to reduce or remove or avoid my anxiety.  I made a post on this and it had overwhelming positive responses. Meaning, I agree, there was a lot of like, “Oh, I feel called out or hashtag truth.” A lot of people were resonating with this idea that being busy can be a very sneaky compulsion that we do to run away from fear or uncertainty or discomfort or sadness and so forth. But then some of my followers, my wonderful followers came in hot—when I say “hot,” like really well—with this beautiful perspective on this topic and I really feel like it was valid and important for us to discuss here today. Let’s talk about that, because I love a good discussion and I love seeing it from both sides. I love getting into the nitty gritty and determining what is what. Let’s talk about me just because it’s easy for me to use an example. Let’s say I have a thought or a feeling of anxiety. Something is bothering me. I’m having anticipatory anxiety or uncertainty about something. My brain wants to solve it, but because I have all these mindfulness tools and CBT tools, I know there’s no point in me trying to solve it. I know there’s no point in me ruminating on it. I’m not going to change it or figure it out. I have that awareness, so I go, “Okay, now I’m going to get back to life,” which is a really wonderful tool. But what I find that I do is I don’t just get back to life. I, with a sense of urgency, will start typing, cleaning, folding laundry, whatever it is, even reading. I will notice this shift in me to do it fast, to do it urgently, to try and get the discomfort to be masked, to be reduced.  And then, of course, I want to share with you, what I then do is when I catch that is I go, “Okay.” I feel the rev inside me and then I ease up on it. I pump the brakes and I try to return back to that activity without that urgency, without that resistance to the anxiety, or without that hustle mentality. But it is a default that I go to that often I don’t catch until later on down the track. It’s usually until I start to feel a little dizzy, I feel a little lost, a little bit overwhelmed. And then I’m like, “Oh, okay, I’m overusing busyness to manage my anxiety.” The perspective that I loved was people saying, and one in particular said, “I want us to be really careful around that message because I think that some people can hear this idea that being busy is a compulsion and then start to question their own normal busyness throughout the day.” I’ll use the exact terms because I thought it was so beautifully said. They said, “You have to be pretty careful with how you explain this to some people with OCD because we’re told to lean into our values or live a ‘value-based’ life, and that does require us to be busy,” and I wholeheartedly agree.  I think that’s where I’m coming from. I want to offer to you guys that I want you to just check in and see if you’re using busyness, this urgent, rushing movement, or frantic experience in your body to avoid discomfort. And if so, that’s good to know. Let’s not judge that. Let’s not beat you up. Let’s not be unkind. Let’s just acknowledge that that is a normal response to having anxiety. In fact, it’s a big part of what’s kept us alive for all these years. That’s true. And we can return back. Once we catch that we’re doing those behaviors, we can return back to staying effective in our skills. But I don’t want you guys to worry that you are overusing busyness.  I think that the discussion I had online was to say, isn’t this a wonderful opportunity for us to see how anxiety or OCD or any anxiety disorder can make a really healthy behavior into a compulsive behavior? You might flip between the two, it mightn’t be all or nothing. An example of that might be prayer. Prayer is a beautiful practice for those who are spiritual. However, we can sometimes overuse prayer in a compulsive manner in this urgent, frantic, trying to get anxiety to go away manner, and then it’s being misused.  There may be sometimes you use prayer in this beautiful non-compulsive way and there’ll be other times when you’re absolutely using it as a safety behavior. Same goes for cleaning, same goes for thinking through your problems. There will be times when thinking through problems and solutions is a very effective behavior. However, there will be other times if you’re doing it with a sense of urgency to make the discomfort go away or you’re doing it to try and figure out something that you know you won’t figure out because there’s really no solution to it—that’s something for us to keep an eye out for. There are so many ways in which this can get blurred. Asking for help and reassurance. It’s not a problem to go to your loved ones and say, “I have this really huge presentation at work, would you let me rehearse it to you and you can give me feedback?” That’s an effective behavior. However, if we are doing that repetitively and we are doing it coming from this desperate place of urgency to get certainty and removal of discomfort, that’s how we may determine whether the behavior is a safety behavior that we want to start to reduce. I want to just offer this to you. If we’re being honest, this episode isn’t really about just the busyness. It’s being able to, again, for yourself, determine are the behaviors you’re doing being done because they line up with your values? Are they being done with a degree of willingness to also bring anxiety with you? I think that’s a huge piece of the work that I have to catch, which is, okay, I’m rushing, I’m hustling, I’m engaging in busyness just for the sake of trying to get rid of that discomfort. Can I pause and return back to that behavior? Because it might be a behavior or an activity I need to get done. But can I do it with an increased sense of willingness to bring anxiety along for the ride? Can I do it with a sense where I’m not trying to train my brain that anxiety is bad? Can I just say, “Yeah, it’s cool. Anxiety is here, let’s bring it along”?  I want to, again, reinforce to you guys, it’s okay that you haven’t figured this out because it’s probably ever-changing. There will be times when you are engaging in compulsive busyness and there’ll be other many times in which you’re not. What I would encourage you to do is not to spend too much time trying to figure out which is which, because that can become a compulsion as well. A lot of this is just accepting that nothing is perfect and just moving one step at a time moving forward as you can kindly and compassionately.  The only other thing I want to address here is this idea of a good distraction and a bad distraction. I think that this has been an argument or a complex discussion in the anxiety field for a long time. When I first was trained as an anxiety specialist, there were all these articles that talked about bad distraction, that distraction is bad and we shouldn’t do it, and we should just have our anxiety and let it be there and then focus on it and so forth. I actually don’t agree with that. In fact, I would go as far as to say, a real mindful practice would be taking the judgment out of destruction in general and saying that distraction is neither good nor bad. What distraction is, is up to you to decide whether it’s helping you and is helpful behavior that brings you closer to your recovery goals or not. I don’t want you to spend too much time trying to figure it out either, again, because I think it gets us caught in this mental loop of, am I doing recovery right? Am I doing my treatment right? Am I using the skills perfectly?  I think when we get to that point, we’re too far in the weeds and we have to pause and let it be imperfect and let it be uncertain and do our best not to try and solve that one, because often how would we know? There isn’t actually an answer to what’s bad and what’s good. I wouldn’t encourage you to place good and bad labels on those kinds of things because that usually will just keep you in a loop of anxiety anyway.  That’s just a few ideas on this idea of being overly busy being a compulsion. I really want to make sure I say one more time. I think there is absolutely an opportunity for us to consider that busyness is also neither good nor bad. It just is, and that you for yourself can determine whether it’s helpful for you to stay busy or not. What I will say—and I will use this as an example, I think I actually did a podcast episode on this—not long ago, my parents were voyaging across the Drake Passage, which is a very dangerous body of water that takes you from South America to Antarctica. It’s usually very, very calm or it can be incredibly dangerous to pass the Drake Passage. For the 18 hours that they were passing that, I engaged in a lot of busyness. I would say it wasn’t compulsive either. It was, I knew they were doing something scary. I knew that it would be probably fine, but it was still uncertain. I knew that there was nothing I would do to make my anxiety go down during that 18 hours. I knew I probably wouldn’t get a good sleep because I love them dearly and I want them to have a safe trip. I just said to myself, “I’m going to mindfully go from one activity to another. Because I don’t want to engage in a bunch of mental rumination, I’m just going to gently stay busy.” I think that’s fine. I think that that is effective. In fact, I was very proud of how I handled that. I was able to resist the urge to text them at two in the morning and be like, “Take a photo of the waves. I want to see that you’re okay.” You know what I mean?  I want to just offer to you that to check in whether your busyness is compulsive, be gentle with yourself either way to discuss with your mental health provider on what is a great way for you to engage in this kind of behaviors and for you to come up with your own protocol on how to determine when you’ve crossed over from being busy into compulsive busyness. That’s it. I think that from there, you can be gentle with yourself and practice being uncertain about what’s right and wrong.  I hope that was helpful. I’m very much just chatting to you. I didn’t do a whole ton of prep for this. I just wanted to include you in the conversation on “Is being overly busy a compulsion?” I wanted to give you some ideas and things to look out for and I hope that it helps you move forward towards the recovery that you’re looking for. Have a wonderful, wonderful day. If you guys want additional resources from me, you can head over to CBTSchool.com. We have all kinds of online options there for you. If you’re looking for one-on-one therapy, if you live in the state of California or Arizona, you can go to www.kimberleyquinlan-lmft.com and I look forward to chatting with you next week.

Hello and welcome back, everybody. We have an amazing guest today. This is actually somebody I have followed, sort of half known for a long time through a very, very close friend, Shala Nicely, who’s been on the show quite a few times, and she connected me with Dr. Ashley Smith. Today, we are talking about happiness and what makes a “good life” regardless of anxiety or of challenges you may be going through.  Dr. Ashley Smith is a Licensed Clinical Psychologist. She’s the co-founder of Peak Mind, which is The Center for Psychological Strength. She’s a speaker, author, and entrepreneur. She has her own TED Talk, which I think really shows how epic and skilled she is.  Today, we talk about how to be happy. What is happiness? How do you get there? Is it even attainable? What is the definition of happiness? Do we actually want it or is it the goal or is it not the goal? I think that this is an episode I needed to hear so much. In fact, since hearing this episode as we recorded it, I basically changed quite a few things. I will be honest with you, I didn’t actually change things related to me, but I changed things in relation to how I parented my children. I realized midway through this episode that I was pushing them into the hamster wheel of life. Ashley really helped me to acknowledge and understand that it’s not about success, it’s not about winning things, it’s not about achievement so much, while they are very important. She talks about these specific things that science and research have shown to actually improve happiness.  I’m going to leave it at that. I’m going to go right over to the show. Thank you, Dr. Ashley Smith, for coming on. For those who want to know more about her, click the links in the show notes, and I cannot wait to listen back to this with you all. Have a great day, everybody.  Kimberley: Welcome, Dr. Ashley Smith. I’m so happy to have you here. Dr. Ashley: I am excited to be here today. I’ve wanted to be on your podcast for years, so thank you for this. Kimberley: Same. Actually, we have joint friends and it’s so good when you meet people through people that you trust. I have actually followed you for a very long time. I’m very excited to have you on, particularly talking about what we’re talking about. It’s a topic we probably should visit more regularly here on the show. We had discussed the idea of happiness and what makes a good life. Can you give me a brief understanding of what that means or what your idea about that is? Dr. Ashley: Yeah. Oh, this is a topic that I love to talk about. When I think about it, I have a little bit of a soapbox, which is that I think our approach to mental health is broken. I say that as someone who is a mental health practitioner, and I really love my job and I love working with people and helping. But what I mean by that is our traditional approach has been, “Let’s reduce symptoms. Let’s correct the stuff that’s ‘wrong’ with someone.” When it comes to anxiety or depression, it’s how do we reduce that? And that’s great. Those are really important skills, but we’ve got this whole other side that I think we need to be focusing on. And that is the question of how do we get more of the good stuff. More happiness, more well-being. How do we create lives that are worth living? That’s not the same as how do we get rid or reduce anxiety and depression. In the field of psychology, there’s this branch of it called Positive Psychology. I stumbled on that 20 years ago as a grad student and thought, “This is amazing. People are actually studying happiness. There’s a science to this.” I looked at happiness and optimism and social anxiety and depression and how those were all connected. Fast forward, 15 years or so, I really hit a point with my professional life and my personal life where I was recognizing, “Wait a minute, I need more. I need more as an individual. The clients I work with need more. How do we get more of this good stuff?” This is the longest preamble to say, I did a deep dive into the science of happiness and learned a lot over the years, and I want to be really clear about a couple of things. When we talk about happiness, a lot of people think pleasure. “I want good experiences, I want to enjoy this.” That’s a part of it, this positive emotion that we all call happiness or joy. But that’s only a piece of it. There’s actually this whole backfiring process that can happen when we chase that. If I’m just chasing the next pleasant event, what that actually does is set me up to not have a happy life. Think about it. I mean, I love chocolate, and if I eat that unchecked because it brings me pleasure, at some point, it’s going to take a toll on my health. What does that actually do to my well-being and happiness?  What was really interesting getting into this area was, it’s not just this transient state of pleasure or enjoyment, but they’re the other factors that contribute to a good life. It’s things like relationships. It’s things like meaning and purpose. It’s engagement. It’s achievement even. It’s these things that are not always pleasant in the moment, but that really contribute to this sense of satisfaction with life or contentment with life. I think it’s really important that we need to be looking at what are the ingredients that really make a good life.  WHAT IS CONSIDERED A GOOD LIFE?  Kimberley: I love this, and I love a good recipe too. I like following recipes and ingredients. It’s funny, I’m actually in the process of getting good at cooking and I’m realizing for the first time in my life that following instructions and ingredients is actually a really important thing, because I’m not that person. First of all, what is a good life? When I looked at that, I actually put it in quote marks. What is a good life? What do you think? You explained it; it’s not chasing pleasure. We know that doesn’t work, otherwise, you just buy a bunch of stuff you don’t want and behave in ways that aren’t helpful. Not to also villainize pleasure, it’s a great thing, but what would you describe as a good life? Dr. Ashley: On the one hand, it’s the million-dollar question. Philosophers and scientists and religious leaders and all kinds of people have been trying to answer that question for eons. I don’t know that I have it nailed down. I think I’m humble enough to say I have my own ideas about it. To me, what makes a good life, it’s really when the way we spend our time lines up with what’s important to us, when we’re living in accordance with our values to use some psych buzzwords, but when we’re doing the things that really matter. I think also part of a good life is having daily rhythms and lifestyle habits that support us as biological creatures. I want to contrast that with the demands of modern life, which are that we should be productive 24/7, that we should be multitasking. People sacrifice sleep and movement and leisure time and stillness. I think all of that compromises us. It impacts us on a neurological level. Our brains are part of our system. If we’re not taking care of our system, they’re not going to function optimally. That gets in the way of a good life.  When we’re sacrificing relationships, when I look at all of the research, when I look at my own experience, a huge component of a good life is having quality relationships. Not quantity, quality. Trusting ones that are full of belonging and acceptance that are two-way support streets, those are really important. I think a lot of times, modern life compromises that. We get pulled in all of these other directions. Kimberley: Yeah. Oh my gosh, there’s so many things. I also think that anxiety and depression pull us away from those things too. You are anxious or you’re depressed and so, therefore, you don’t go to the party or the family event or the church service. That’s an interesting idea. I love this. Tell us about this idea of meaning. How do we find meaning? I’ll just share with you a little bit of my own personal experience. I remember when I was actually going through a very difficult time with my chronic illness and I know I was depressed at the time. It was the first time in my life where I started to have thoughts like, “What’s the point?” Not that I was saying I was suicidal, but I was more like, “I just don’t understand why am I doing all this.” I think that that’s common. What are your thoughts on this idea of the meaning behind in life? Dr. Ashley: That’s a fantastic question. I have a vision impairment, so I’m legally blind. It’s a really rare thing and it’s unpredictable. I don’t know how much sight I will lose. Ultimately, the doctors can’t tell me there’s no treatment options. It’s just I go along and every so often, there’s a shift and I see less. For me, I hit that same point you were talking about back in 2014 when I had to stop driving. I was anxious and I would say depressed and really wallowing in this, “What does this mean for my life? I can’t be independent. People aren’t going to associate with me personally or professionally when they see this flaw.” It was a dark point. For me, that’s when I went back to the science of happiness when I finally got tired of being stuck and I realized my anxiety skills and my depression skills. They’re helpful and I practice what I preach, but it wasn’t enough. And that’s really what propelled me back into this science of happiness where I figured, you know what, someone has to have done this.  I did come across this theory of well-being called the PERMA factors. These are like the ingredients that we need. I’m getting back to that because the M in this is meaning. With this, the PERMA factors, P is positive emotion. That’s the pleasure, the joy, the happiness. Cool. I know some strategies for boosting that. E is engagement. Are you really involved and engaged in what you’re doing? Are you present? Are you hitting that state of flow? R is the relationships, A (skipping ahead) is achievement, but M is this meaning, and it’s a hard one to figure out.  I remember then, this started what I was calling my blind quest for happiness where I started to think about, what do I need to do? How do I experiment? How do I live a happy life despite these cards I’ve been dealt? We don’t get to choose them. You’ve got a chronic illness, I have a vision impairment, listeners have anxiety and depression, and we get these cards. I think of it like if life is a poker game, we don’t get to choose the cards we’re dealt, but by golly, we get to choose how to play them, and that’s important. I think a lot of times people can turn adversity into meaning. For me, I’m now at a point where it’s not that I don’t care about my vision, it’s just I really accepted it. It is what it is, it’s going to do what it’s going to do, and I’m focusing on the things I can control. That has given me a sense of meaning. I want to help other people live better lives. I want to help other people crack the code of how our brains work against us and how do we play our cards well. If we go to all of this, “meaning” is really just finding something that’s bigger than you are, finding something to pursue or contribute to that’s bigger than you. I think when we look at anxiety and depression, the nature of those experiences is that they make us very self-involved. I mean, people with anxiety and depression, in my experience, have giant hearts, tons of empathy, but it locks our thinking into our experience and what’s going on in these unhelpful thoughts.  When we can connect with something bigger than us, it gets us outside of that.  If I go back to grad school, writing my dissertation was decidedly not a fun experience. Would I do it again? Yes. Because it was worth it on this path to my reason for being—helping people live better lives. Sometimes I think when we have this meaning, this purpose, this greater good, it helps us endure the things that I want to say suck. Kimberley: You can say suck. Dr. Ashley: Yeah. That’s where it’s not just about how do I get rid of anxiety or depression. Sometimes we can’t. Chronic health conditions, anxiety is chronic. My vision is chronic. I’m not getting rid of this, but how do I live a good life despite that? I think there are a ton of examples throughout history and currently of people doing amazing things despite some hardship.  Kimberley: Yeah. I love this idea. It’s funny, you talk about being outside yourself. When I’m having a bad day, I usually go, there’s like a 10 minutes’ drive from us that looks over Los Angeles. If let’s say I’m having a day where I’m in my head only looking at my problems, and then I see LA, I’m like, “Oh honey, there is a whole world out there that you haven’t thought about.” I’m not saying that in a critical way, just like it gives me perspective. Dr. Ashley: I think that’s so important, to realize there’s so much more. When it does shrink our problems, all of a sudden, it’s manageable. Kimberley: Right. Let’s talk about just one more question about meaning. I’m guessing more about people finding what’s your why and so forth. What would you encourage for people who are very unhappy, have been chasing this idea of reducing anxiety, reducing depression, chasing pleasure, and feeling very stuck between those? Let’s say I really have no idea what my meaning is. What would be your advice to start that process?  Dr. Ashley: Experimentation. I think experimenting is a lifestyle that I wish everyone would adopt, because what happens is we want to think. We are thinkers. That’s what our minds were designed to do. That’s awesome and sometimes it’s really helpful, but I don’t think we’re going to think our way into passion or meaning or a good life. I think we have to start trying things. What will happen, if you notice, is your mind is going to have a lot of commentary. It’s going to say, “That’s dumb. That’s not going to work. Who are you to try that? You can’t do that.” It’s all just noise that if we look at what is it doing, it’s keeping you stuck. With the experimentation, I’m just a big fan of go try it. Whether you think it’s going to work or not, you don’t know. We want to trust our experience, not what our mind tells us. Trust your actual experience.  For me, I remember getting my first self-help book. It was actually called Go Find Your Passion and Purpose. Because I was at this crossroads, I had been doing anxiety work for a long time, had plateaued, and was feeling a little bored, and that coincided with the stopping driving. My whole personal world was just in disarray and I was like, “I’m going to go hike part of the Appalachian Trail while I can. While I do that, I’m going to find my purpose in life.” I did not find it, but it was an experiment. I go and I get this experience and I can say, “Okay, I’m not going to be someone who does a six-month hike. I made it four days. Awesome.” But go and experiment with things. I never thought that I would really want to write and I started a blog, and that has turned out to be such a positive experience. Prior to that, my writing experience had been very academic where it was a chore. Now, this is something I really enjoy, or talking to people.  I would say experiment and continue to seek out those new experiences. One, seeking out new experiences helps on the anxiety side because you’re continually putting yourself into uncertain and new, so your confidence level is going to grow, your tolerance for not knowing grows, and your tolerance for awkward grows. That’s my plug for go try new things, period. Somewhere along the way, you’re going to find something that sparks an interest or that sparks this sense of, “Yeah, this is me.” Notice that. I know you talk a lot about mindfulness, we need to notice what was my actual experience, not what did my head tell me. What did I actually feel? And keep experimenting until you find something. I think that’s really the key. Kimberley: I love that you said your tolerance for awkwardness. I think that is a big piece of the work because it is a big piece. We talk about tolerating discomfort, tolerating uncertainty, but I think that’s a very key point, especially when it comes to relationships, which I know is one of the factors. Tolerate the awkwardness is key. Dr. Ashley: Yeah. I think it’s huge. I’ve been seeking out new experiences since 2017. This is going to be my New Year’s resolution. It was such a transformational experience over the course of the year that I’ve just continued it, and I’m trying to get everybody to join me because it’s such an expansive practice. I think it’s great for anxiety and depression, it’s great for humans, it’s been great for me on this quest for a good life. But with this, it means I have put myself into some awkward situations on purpose. Sometimes I know going into it, sometimes I don’t.  I went to this one, it was called Nia. I practice yoga. That’s cool. That’s very much in my comfort zone. This was yoga adjacent, but it was also an interpretive dance with sound effects. You had to make eye contact with people and dance in these weird ways. I distinctly remember having this conversation with myself when I showed up, “What did you just get yourself into?” And then it was immediately, “Okay, you have two choices here. You can grit your teeth and hate the next hour, or you can embrace the awkward and dance at a three. Because she said, you can dance at a one, itty bitty, at a two or at a three and really go for it.” That for me was my, “All right, let’s just do this.” I embrace the awkward, and that was a turning point. That was amazing. And then now, when I think about good life, I feel like so many doors are opened because I’m not afraid of, “This is going to be awkward.” It’s going to be and you’re going to be okay or it’s going to make a hilarious story. I said, “Go for it.” Kimberley: You’re here to tell the story. I love it. You didn’t die from awkwardness. Dr. Ashley: No. Kimberley: Can you tell me about the P? Can you go through them and just give us a little bit more information? Because I think that’s really important. Dr. Ashley: Yeah. I love this theory because you can think about it as like, how are my PERMA factors doing? When you’re low, raise them. You know that those are the ingredients for a good life. The P is positive emotion. That is, we do need to spend time in positive emotional states. The more time we’re in the positive emotional states, the better compared to the negative ones like anxiety or sadness, or anger. Now that said, we know if we try to only pursue pleasure, it’s going to backfire. If I’m trying to avoid anxiety, I’m actually going to get more anxiety. But this is where behavioral activation comes in. Do things that are theoretically enjoyable and see if it puts you in a positive state. Again, theoretically enjoyable, because if you’re in the throes of depression, nothing feels enjoyable, do it anyways. And then notice, did it bring on a pleasurable emotional state? Cool. We want to do those things.  E is engagement. This is when people talk about finding flow or being in the zone. These are the activities that you’re fully engaged in it. Self-consciousness goes away. You lose track of time because you’re just in it. We know that the more consistently we are able to put ourselves in states of flow, the higher our well-being tends to be. Athletes will talk about this a lot. When they’re on the field, they’re in the zone. Musicians, artists. But there are other ways to do this. This is a place for me personally, I didn’t know. I was like, “Well, okay, great. I need E, I need engagement. What puts me in a state of flow?” It took experimentation and noticing. For me, writing does it. Web design, I’m not techy, but when I start to do design projects, I get in that state of flow. It has to be this perfect apex, this perfect joining of skill and pleasure, like enjoyment. If it’s too easy, you will not go into a state of flow. That’s just the P. If it’s too hard, we go into a state of stress or anxiety, so that’s not flow. We have to be right on the cusp of our skillset. It’s hard work, but we’re into it. That’s the E. R is relationships. We need quality relationships where we are being open, where we are being vulnerable, we’re really connecting with other people. That is huge. I mean, if we look at what’s the best predictor of life satisfaction, it’s quality relationships. This also is doing things for other people. Altruism, ugh, I love this side note. The act of kindness thing hits on three different factors. It feels good to do something good for other people. If you want a mood boost, go do an act of kindness. That reliably boosts our mood. It also improves relationships and it can tap into that meaning. I love that as just a practice.  The M we talked about, that’s meaning. And then the A, that’s achievement for achievement’s sake. As humans, it feels good to conquer goals. It feels good to accomplish things. And that contributes to our well-being independently of the positive feelings that we get from it, or the meaning in the relationships or the engagement. I’m also a really big fan of set goals and then crush them. It can be silly little things like, I’m going to hold my breath for two minutes. Okay, cool. That’s a silly little thing, but then it feels good to do it. Or it could be something huge like crossing those bucket list things off your list. Kimberley: You know what’s funny around achievement? I’ve got a couple of questions, but first I want to tell you your stories. Last year, I was struggling to do a couple of things that were really important to me for my medical health. I found an app called Streaks. Have you heard of Streaks? It’s a $5 app. But when you do the action, and for me it was taking my medicine, it does this little spiral and then it’s like, “You’ve done this for three days in a row.” And then tomorrow you click it and then it says, “You’ve done it for four days in a row.” You would think that the benefits of taking my medicine would be enough. But for me, it’s actually knowing I get that little positive reinforcement of like, “Look at me, I’ve taken my medicine for 47 days in a row, or now are like 300 days in a row.” I don’t think I deserve a medal for being able to take my medicine. But for me, that little bit of reward center on the achievement was a huge shift for me. And then it became, how many days did you practice your Spanish in a row? Even like, how many days did you do your Kegels? I’ve got all of the streaks happening and it’s really incredible how that little achievement piece does boost your mood. Dr. Ashley: Yeah. But what I love about this is you’re also talking about how to hack the system. We’re talking about our brains and this is the stuff that just lights me up, because oftentimes our minds will say, “Well, you should just take your medication. You should just do these things.” Well, that’s not how it works. There’s a million reasons why we don’t do the things we know we should do. But can we figure out how to hack the system? Yeah. Our brains love streaks. They love streaks.  it taps our reward centers, like you’re saying, and so let’s use the tools that work. That got you if your goal is to take your medication consistently. Using our brain’s glitchy wiring to our own advantage is something that’s huge. That did it. And then it does feel good. And then you get some momentum going and then you create a habit around that and it’s fantastic. Kimberley: Yeah. What about those who are overachieving to the point that it’s bringing their happiness down? What would we do there?  Dr. Ashley: Yeah. I think that’s a great question and it’s something that comes up a lot, especially when we look at anxiety and perfectionism. At least the way I think about it is coming back to what’s driving this. Is this being driven by fear? Is this being driven by values? For me, I almost think of it as—I’m going to try to make sense with it—is it the -ing or the -ed? Meaning, the doING (I-N-G) or the -ed as in I did this past tense. What I mean by this is, I notice for me when I’m approaching something, say a big goal, like I want to write a book this year. If I can approach that from a place of, “I am doing this because this is important to me, I feel driven to get this message out into the world,” the -ing, the process of doing it, that feels like it’s going to boost my wellbeing when I start to get pulled into the thoughts of the outcome. I’m going to write this book and how many people are going to read it and is it going to sell? I’m really looking at all of this, and underneath that is fear. What if it doesn’t sell? What if people judge it? What if they think it’s stupid? Then I’m focusing on the outcome, kind of when it’s done. That I think is actually going to detract from my well-being because it’s not coming from a valued place; it’s coming from this feared place.  A lot of times with overachieving, we’re chasing this other people’s expectations or we’re chasing this promise of happiness. When you do this, then you’ll be happy. It’s not going to work like that. It may be for a moment and then the bar just changes again. Now you’ve got another target. We have to come back to this, I think the process or the journey. Are you doing this because it matters to you, or are you doing this because some sort of fear is compelling you?  Kimberley: Right. I’m just asking questions based on the questions I would’ve had when I was struggling the most. I remember hearing something that blew my mind and I actually want your honest opinion about it. I remember I used to chase happiness, like you talked about, even though I was doing all these things. I was doing all these things, but there was that anxious drive behind it. I remember hearing somebody saying life is 50/50. Even though you’re doing all these things, you’re still going to have 50% great and 50% hard. For me, that was actually very relieving. I think I was caught in and I think a lot of people experienced this like, “Okay, I’m at 50%, how can I get to 55? How can I get to 56?” What are your thoughts on also accepting that you won’t be happy all the time, or what are your thoughts on balancing this goal for happiness or this lifelong playfulness around happiness?  Dr. Ashley: I agree with you completely. I think we have this cultural myth that we should be happy all the time. If you’re not happy, there must be something wrong. You’re doing something wrong. It sets up even this idea that being happy all the time is possible. It isn’t. If we look at, again, happiness, what people mean by that is a pleasurable or enjoyable state, an emotion that we like. Humans are wired. Two-thirds of our emotions would be under that negative category. Just by the way we’re wired, we’re more likely to have negative emotions, and they’re just messengers. They’re just designed to give us information about a situation. Some of them are going to be dangerous, so we’re going to feel anxious. Or we’re going to lose something we care about, so we’re going to be sad. We’re going to mess up, so we’re going to feel guilty. It’s unrealistic to expect to not have those emotions. I think that is a hundred percent something that we need to work on, just accepting happiness all the time is not possible and pursuing it is like playing a rigged game.  The other thing, you know how on the anxiety side we talk about facing fears because then you habituate or you get used to them. But that habituation process happens on the pleasurable side too. This is why when we chase happiness, we end up on this hedonic treadmill where it’s, “Oh, I’m going to go buy this thing. And then I’m going to feel really happy,” and you are. And then you’re going to habituate. Your body goes back to baseline so that happiness fades. If you’re looking to an external source, you’re going to get caught up in this always chasing something bigger and better, not sustainable.  I like to look at happiness as the side effect of living a good life. Do the things that we know matter. Take care of your health and wellbeing. Sleep, eat well, move your body, practice mindfulness, the PERMA factors that we talked about, and live in line with your values. If you’re doing those things, happiness is the side effect of that. Kimberley: To make that the goal, not happiness the goal.  Dr. Ashley: Yeah.  Kimberley: I think that’s very, very true. Again, for me, it was a massive relief. I remember this weight falling off of like, “Oh,” because I think social media makes it so easy to assume that everyone is just happy, happy, happy content, to feel all the things. It was delightful to be like, “Oh no, everyone’s got a 50/50.” Dr. Ashley: Exactly. When we know that’s normal, then all of a sudden, you can accept it. Like, I’m anxious for now, I’m sad for now. To do that, it does keep us from piling on extra. I have this saying that I love, “Just because life gives you a cactus doesn’t mean you have to sit on it.” A lot of times, we sit on it because we’re ruminating or I don’t want to feel this way and we’re fighting it. And that’s just amplifying it and making it a lot harder. When we can say, “Oh, this is where I’m at today. I’m still going to choose to do the things that I know are good for me, that are part of me, living a good life by my standards or my terms,” that’s going to be the side effect, is I’m going to end up with more happiness down the road, but not chasing it in that moment. Kimberley: I love this. Thank you for coming on and talking about this. I think this has been enlightening and so joyful to have these conversations. I feel a little lighter, even myself, after chatting with you, so thank you. Tell me how people can hear from you, get in touch with you, learn about your work. Dr. Ashley: Yeah, absolutely. I have a blog that I publish every week, so if you’re interested in that, you can subscribe at PeakMindPsychology.com/subscribe, o you can just check out all of the blog posts. That’s probably the best way to follow me and follow my work. I also have a TEDx Talk that came out pretty recently and you can watch that as well. It’s called Is Your Brain Deceiving You, and talk a little bit about learning to play my cards well. Kimberley: I love the TED Talk. Congratulations on that. It was so cool.  Dr. Ashley: Thank you.  Kimberley: Thank you again for coming on. This has been just delightful. Really it has. Dr. Ashley: I appreciate you having me.

Hello and welcome back, everybody. I’m so happy to be here with you. This is not the normal format in which we do Your Anxiety Toolkit podcast, but I wanted to really address a question that came up in ERP School about how to manage 10 out of 10 anxiety.  For those of you who don’t know, over at CBTSchool.com, we have a whole array of courses—courses for depression, generalized anxiety, panic, OCD, hair pulling, time management, mindfulness. We have a whole vault of courses. In fact, we have a new one coming out in just a couple of weeks, which is a meditation vault. It will have over 30 different meditations. The whole point of this is, often people say to me that the meditations that they listen to online can become very compulsive. It’s things like, “Oh, just let go of your fear or make your fear go. Cleanse away and dissolve,” and all the things. That’s all good. It’s just, it’s hard for people with severe anxiety to conceptualize that. That whole vault will be coming out very, very soon.  But this is actually a question directly from ERP School. Under each video of all the courses, there is always a place you can ask questions, and I do my best to respond to them as soon as I can. But I did say to this student, I will actually do an entire podcast on your question because I think it’s so important.  Here is what they said: “Hi Kimberley, I love all the information you give us. I get so much more out of this than I do with a therapy session for one hour once a week. That being said, I’m feeling a little bit overwhelmed. There is just so much information and so many tools.”  Yes guys, I admit to that. I do tend to heavy-dose all of my courses with all the science. I can bring in as many tools as I can with the point being that I want you to feel like you have a tool belt of tools, in which you can then choose which one you want to use, so I totally get what they’re saying here.  They said: “When I’m at a 10 out of 10, I’m hardly able to function and it all seems to go out the window. It either seems that noticing works as I run through my list of tools or I can’t even think straight enough to check in with myself or even think about the tools I could use. So, where do I even start in those terrible moments?” This is a really good question, and I think every single one of my clients in my history of being a therapist has asked this question. I know I have asked this question to my therapist because even as a therapist who has all the tools in those moments, it can feel overwhelming. What I did here is I pulled all of my followers on Instagram and asked them to give me their tools that they find helpful, and then I’m going to weigh in myself, and then I’m going to encourage you to just practice any of them. Now, often what happens—and this is the case for what obviously someone’s bought a course from me—is when you have all of these options, we fall into the trap of thinking there is a “right” tool to use, and I want to reframe that. In addition, there’s another myth that that one tool will make all your discomfort go away or that will be the tool of all tools for recovery. I want to really normalize that there is no one tool.  The whole reason that I do Your Anxiety Toolkit is to remind you that you’re going to have to practice multiple different things, you can’t put all your eggs in one basket, and it’s okay if it’s not a 10 out of 10 win. Meaning, it’s okay if it’s not perfect. Often I’ll say to clients, use the tools, even if it’s 50% effective. That’s still 50% effective more than what it would be in the past, which might be 0% effective or 1% effective. We take any wins we can take and we use it not as a fact that you’re a failure if it didn’t work, but more as just data on what to use for the next time. At the end of the day, the goals are: Did it give me a 1 or 2% improvement on how I handled it the last time? 1 or 2%, folks. That’s all I’m goaling for here. Was I kind as I practiced it? And, did it move me towards the five-year you, or the three-year you, or the one-month you? The you who’s in one month, does it move you towards that person that you’re trying to be? I often will think about me through the terms of, what would the five-year me do in this situation? What would the three-year me do? What would the three-month me do? It might be different, and then I just pick one. Knowing it’s probably not perfect, but that’s okay.  I have polled a whole bunch of people on Instagram because I honestly feel like folks who were in the thick of it actually are better at giving tools than even I am as a trained clinician who’s been through it. Of all of the different responses we got, I’ve actually broken it down into two separate sections per se. We’ve got mindset shifts and tools and actions. Again, these may actually feel again like, “Oh my gosh, now I have even more tools,” which is not a bad problem.  TAKE ONE MOMENT AT A TIME  But I want you in the moment that you’re at a 10 out of 10 to just pick one and be curious about it. I’m going to say here that the one I loved the most—I’m going to just actually give you one of the tools and actions first—is somebody (multiple people wrote this, in fact) said, just take one moment at a time. I have to say at a 10 out of 10 anxiety, that has been the most helpful for myself and for my clients. That when you slow down and you make it really simple, that’s actually the best way to respond.  We have these bigger concepts like ERP and habit reversal training and mindfulness and all these big concepts. What’s the saying? The rubber hits the road or something like that. When it gets really hard, simplify things, go back to basics, slow down, and just go, “Okay, all I have to do is get through this minute. What can I do in this one minute?” Slow it down. That’s one of the tools and actions.  BE AN OBSERVER  The second tool and action is somebody says, “I notice my five senses,” which is a more tactical skill of being present (be an observer) and in the moment, which is your mindfulness skill. For them it might be: What do you see? What do you smell, what do you taste? Some people play games with this. A lot of my clients have said, “When I’m at a 10 out of 10 and I’ve just faced my biggest fear, or I’ve been triggered, I find six different colors.” You’re not doing that to suppress your thoughts or make the fear go away. You’re doing it because that’s response prevention. You’re not engaging in catastrophization and mental rumination. Instead, you’re just being an observer of what’s in your present moment.  BREATHE A lot of you folks said, “Breathe, that the only thing I do is breathe.” Again, I love this because it’s simple. Now, does that mean we have to breathe a certain way? A lot of people said three breath-in and four counts out, or box breathing. It doesn’t matter. Please don’t put pressure on yourself. For me, I just really put attention on my breath in and my breath out. I say to myself, “I’m breathing in knowing that I’m breathing in and I breathe out knowing I’m breathing out.” Very, very simple.  DO NOTHING! ACCEPT IT IS HERE A next person said, “It feels awful, but I do nothing more than just talk to it, accept that it’s here, and breathe.” Again. These are really simple things. What I’m going to encourage you guys to do is just pick one of these things and play with it for a day or a couple of days, whatever it feels good. And then check in and be like, “How did that work? Was that successful at helping me stay present and reduce behaviors that actually create more problems?”  FEEL YOUR FEET ON THE FLOOR Someone says, “I just feel my feet on the floor.” Again, these are so basic, but almost everybody’s response wasn’t like, “I practice these very complex skills.” They’re just talking about simple, really basic things. “I put my feet on the floor.” USE TEMPERATURE Someone says, “I splash cold water on my face.” Again, simple. They’re just bringing their attention to sensations in the present.  CONNECT WITH YOUR SPIRITUALITY Someone said, “I pray.” I love that some of you bring your religion into it or your faith. “I pray and I be quiet.” Some of you might call that a form of meditation.  FEEL YOUR EMOTIONS & CRY This one I really love. Someone said, “I cry. I embrace crying. It’s such a good emotional release.” This one’s really hard for me, you guys. I’m a crier, but when I’m at a high level of anxiety, I feel like there are no tear ducts in my eyes, like I can’t get myself to cry. But really when I do allow myself to cry, it is such a cathartic experience, especially if I do it kindly.  EXERCISE Someone says they work out. I think that there’s some interesting piece to that. Let me just bring a little nuance to that. When we work out, really what I think we’re doing is we’re putting our attention on something that is very strategic, like 15 bicep curls. Or you get on the treadmill, you listen to some music, and so forth. I love this tool.  SOMETHING TO THINK ABOUT (IF YOU ARE PRONE TO EATING DISORDERS) One thing to think about, and the only reason I’m telling you this is just because I myself used to use working out as a skill and it was very helpful. But if you are someone who’s prone to an eating disorder or compulsive exercise, just keep an eye out for that because, for me, my healthy practice of working out ended up becoming a compulsive eating disorder compulsion. Now, for most of you, that’s probably not the case, but I think with any of these things, like any time we overdo it or we do it to make the fear go away or to avoid the fear, we can get ourselves a little bit into trouble there. So just keep an eye out for that. For me, when I heard that, I was like, “Oh gosh, no, I couldn’t do that.” But I think for most of you and many of you, that is a really effective tool. We do have research that exercise is a very, very helpful way of managing anxiety. I do still work out for that exact reason, but we have to be careful of becoming compulsive VALIDATE YOURSELF Now, of the last of the tools, P.S. It’s actually mine. I did weigh in on the end. My tool and action that I would weigh in, in addition to all of these great ideas, is validate, validate, validate. One of the things I think we miss is when we’re at a 10 out of 10, whether that be anxiety, sadness, depression, stress, panic, whatever it may be, we forget to validate ourself by going, “This is really hard.” It makes complete sense that you can’t think about what tools. You’re at A 10 out of 10. It makes complete sense that this is something that is rocking your world. You could say, “Anybody in this position would struggle to find tools.”  Validate, validate, validate. That’s a self-validation, guys. A self-validation. It might be simply as much as you saying, “It’s okay that you’re struggling, I got you,” which moves me to the mindset shifts. There’s only four of them, but I thought they were beautiful. The reason I separated them is sometimes when we are in the 10 out of 10, naturally, our brain will send us to get away from here, fight, flight, freeze, and fawn. How can we make the fear go away and get out of this “dangerous” situation? If you can, often you won’t be able to. Again, there is some research that when you’re at a 10 out of 10, it’s very hard to actually have a mindset shift. But on the lower 6s, 7s, and 8s out of 10s, if you practice it, I think it gets a little easier.  Here are some of the things that a lot of the folks did weigh in on and say.  MINDSET SHIFTS TO CONSIDER Number one mindset shift is, “I remind myself that I don’t have to solve the thoughts I’m having.” Great mindset shift because in those moments, we’re like, “What is the answer? What is the answer? We need to figure it out,” and so forth. I love that.  The second one is, “I remind myself that I’m resilient and strong.” Total shift, away from, “I can’t handle this, what do I do” to “I’m resilient and strong.” For me—I’ll weigh in here—I often say, “Everything is figureoutable. I’ll figure this one out.” That sentence has changed my life because it takes away the pressure of having to find solutions right now and says, “I’m in a process now. I’ll figure it out. We’ll get to the end of it. It might take some bounces and bumps.” The third one is of course my all-time favorite, which is, “I can do hard things.” Today is a beautiful day to do hard things. So good. It can remind you that this is a moment to lean into.  I think this last one here is really important. someone weighed in and said, “I remind myself that being uncomfortable doesn’t mean dangerous.” This is gold, you guys.  There are some ideas of the people who weighed in and the most common responses. Let me also say, to be honest, a lot of people wrote, “I totally can’t handle it and I just fall apart.” A lot of people were making jokes like, “I throw a tantrum on the floor.” They were basically saying, “I haven’t figured it out yet.” I want to just really emphasize again the importance that it’s okay if you don’t have the 10 out of 10s figured out. We are not here to win all of the challenges.  I have been thinking about this a lot lately and I’ll actually use this as the final point. In our society and even in the community that I have built here, I have to also acknowledge that we can sometimes overdo the “Face your fears, use the tools, fix yourself, get better.” That message can be very, very helpful but also sometimes a little overachieving, a little condescending, a little pressured.  I want to just conclude here, if you are early in your recovery and you’re working on the 4s, 5s, and 6s out of 10, you’re doing enough. If you’re in the middle of your recovery or you’re accelerating in your recovery and you’re doing the 7s, 8s, and 9s, it’s okay that you don’t yet have the skills to do the 10s. Don’t focus too much on that. Just keep the expectations realistic. I don’t want you to leave today thinking, “Okay, now I have to go do those tools and I have to handle 10 out of 10s well.” That’s a lot to ask. I don’t handle the 10 out of 10s perfectly. Nobody does. I know so many anxiety specialists who also don’t handle the 10 out of 10s perfectly. Let’s not fantasize that or let’s not make that a thing so that you are constantly feeling like you have to be doing this perfectly.  Again, do what you can. Practice. This is trial and error. If it does work, great. If it doesn’t work, well good to know. Let’s just try again next time. It mightn’t work next time, that’s fine. Just good to know. We’re not here to always win every battle, but the fact that you asked this question, the fact that your inquiring shows me how much you value your recovery and how much you want to overcome this problem. For that, I applaud you. I applaud everyone listening. I hope that today was helpful for you.  Again, for those of you who are interested, go to CBTSchool.com. We have a whole vault of different courses you can take. We do have some new ones coming out here this year, which I’m super excited about. We’ve got courses for depression, all the things. You can go and listen to those. They are on demand. You have unlimited access. You can watch them as many times as you want. Take notes. Just listen, whatever you want to do, and I hope that you find them helpful.  Have a wonderful day, everybody, and I will see you next week.

Welcome back, everyone. I am so happy to do the final episode of our Sexual Health and Anxiety Series. It has been so rewarding. Not only has it been so rewarding, I actually have learned more in these last five weeks than I have learned in a long time. I have found that this series has opened me up to really understanding the depth of the struggles that happen for people with anxiety and how it does impact our sexual health, our reproductive health, our overall well-being. I just have so much gratitude for everyone who came on as guests and for you guys, how amazing you’ve been at giving me feedback on what was helpful, how it was helpful, what you learn, and so forth.  Today, we are talking about PMS and anxiety, and it is so hopeful to know that there are people out there who are specifically researching PMS and anxiety and depression, and really taking into consideration how it’s impacting us, how it’s affecting treatment, how it’s changing treatment, how we need to consider it in regards to how we look at the whole person. Today, we have the amazing Crystal Edler Schiller on. She is a Psychologist, Assistant Professor, and Associate Director of Behavioral Health for the University of North Carolina Center for Women’s Mood Disorders. She provides therapy for women who experience mood and anxiety symptoms across the lifespan. She talks about her specific research and expertise in reproductive-related mood disorders. She was literally the perfect person for the show, so I’m so excited.  In today’s episode, we talked about PMS, PMDD, the treatments for these two struggles. We also just talked about those who tend to have an increase in symptoms of their own anxiety disorder or mood disorder when at different stages of their menstrual cycle. I found this to be so interesting and I didn’t realize there were so many treatment options. We talked about how we can implement them and how we may adjust that depending on where you are in terms of your own recovery already.  I’m going to leave it there and get straight over to the show. Thank you again to Crystal Schiller for coming on, and I hope you guys enjoy it just as much as I did. Kimberley: Thank you so much for being here, Crystal. This is a delight. Can you just share quickly anything about you that you want to share and what you do? Crystal: Sure. I’m a clinical psychologist at UNC Chapel Hill. I’m an Associate Director of the UNC Center for Women’s Mood Disorders, where we provide treatment to people with reproductive hormones across the lifespan—starting in adolescence, going through pregnancy, postpartum, and all the way up through the transition to menopause. We also do research. My research focuses on how hormones trigger depression and anxiety symptoms in women. I do that by administering hormones, so actually giving women hormones and looking at the impact on their brain using brain imaging and then also studying specific symptoms that they have with that treatment. We’ve given hormones that mimic pregnancy and postpartum, and we also use hormones to treat symptoms as women transition through menopause and look at, like I said, how that impacts how their brain is responding to certain kinds of things in the environment and also how they report that changes their mood.  WHAT IS PMS?  AND WHAT IS THE DIFFERENCE BETWEEN PMS AND PMDD? Kimberley: Wow. You couldn’t be more perfect for this episode. You’ve just confirmed it right there. Thank you for being here. Before we get started, mostly we’re talking about what we call PMS, but I know that’s actually maybe not even a very good clinical term and so forth. Can you share with us what is PMS and What is the difference btween PMS and PMDD?  Crystal: Yeah. PMS stands for premenstrual syndrome. It actually is a medical diagnosis and it includes a host or a range of physical symptoms as well as some mild psychological symptoms. It can be things like breast tenderness or swelling, bloating, cramps, menstrual pain, as well as some anxiety, low mood, mood fluctuations. But those tend to be mild in a PMS diagnosis. PMS is really common in the general population. Some studies estimate 30, 40, 50% of women experience these symptoms. Very, very common. On the other hand, premenstrual dysphoric disorder is a condition that is associated with more severe depression and anxiety symptoms. The mood symptoms are more at the forefront, although those physiologic symptoms like the breast tenderness, swelling, pain, cramps can certainly be a part of it.  HOW CAN WOMEN DISTINGUISH BETWEEN NORMAL PREMENSTRUAL SYMPTOMS AND THOSE ASSOCIATED WITH PMS OR PMDD? Most women with PMDD do have those physical symptoms as well. Pain is a commonly reported symptom in folks with PMDD, but the mood fluctuations are more severe. People spend about half their menstrual cycle usually with pretty severe symptoms. And then once the period starts, those symptoms go away in PMDD. That’s actually part of the criteria for the disorder that the symptoms have to what we call clear out or remit soon after menstrual bleeding starts. So, that’s for the formal diagnosis of PMDD.  But then all sorts of people with anxiety or depression have what we call a premenstrual exacerbation of symptoms, so it’s also possible to have, let’s say generalized anxiety disorder or panic disorder, OCD, and have those symptoms get worse during certain periods of the menstrual cycle. We wouldn’t say that that person has PMDD; they just have a premenstrual worsening of symptoms. For some women, that occurs during that time, the week or two leading up to a period, but others have symptoms that are more around ovulation. Other women have symptoms that persist through the period. That’s the interesting thing. But also, the really complicated thing about this space is that there’s so many individual differences where some people have symptoms that sometimes, but not others. And then if you look at symptoms across the menstrual cycle and the next person, it may show a totally different pattern. But then over time, that pattern is maintained. It is clearly a pattern and a function of hormone change, but it can look different between different people. PMS SYMPTOMS VS PMDD SYMPTOMS? Kimberley: Why is it so different for different people? Do we understand that yet, or do we not have enough research? Crystal: We don’t have enough research. This is a relatively new area that one of my colleagues, Dr. Tory Eisenlohr, has been working on at the University of Illinois at Chicago. What she has been finding is that there are different subgroups or subtypes of people with this premenstrual worsening where, like I said, some people have it right before their period; others more around ovulation. Some people seem to have worsening symptoms when their hormone levels are going up. Other people have worsening symptoms when their hormone levels are going down. Some people have worsening symptoms anytime there’s a fluctuation or change. That’s what we see in my research as well. When I start administering hormones in some women, they almost immediately start experiencing anxiety and irritability. And then as soon as I take the hormone away, they feel better. Whereas other women feel terrible until their hormones even out again, and I’ve stopped messing with them so much. It’s really individualized and it probably has something to do with genetic predisposition as well as early environment. It’s this combination of factors. DOES ANXIETY INCREASE DURING PMS? Kimberley: Right. I could be so off base here, and please just tell me if I am. While we know it’s chemical, hormonal, biological, and genetic, is there also a small percentage of people who have these shifts from a cognitive component to where they’ve maybe had some depressive symptoms in the past, and so that when it comes on, they’re anxious about the symptoms coming on? Does anxiety increase during PMS? Is it as cognitive as well, or are you more looking at just the physiological piece? Crystal: Both, for sure. First of all, you’re not way off base. That’s totally what I see in the clinic, that as folks have had these experiences with hormonal shifts and they had some anxiety or symptoms of depression during those times, it raises concern as they go through those similar hormonal shifts in the future. It becomes, in some ways, a self-fulfilling prophecy. Like, “Oh my gosh, this time is going to be so horrible, I must prepare for it. Oh no, here it comes.” And then it is terrible because you’re expecting it to be terrible on some level.  TREATMENT OPTIONS FOR PMS AND PMDD Crystal: There are great treatment options for PMS and PMDD. That’s what we do in cognitive behavioral therapy for these very symptoms, is working through some of those expectations about how things are going to be and what we can actually do to prepare for it so that it doesn’t end up being bad just because we think it’s going to be bad. But that’s not to say that there isn’t also a hormonal driver because for some people, there clearly is. Again, that’s what makes this work so interesting and complicated, is that it’s both for so many people. And that’s what makes treatment somewhat complicated. CBT can go a long way toward helping with these symptoms. Not everybody, of course, can afford to access CBT. There are medication options as well, but the combination of these treatments seems to work the best for that reason. Kimberley: Yeah. CBT is good for so many things, isn’t it?  Crystal: Yeah.  Kimberley: This is a perfect segue into questions I commonly get. I’m not a medical professional, everybody knows that. I’m a therapist. But people will often report to me that their doctor said, “There’s nothing you can do. It’s your hormones, it’s your cycle. You have to ride it out and ride the PMDD or ride out your OCD or ride out your anxiety or your panic and just wait.” Would you agree with that? If so, or if not, what treatments would you encourage people to consider? Crystal: Okay, I want people to know that that is absolutely not true. If a medical provider tells you that, go see someone else because it’s just not true. I actually hear the same thing all the time from my own patients and from our research participants too. They raised this concern with their physician; it wasn’t taken seriously. That’s why I do this work because I think it’s really important. We do have good treatments that work. There are a whole bunch of different things that people can try.  MEDICATIONS FOR PMDD + PMS Crystal: Because I mentioned there are different ways in which hormones influence mood symptoms across individuals, the unfortunate news is that we have certainly different medication for pmdd + pms treatments that work for a lot of people, but you have to work with a physician that you like to find the combination or the exact right treatment for you. It’s not like a one-and-done where you would go in and say, “Okay, great, you’re going to put me on this low-dose antidepressant and I will feel better and it will completely take care of this.” The thing that I would really encourage people to do is find a physician who’s willing to work with them and see them regularly in the beginning, once every few weeks, or even more often as they try these different treatments to see what’s going to work. I already mentioned cognitive behavioral therapy. That’s a first-line treatment option for PMDD as well as for this premenstrual exacerbation or cyclic exacerbation of underlying anxiety or depression.  The other thing that works well for PMDD is selective serotonin reuptake inhibitors. SSRIs that are used to treat depression and anxiety work well for PMDD but the mechanism is different, which is really interesting. A lot of people I hear from are reluctant to take SSRIs because they’ve heard that they’re difficult to come off of eventually if they wanted to, that you can become dependent on them. The good news for PMDD, for people who are worried about those studies, is actually, you don’t have any dependence on it because you only take it during that period of the menstrual cycle that’s problematic for you. You can take it just those two weeks leading up to the beginning of your period and then stop taking it once the period starts. That has been shown to fully prevent PMDD symptoms in some women. And then some other people take it all the time, like around the whole menstrual cycle just because it’s hard to remember to start it, or because they’re not exactly sure when their period is going to start. If you’re not super regular, it’s hard to know and you might miss that window of opportunity to start it before the mood symptoms. That’s another option. But SSRIs are another first-line treatment option.  And then some women have really good success with oral contraceptives. Low-dose combined estrogen-progestin contraceptives are what’s recommended. Yaz is the only one that’s FDA-approved to treat PMDD, but it’s not all that dissimilar from any other low-dose combined oral contraceptive. Sometimes it isn’t covered by all insurances. If that one is not covered, I tell people to ask their doctor about what are the other alternatives because you shouldn’t be paying tons and tons of money for your oral contraceptive.  And then the other thing that often helps, for women who have some symptom relief with Yaz or other oral contraceptives, is to take it continuously because, as I mentioned, it is often that hormone change that seems to provoke symptoms in folks. If you don’t have a period, then you don’t have any hormone change. It’s those placebo pills that cause a period, it’s the switching from a low-dose hormone to then having that withdrawal of progestin that causes a period. But you don’t medically need one. You can ask your doctor to prescribe the hormone continuously and not have a period at all. And that works well for a lot of folks with PMDD as well. And then you can combine all these different treatments.  LIFESTYLE CHANGES TO HELP PMS ANXIETY + PMDD  And then, in addition, some other non-pharmacologic lifestyle changes to help PMS anxiety and PMDD. Exercise has been shown to help. Regular exercise I think enhances all of our moods. It has the same effect within PMDD. There’s some studies showing that taking calcium seems to reduce symptoms as well. For most of our patients, I just have them start taking a multivitamin and try to boost up that calcium a little bit. But like I said, a lot of people need a combination of treatments. Different SSRIs work in slightly different ways and may be more effective for some people than others. Just because the first SSRI doesn’t work doesn’t mean that you couldn’t try another one. Again, it’s just a matter of finding a physician that’s willing to work with you to find the right combination and dose of these various treatments. Also possible for some people that none of these things work and those cyclic mood symptoms persist. And then there are other more invasive options for folks who don’t have good success with any of these. Kimberley: Right. I have a couple of questions about that. You’ve just given us an amazing treatment plan, or treatment options for someone who is experiencing PMDD or they’re having more onset of anxiety not to maybe that degree. I just want to clarify, for those who also have a chronic anxiety disorder, I’m assuming, but please again correct me, that they wouldn’t be one of the people who should be coming off of their SSRIs; they should stay on them if you’ve got an additional psychiatric or a mental illness on the side. Crystal: Correct. I would never advise someone to come off of their SSRI if they’re still having some breakthrough cyclicity in their symptom exacerbation. What I would suggest instead is to try adding on some of these other options. If you’re already on an SSRI and not doing CBT, that’s maybe where I would start, is to first track your mood symptoms relative to your period. This is a step that many people skip. The only way to diagnose PMDD, but also an important indicator for this cyclic exacerbation of symptoms, is to track every day your mood symptoms. You can just do this really easily on a calendar, even in the Notes app on your phone. I just have my patients make a mood rating of 0 to 10. 0 is feeling terrible, awful, worst I’ve ever felt; 10 is the best I’ve ever felt. It can be as simple as that. Or you can even use a smiley face symptom like, okay, feeling happy, feeling terrible. It doesn’t have to be anything special. There are apps and things you can use as well to do this. But what we’re looking for is a regular pattern of mood change relative to the menstrual cycle. Once you’ve established there is a regular pattern, then a CBT therapist can help you, like I said, prepare for those times and use some coping skills or strategies to manage those mood symptoms.  But I think the treatments are largely the same for people with PMDD versus other anxiety and depressive disorders. But if you have more of a chronic picture that just has some change in symptoms around the menstrual cycle, then you wouldn’t come off your SSRI. That’s just for people with pure PMDD.  CBT FOR PMDD and PMS ANXIETY Kimberley: I’m thinking about questions I’m assuming people will ask, and what comes to mind is, as myself as an OCD Specialist and as an anxiety specialist, we use CBT, but there are different types of CBT. We do a lot of exposure and response prevention for OCD and so forth. When we are talking about CBT, I want us to really be clear about what that looks like compared to all these other forms. What would that look like specific to somebody who has these symptoms, particularly around their menstrual cycle? Would it be more focused on the cognitive component or would it be an equal balance between managing cognitive distortions and behavioral activation? If we did behavioral activations, what would that look like? Crystal: I’m just going to lay my bias out on the table that I tend to lean more on the B side of CBT. I tend to be a behaviorist, and I do a lot of behavioral activation because, in my experience, it tends to work well in this space and for this population of folks. We do some behavioral planning. We track behaviors and mood symptoms. What did you do or not do when you were having that feeling of frustration or irritability and how did that work out for you? We get pretty in the weeds of like, what did you say, and then what happened next, and that sort of thing, and then we figure out like, okay, how do we prevent this kind of exchange from happening in the future when you’re feeling really frustrated or irritable, if it caused problems, because sometimes it doesn’t. Sometimes anger, frustration, or irritability serves as fuel to make a behavior change that needs to be made. It’s a signal that something isn’t working well. I don’t want to pathologize all negative emotions because they’re not always bad.  Anyways, we look at what happened and where are the points at which we could have intervened and we rewind back in time to say, “Okay, how did you sleep the night before that thing happened that didn’t go so well? Were you eating that day? What was that like? Were you already pretty depleted going into this negative interaction with your boss?” How do we prepare for the next cycle to make sure that you are allotting enough time to sleep and protecting that sleep time, not staying up super late, getting emails done or something, but really taking good care of yourself, eating well, drinking enough water, taking care of yourself the way you would take care of a child? And then from there, we talk about, “Okay, let’s say this frustrating thing happens again and you’re noticing yourself getting anxious or frustrated in that moment. What are some tools or skills we could use to respond?” Here, we might use something like taking a break, like, “All right, I noticed I’m getting really upset. I need to take a break from this interaction so that I don’t say something that I might regret.” We might practice a skill like, “Thank you for that feedback. I’m feeling myself just getting flustered. I’m going to take five minutes and then I’d like to come back and have this conversation with you later, or an hour,” or “Can we come back and have this conversation next week,” depending on what it is and how out of sorts the person is feeling. And then using some skills to calm down. These might be mindfulness skills or any kind of self-care, emotion regulation skill that a person could use.  We tend to start with skills that folks have already had good success with. I’m not teaching Buddhist meditation on the first day of treatment, but instead, it might be simple things like, “Oh, I feel better when I get some sunshine and take a walk outside,” so that might be a good skill we could just use right off the bat. It’s pretty skill-based. And then we create a behavioral plan around that time of the month that tends to be more problematic so that we can keep people feeling well and well supported. A lot of times, that’s all it takes. It doesn’t require much more than that.  Kimberley: I love that. I love that you’re bringing in the mindfulness piece and a lot of self-care. This is really more of a question of curiosity, but I remember as a young teen, having a lot of PMS, being told you have to drink a lot of water. Is that like an old wives’ tale? Because now I’m telling my daughter. I’m curious, is that an old wives’ tale or is that actually a treatment or a part of the work? Crystal: I don’t know. I mean, I think Americans probably go a little overboard on water consumption, but I think it’s a good part of self-care to stay well-hydrated as well as well-fed and well-rested. You do lose some water through menstruation, and so it’s probably good practice in general just to keep yourself well hydrated. That doesn’t mean drinking a certain amount of water every day, but just noticing when you’re thirsty and drinking something when you are. Kimberley: Okay, I’ll be better about that because, like I said, as I tell my daughter, I’m always like, “This is probably an old wives’ tale.” Maybe we could talk this one through together. Let’s say I’m treating somebody. They’ve got severe OCD, severe panic disorder or severe health anxiety, severe social anxiety. They know and they’ve tracked using an app or, as you said, the notes on their phone or on paper, they’ve tracked it. They know around approximately that such and such day of the month, they’re going to probably have an onset of treatment. How prepared should they be in terms of what would that preparation time look like? Is there a strategy you would give people? I know for us, on the clinical side, I’m amping up homework skills for them to manage the actual disorder, but is there something they could be doing on the PMS side that we should remember to do? Crystal: I think it’s in my mind really specific to the individual and the symptoms that they’re having that they find tend to get worse as well as the physical symptoms. If they’re having a lot of pain around that time, then we want to also work on some pain management. Because when you’re feeling a lot of pain, that can make your anxiety worse. That would be something I would think about in addition to the standardized ramping up of homework that you would ordinarily be doing. Pain management can again look more like mindfulness, some meditative practice, or it can mean talking with one’s doctor about how to manage pain because there are non-addictive ways of managing pain as well. Kimberley: Right. You mentioned before talking to your doctor. Are you speaking specifically about just a GP or should they be going more to a reproductive doctor, OB-GYN? What kind of medical professional would you encourage people to reach out to?  Crystal: I think if you have a doctor that you trust, whether it’s a GP, OB-GYN, or even a psychiatrist, all of those are good options. Any of them can help treat these symptoms. Sometimes if the symptoms are really severe, then going to a specialist in reproductive mental health—that person would be a psychiatrist—can be helpful. There aren’t that many of us out there though. I have a number of really wonderful colleagues that I work alongside in our clinic and we treat patients together. I provide the psychotherapy and then they provide the pharmacotherapy and then I also have an OB-GYN on the team who provides the hormonal treatment. Not everyone can access this highly skilled team, however, and I do recognize that. I think starting with a GP or your OB-GYN is a good place to start. Again, if they’re not as knowledgeable as they need to be and they’re telling you, you just have to suck it up and deal with it, that’s not the right person.  Kimberley: I appreciate you saying that because I do think—I’ll be transparent—even to get somebody as skilled as yourself on the show for this was a really difficult thing. I was surprised how few people really understand it and are knowledgeable about the treatment options. It was harder than I thought and I’m so grateful for you to be here and talk about it with us. Crystal: I’m really sorry to hear that. I think there are a growing number of people interested in this, and I have a number of wonderful colleagues. But like you mentioned, there aren’t that many of us out there. The bright spot, I would say, is that we have a training program at UNC Chapel Hill with lots and lots of applicants every year. We’re training clinical psychologists and social workers and psychiatrists to do this work. Kimberley: Amazing. Thank you. Last question: Any final advice you would give someone who is experiencing symptoms of PMS and PMDD in regards to getting better or seeking treatment and help? LAST PIECE OF ADVICE FROM CRYSTAL Crystal: You’re not alone. It’s not all in your head. You deserve access to treatments that work. There are lots of treatments that work. Unfortunately, our medical system is really complex and sometimes you have to really advocate for yourself in this space. But if you are persistent and know what you’re looking for in a provider, you, I hope, will be able to find one that can be a good advocate and supporter of you to recovery because you don’t have to experience these symptoms by yourself or forever. Kimberley: Thank you so much for saying that. I think a lot of people feel like they’re crazy or they’ve been told they’re being crazy, which doesn’t help. Crystal: Yeah. I mean, the word “hysteria” came from studying or psychiatrists working with women who they felt were hysterical and their uterus was traveling around their bodies. The roots of all of this are in this really misogynistic place where many of us are working really hard to overcome that unfortunate history, but there’s often still a lot of stigma and misinformation out there. Kimberley: I remember in my master’s degree, that was the first part of the history of Psychology, that women who were just having PMS were being totally hyper-pathologized. Horrible. Crystal: Yeah. Really horrible. I hope that the work that we do makes a difference. I’m so glad that you’re tackling this topic on your podcast. I think this will, I hope, reach a lot of people. Kimberley: Thank you. Can you tell us where people can get ahold of you, where they might learn about you and the work that you’re doing? Crystal: Yeah. I have a website, it’s CrystalSchiller.com. C-R-Y-S-T-A-L S-C-H-I-L-L-E-R.com. I’m actually starting to write a book on this topic, so I really appreciate you reaching out and to know that people have questions about this because that’s what I see where I’m at too. And then the UNC Center for Women’s Mood Disorders, if you just Google that, you’ll find our website and you can read more about the different research studies that we’re doing and about our treatment program as well. Kimberley: Thank you so much and congratulations on writing a book. It’s a big challenge and a big accomplishment. Crystal: Thanks. Kimberley: Thank you so much for coming on. It’s been an absolute pleasure.Crystal: It was wonderful being with you today. Thank you so much. Take care.

In this week's podcast episode, we talked with Dr. Katherine Unverferth on Menopause, anxiety, and mental health. We covered the below topics: How do we define peri-menopause and menopause?  What causes menopause?  Why do some have more menopausal symptoms than others?  Why do some people report rapid rises in anxiety (and even panic disorder) during menopause.  Is the increase in anxiety with menopause biological, physiological, or psychological?  Why do some people experience mood differences or report the onset of depression during menopause?  What treatments are avaialble to help those who are suffering from menopause (or perimenopause) and anxiety and depression? Welcome back, everybody. I am so happy to have you here. We are doing another deep dive into sexual health and anxiety as a part of our Sexual Health and Anxiety Series. We first did an episode on sexual anxiety or sexual performance anxiety. Then we did an episode on arousal and anxiety. That was by me. Then we did an amazing episode on sexual side effects of antidepressants with Dr. Aziz. And then last week, we did another episode by me basically going through all of the sexual intrusive thoughts that often people will have, particularly those who have OCD.  This week, we are deep diving into menopause and anxiety. This is an incredibly important episode specifically for those who are going through menopause or want to be trained to understand what it is like to go through menopause and how menopause impacts our mental health in terms of sometimes people will have an increase in anxiety or depression. This week, we have an amazing guest coming on because this is not my specialty. I try not to speak on things that I don’t feel confident talking about. This week, we have the amazing Dr. Katherine Unverferth. She is an Assistant Clinical Professor at The David Geffen School of Medicine and she also serves as the Director of the Women’s Life Center and Medical Director of the Maternal Mental Health Program. She is an expert in reproductive psychiatry, which is why we got her on the show. She specializes in treating women during periods of hormonal transitions in her private practice in Santa Monica. She lectures and researches and studies areas on postpartum depression, antenatal depression, postpartum psychosis, premenstrual dysphoric disorder—which we will cover next week, I promise; we have an amazing guest talking about that—and perimenopausal mood and anxiety disorders. I am so excited to have Dr. Unverferth on the show to talk about menopause and the collision between menopause and anxiety. You are going to get so much amazing information on this show, so I’m just going to head straight over there. Again, thank you so much to our guest. Let’s get over to the show. Kimberley: Welcome. I am so honored to have Dr. Katherine Unverferth with us talking today about menopause and anxiety. Thank you for coming on the show. Dr. Katie: Of course. Thanks for having me. HOW DO WE DEFINE PERI-MENOPAUSE AND MENOPAUSE?  Kimberley: Okay. I have a ton of questions for you. A lot of these questions were asked from the community, from our crew of people who are really wanting more information about this. We’ve titled it Menopause and Anxiety, but I want to get really clear, first of all, in terms of the terms and whether we’re using them correctly. Can you first define what is menopause, and then we can go from there? Dr. Katie: Definitely. I think when you’re talking about menopause, you also have to think about perimenopause. Menopause is defined as the time after the final menstrual period. Meaning, the last menstrual period somebody has. It can only be defined retrospectively, so you typically only know you’re in menopause a year after you’ve had your final menstrual period. But that’s the technical definition—after the final menstrual period, it’s usually defined one year after. Perimenopause is the time leading up to that where people have hormonal changes. Sometimes they have vasomotor symptoms, they can have mood changes, and that period typically lasts about four years but varies. I think that people often know that they’re getting close to menopause because of the perimenopausal symptoms they might be experiencing. Kimberley: Okay. How might somebody know they’re going into perimenopause? I think that’s how you would say you go into it. Is that right?  Dr. Katie: Yeah. You start experiencing it there. I don’t know if there’s a specific term.  Kimberley: Sure. How would one know they’re moving in that direction?  Dr. Katie: Typically, we look for a few different things. One of the earliest signs is menstrual cycle changes. As someone enters perimenopause, their menstrual cycle starts to lengthen, whereas before, it might have been a normal 28-day cycle. Once it lengthens to greater than seven days, over 35 days, we would start to think of someone might be in perimenopause because it’s lengthened significantly from their baseline before.  Other symptoms that are really consistent with perimenopause are vasomotor symptoms. Most women who go through perimenopause will have these. These are hot flashes or hot flushes—those are synonyms for the same experience—and night sweats. Hot flashes, as the name describes what it is, they last about two to four minutes. It’s a feeling of warmth that typically begins in the chest or the head and spreads outward, often associated with flushing, with sweating that’s followed by a period of chills and sometimes anxiety. The night sweats are hot flashes but in the middle of the night when someone is sleeping, so it can be very disruptive to sleep. That combination of the menstrual cycle changes plus these vasomotor symptoms is typically how we define perimenopause or how we diagnose perimenopause. Once someone is later in perimenopause, when they’re getting closer to their final menstrual period, often they’ll skip menstrual cycles altogether, so it might be 60 days in between having bleeding. Whereas before, it was a more regular period of time. I think one of the defining features too is hormonal fluctuations during those times. But interestingly, there’s not much clinical utility to getting the blood test to check hormone levels because they can vary wildly from cycle to cycle. Overall, what we do see is that certain hormones increase, others decrease, and that probably contributes to some of the symptoms that we see around that time as well. Kimberley: Right, which is so interesting because I think that’s why a lot of people come to me and I try to only answer questions I’m skilled to answer. Those symptoms can very much mimic anxiety. I know we’ll get into that very soon, but that’s really interesting—this idea of hot flashes. I always remember coming home to my mom from school and she was actually in the freezer, except for her feet. It was one of those door freezers. So, I understand the heat that they’re feeling, this hot flash, it’s a full body hot flash stimulant like someone may have if they’re having a panic attack maybe.  Dr. Katie: Exactly. There are lots of interesting studies really looking at the overlap of menopausal panic attacks and hot flashes too. There’s a lot of this research that’s really trying to suss out what comes first in perimenopause because we know that anxiety predisposes someone to hot flashes and it can predispose someone to panic attacks, which is interesting. It seems like there’s this common denominator there. But I think that that’s a really interesting thing that hopefully we’ll get into this overlap between the two. WHAT AGE DOES SOMEONE GET PERIMENOPAUSE AND MENOPAUSE? Kimberley: I’m guessing this is something I’m moving towards as well. What age groups, what ages does this usually start? What’s the demographics for someone going into perimenopause and menopause? Dr. Katie: The average age of menopause is 51, and then people spend about four years in perimenopause. Late 40s would be a typical time to start perimenopause. Basically, any age after 40, when someone’s having these symptoms, they’re likely in perimenopause. If it happens before the age of 40 where someone’s having menstrual cycle abnormalities and they’re having these vasomotor symptoms, that might be a sign of primary ovarian insufficiency. It used to be called premature ovarian failure, but that would be a sign that they should probably go see a doctor and get checked out. If it’s after 40, it’s very likely that they’re having perimenopausal symptoms. Kimberley: Okay. What causes this to happen? What are the shifts that happen in people’s bodies that lead someone into this period of their life? Dr. Katie: I think there are a lot of things that are going on. I think it’s really important to emphasize that menopause is a natural part of aging. That this isn’t some abnormal process. Nothing is wrong. It’s a natural part of aging. It can still be very uncomfortable, I think. But basically, over time, a woman’s eggs decline and the follicles that help these eggs develop also develop less. There’s this decline in the functioning of the ovaries. There are a few reasons this might be. There are some studies that show that blood flow to the ovaries is reduced as a result of aging, so maybe that makes them function a little bit less. The follicles that remain in the ovaries are probably aging, and then the follicles, which are still there, also might not be the healthiest of follicles, which is why they weren’t used earlier.  There’s this combination of things that leads to these very significant hormonal changes that start around perimenopause. The first of these is an increase in follicle-stimulating hormone. Follicle-stimulating hormone is released by the pituitary and encourages the ovaries to develop follicles. That increases over time because the follicles aren’t developing in the same way. It’s like the pituitary is trying harder and harder to get them to work. At the same time as these, as the follicles and ovaries are aging, what we see is that the ovaries produce less estrogen and progesterone overall. But there’s still these wild fluctuations that are happening. FSH is going up, but it’s fluctuating up; estrogen and progesterone are going down, but they’re fluctuating down. It’s these really big shifts that seem to cause a lot of the symptoms that we associate with this time. WHY DO SOME HAVE MORE MENOPAUSAL SYMPTOMS THAN OTHERS?  Kimberley: Is there a reason why some people have more symptoms than others? Is it your genetic component or is there a hormonal component? What’s your experience? Dr. Katie: I think there are lots of different reasons and we probably need more research in this area. There are definitely genetic components that influence it. For example, we know that women who have family members who went through menopause earlier are likely to go through menopause themselves earlier. There’s some genetic thing that’s influencing the interplay of factors. I think we know that there are certain lifestyles. There are certain behaviors, like certain behaviors in someone’s life that can influence, I think, their symptoms. We know that smoking, obesity, having a more sedentary lifestyle can impact vasomotor symptoms. I think some really interesting research looks at the psychological influences here. We know that women who have higher levels of neuroticism, when they go through perimenopause, have more anxiety and mood changes associated with it. People who have higher levels of somatic anxiety, coming into this perimenopausal transition, can also have a tougher time. I think that makes sense when we think about someone with somatic anxiety. They’re going to be very, very attuned to these small changes in their body. During perimenopause, there are these huge changes that are happening in your body. That can trigger, I think, a lot of anxiety and a focus on the symptoms.  I think with vasomotor symptoms specifically, like hot flashes and hot flashes specifically, night sweats, not quite as much, we know that there are these psychological characteristics that probably perpetuate and worsen hot flashes. When someone has a hot flash, it’s certainly uncomfortable for most people. But the level of distress can be very different. They’ve looked at the cognitions that occur when people have hot flashes and at some point, people believe like, “Oh, this is very embarrassing, this is very shameful.” That doesn’t help them process it. They might believe, “This is never going to go away. I can’t cope with it.” That’s also not going to help. I think that’s really a target for cognitive behavioral therapy to help people during this time. Kimberley: It just makes me think too, as somebody who has friends going through this, and you can please correct me, what I’ve noticed is there’s also a grief process that goes along with it too, like it’s another flag in terms of being flown, in terms of I’m aging. I’ve also heard, but maybe you have more to say about people feeling like it makes them less feminine. Is that your experience too, or is that just my experience of what I’ve heard? Dr. Katie: No, I agree. I think in my clinical experience, people go through it in a lot of different ways. I think that there is this grief. I think it can bring out a lot of existential anxiety. It is a sign that you are getting older. This can bring up a lot of these questions like, who am I? What’s my purpose? Where am I going? But I think it’s really important to remind women that we’re not defined by our reproductive functioning. I think that that’s something that people forget. Were you less of a woman when you were 15 or when you were 10 maybe and you hadn’t gone through puberty? You’re still the same person. But I do think that there’s a lot of cultural stress around this, and I think there are a lot of complexities around the way society sees aging women. I think that those are cultural issues that need to be fixed, but not necessarily a problem within the woman themselves. WHAT CAUSES MENOPAUSE AND ANXIETY SYMPTOMS?  Kimberley: That’s really helpful to know and understand. Okay, let’s talk about if I could get a little more understanding of this relationship with anxiety. Maybe you can be clearer with me so that I understand it. Is it more of what we’re saying in terms of like, it’s the chicken and the egg? Is that what you mean in terms of people who have anxiety tend to have more symptoms, but then those symptoms can create more anxiety and it’s like a snowball? Or is that not true for everybody? Can you explain how that works? Dr. Katie: With regard to the perimenopausal period, what I think researchers are trying to figure out is, do vasomotor symptoms, like hot flashes, lead to anxiety and panic, or do anxiety and panic worsen the vasomotor symptoms? We don’t have a lot of information there. Part of it is because it’s difficult to study. Because when you’re doing symptom checklists, there’s a lot of overlap between a hot flash and a panic attack. It’s just been difficult, I think, to suss out in research. I think what we do know is there was one study that showed that people who have higher levels of anxiety are five times more likely to report hot flashes than women with anxiety in the normal range. Whether or not the anxiety is necessarily causing it, I do think that there’s probably some perpetuation of like, I think that the anxiety is perpetuating the hot flashes, which perpetuates the anxiety. We just don’t know exactly where it starts.  MENOPAUSE & PANIC ATTACKS  But I mean, if we just think about it for a second, if we think about what’s common between them, I think that both panic attacks and hot flashes have a quick onset. They have a spontaneous onset, a rapid peak, they can be provoked by anxiety, they can include changes in temperature, like feelings of heat and sweating. They can have these palpitations, they can have this shortness of breath, nausea. And then it’s very common that panic is reported during hot flashes, and hot flashes can be reported during panic. I think there’s this interplay that we’re trying to figure out. I think what’s interesting too is that common antidepressants can treat both panic and hot flashes, which is not something that probably everybody knows. There are probably different reasons that they’re treating each of them, but it is still just this other place where there is this overlap.  Kimberley: Okay. That’s really interesting. One thing that really strikes me is I actually have a medical condition called postural orthostatic tachycardic syndrome (POTS), and you get really dizzy. I’m an Anxiety Specialist, so I can be good at pulling apart what is what, but it is very hard. You have to really be mindful to know the difference in the moment because let’s say I have this whoosh of dizziness. My mind immediately first says I’m having a panic attack, which makes you panic. I’m assuming someone with that whoosh of maybe a hot flash has that same thing where your amygdala, I’m guessing, is immediately going to be like, “Yeah, we’re having a panic attack. This is where we’re going.” That makes a lot of sense to me. Now, some people also have reported to me that their anxiety has made them-- and again we have to understand what causes what, and we don’t understand it, but how does that spread into their daily life? What I’ve heard is people say, “I don’t feel like I can leave the house because what if I have a hot flash, which creates then a panic attack,” or “It’s embarrassing to have a hot flash. You sweat and your clothes are all wet and so forth.” Do you have a common example of how that also shows up for people?  Dr. Katie: Yeah. I think that what you were alluding to is this behavioral avoidance that can happen. We can see that with panic attacks where people sometimes develop agoraphobia, fear of being in certain places. Sometimes they don’t want to leave their home. I think with hot flashes, we do also see this behavioral avoidance when people especially tend to find them very distressing. They catastrophize it when they happen. They worry about social shaming. That avoidance, I think, the way that we understand anxiety is that if you have an anxiety and then you change your behaviors as a result of that anxiety, that tends to perpetuate the anxiety. That’s one of the targets of cognitive behavioral therapy for hot flashes, is really trying to unwind some of this behavioral avoidance. Also, we know that temperature changes can trigger hot flashes. Unfortunately, it looks like strong positive and strong negative emotion can trigger hot flashes, just feeling any end of the spectrum. There are certain other triggers that can trigger hot flashes. I think that it’s just this discomfort and this fear of having a hot flash that I think really generalizes the anxiety during this time.  HORMONES, ANXIETY, & MENOPAUSE There’s also this interesting hormonal component too that’s being studied as well. We’ve talked a little bit about progesterone. But in reproductive psychiatry, we really focus on this metabolite of progesterone called allopregnanolone. I think this is interesting because allopregnanolone is a metabolite of progesterone. We know that progesterone is going like this, up and up and down during this time. Allopregnanolone works on this receptor that tends to have very calming effects. Other things that work at this receptor are benzodiazepines like Xanax and Ativan or alcohol. It has this calming effect. But when it’s going like this, it’s calming and then it’s not, and then it’s calming and then it’s not, up and down rollercoaster. There’s some thought that that specifically might contribute to anxiety during this time. It can be more generalized. It’s not always just related to hot flashes, even though we’ve been more specific on that. It can be the same as anxiety at any point in anyone else’s life, like ruminative thoughts, worry, intrusive thoughts, just this general discomfort. I think this is a really exciting area of research where we’re looking at ways to modulate this pathway to help women cope better. There are studies looking at progesterone metabolites to see if they can be helpful with mood changes during this time. Kimberley: Interesting. Let’s work through it. As a clinician, if someone presents with anxiety, what I would usually do is do an inventory of the behaviors that they do in effort to reduce or remove that anxiety or uncertainty that they feel. And then we practice purposely returning to those behaviors. Exposure and so forth. From what you understand, would you be doing the same with the hot flashes or is there a balance between, there will be sometimes where you will go in purposely or go out and live your life whether you have a hot flash or not? How do we balance that from a clinical standpoint? Even as a clinician, I’m curious to know. As a clinician, what would I encourage my client to do? Would it be like our normal response of, “Come on, let’s just do it, let’s face all of our fears,” or is there a bit of a balance here that we move towards? Dr. Katie: It’s more of a balance. I think one of the important things is that what you want to do-- I think the focus is on the cognition here a little bit. I’m not familiar and I don’t think that exposure to hot flashes is intentionally triggering hot flashes repeatedly, like sometimes we do in panic disorders is part of this. What I understand from the protocol is that it’s really looking at the unhelpful cognitions that relate to menopause, aging, and vasomotor symptoms. This idea of like, everybody is looking at me when I’m having a hot flash, this is so shameful. Or maybe it goes further, like no one will like me anymore. Who knows exactly where it can go? We know that when people have cognitive distortions, it’s not really based on rational thinking. I think other part is you work on monitoring and modifying hot flash triggers, so it feels more in your control like temperature changes and doing those things. I think other things that you do is there’s some evidence for diaphragmatic breathing to help with the management of hot flashes. You teach someone those skills. I think your idea is you want to get them back out there and living their life despite the hot flashes, and also just education. This isn’t going to last forever. Yes, this is uncomfortable, but everybody goes through this. This is a normal part of aging. Also encouraging them to seek treatment if they need it. In addition to therapy, we know that there are medications that can help with this. If the hot flashes are impacting their life in a significant way or very distressing to them, go see a reproductive psychiatrist or go see an OB-GYN who can talk to you about the different options to really treat what’s coming up. Kimberley: Right. That’s helpful. I want to quickly just add on to that with your advice. I think what you’re saying is when we come from an anxiety treatment model, we are looking at exposure, but when it comes to someone who’s going through this real life, like their actual symptoms aren’t imagined, they’re there, it’s okay for them to modify to not be going to hot saunas and so forth that we know that they’re going to be triggered, but just to do the things that get them back to their daily functioning, but it is still okay for them. I think what I’m trying to say is it’s still okay for them to be doing some accommodation of the symptoms of perimenopause, but not accommodation of the anxiety. Is that where we draw the line? Dr. Katie: I think that’s a really good way of explaining it. DEPRESSION AND MENOPAUSE Kimberley: All right. The other piece of this is as important, which is how depression impacted here. Can you share a little bit how mood changes can be impacted by perimenopause?  Dr. Katie: Definitely. We know that there’s a significant increase in not only the onset of a new depression, but also recurrence of prior depressive episodes during perimenopause. It’s probably related to the changing levels of hormones, but also, I think what we’ve alluded to and what we have to acknowledge is there are big life changes that are happening around this time as well. I think cultural views of aging, I think a lot of times people have changes in their relationships, their partners. Their libido can change. There’s so many moving parts that they think that also contributes to it.  But specifically with regard to perimenopausal depression, we categorize this in the reproductive subtype of depression. At these different periods of hormonal transition, certain women are prone to have a depressive episode. We know that that’s true during normal cycling. For example, premenstrual dysphoric disorder or PMDD is a reproductive subtype of depression. People sometimes get depressed in those two weeks before their period and then feel fine during the week of their period or the week after. During the luteal phase, they experience depression. We know that that group of women also is at increased risk for perinatal depression, so depression during pregnancy and postpartum. And then that same group is also at risk for perimenopausal depression. What we know is that a subset of women is probably sensitive to normal levels of changing hormones, and that for them, it triggers a depressive episode.  One of the biggest risk factors for depression during perimenopause is a prior history of depression. Unfortunately, the way depression works is that once you have it, you’re more likely to have it in the future. For people who have had depression in their life or have specifically had depression around these times of hormonal transition, it’s probably just important to keep an eye on how they’re doing, make sure they have appropriate support, whether that’s from a therapist or a psychiatrist, and monitor themselves closely. Kimberley: Okay. This is really helpful to know. We know that people with anxiety tend to have depression as well. Have you found those who’ve had previous depression or previous anxiety also have coexisting in terms of having those panic attacks and depression at the same time? Dr. Katie: That’s interesting. I haven’t read any research on that. It wouldn’t surprise me. But I think at least for research purposes, they’re separating it. I think clinically, of course, we can see it being all mixed together. But for research, it’s depression or panic and they keep those separate. Kimberley: Right. One thing that just came to me in terms of just clarifying too is, I’m assuming a lot of people who have health anxiety are incredibly triggered during perimenopause as well, these symptoms that are unexplained but explained. But I’m wondering, is that also something that you commonly see in terms of they’re having these symptoms and questioning whether it means something serious is happening? Has that been something that you see a lot of? Dr. Katie: Definitely. I think the first time someone has a hot flash, it can be extremely distressing. It’s a very uncomfortable sensation. I think there are other changes that happen during perimenopause that, of course, I think, raise concern. We know that in addition to night sweats, people can just have general aches and pains. They can have headaches. Cognitive complaints can be very common during this time. Just this feeling of brain fog, not feeling as sharp as one used to be. They can have sleep disturbances, which can of course worsen the anxiety and the cognitive complaints, and the depression. I think there can be a myriad of symptoms. Other distressing symptoms, I’m not sure if they necessarily-- I think if you know what’s going on, it’s not quite as distressing, but there can be these urogenital symptoms, like vaginal dryness, vaginal burning. There can be recurrent UTIs, there can be difficulty with urination. There are this constellation of symptoms that I’m sure could trigger health anxiety in people, especially if they have preexisting health anxiety. WHAT TREATMENTS ARE AVAIALBLE TO HELP THOSE WHO ARE SUFFERING FROM MENOPAUSE (OR PERIMENOPAUSE) AND ANXIETY AND DEPRESSION?  Kimberley: Yeah, absolutely. Someone’s listened to this episode so they’re at least informed, which is wonderful. They start to see enough evidence that this may be what is going on for them. What would be the steps following that? Is it something that you just go through and like a fever, you just ride it out kind of thing? Or are there medications or treatments? What would you suggest someone do in the order as they go through it? Dr. Katie: I think it depends on what’s going on and how they’re experiencing it. If this is distressing, life interfering, if they’re having trouble functioning, they should absolutely seek treatment. I think there are a few different things they can do depending on what’s going on. For depression and anxiety, medications are the first line. Antidepressants would still be the first-line therapy there. There’s some evidence for menopausal hormone therapy, but there’s not really enough. There is evidence for menopausal hormone therapy, but it’s not currently first line for depression or anxiety. If someone had treatment-resistant depression that came up in the perimenopausal transition, I think it’s reasonable to consider menopausal hormone therapy. But currently, menopausal hormone therapy isn’t really recommended for that.  If someone is having distressing vasomotor symptoms with night sweats and recurrent hot flashes or hot flushes during the day, menopausal hormone therapy is a very good option. That is something to consider. They could go talk to their OB-GYN about it. Certain people will be candidates for it and other people might not. If you think it might be something you’re interested in, I recommend going and speaking to your OB-GYN sooner rather than later.  Antidepressants themselves can also help with vasomotor symptoms as well. They can specifically help with hot flashes and night sweats. If someone has depression and anxiety and hot flashes and night sweats, antidepressant can be a really good choice because it can help with both of those. There was a really interesting study that compared Lexapro to menopausal hormone therapy for hot flashes, for quality of life, for sleep, and for depression. Essentially, both of them helped sleep quality of life in vasomotor symptoms, but only the Lexapro helped the depression. It really just depends on what’s going on.  I think another thing that we’ve also talked about is therapy. This can be a big life transition. I think really no woman going through menopause is the same. Some people have toddlers. Some people have grown children who have just left their home. Some people are just starting their career. Some people are about to retire. Relationships can change. I think that it’s really important to take what’s going on in the context of a woman’s life. I think therapy can be really helpful to help them process and understand what they’re going through. Kimberley: Right. You had mentioned before, and I just wanted to touch on this, vaginal drying and stuff like that, which I’m sure, again, a reason for this series is just how much sexual intimacy and so forth can impact somebody’s satisfaction in life or functioning or in relationships. Is that something that is also treatable with these different treatment models or is there a different treatment for that?  Dr. Katie: With menopausal hormone therapy, when someone has hot flashes or these other symptoms that we were talking about, not the urogenital ones, they need to take systemic menopausal hormone therapy. They basically need estrogen and progesterone to go throughout their body. When someone is just having these urogenital symptoms, they can often use topical vaginal estrogen. It’s applied vaginally. That can be really helpful for those symptoms as well. I think if that’s something that someone is struggling with that they want treatment for, it’s very reasonable to go talk to their OB-GYN about it because there are therapies that can be-- Kimberley: Right, that’s like a cream or lotion kind of thing.  Dr. Katie: Exactly.  Kimberley: Interesting. Oh wow. All right. That is so helpful. We’ve talked about the medical piece, the medication piece. A lot of people also I see on social media mostly talk about these more-- I don’t want to use the word “natural” because I don’t like that word “natural.” I don’t even know what word I would use, but non-medical-- Dr. Katie: Like supplements or-- Kimberley: Yeah. I know it’s different for everyone and everyone listening should please seek a doctor for medical advice, but is that something that you talk about with patients or do you stick more just to the things that have been researched? What are your thoughts? Dr. Katie: I think that supplements can be helpful for some people. I don’t always find that they’re as effective as medications. If someone is really struggling on a day-to-day basis, I do think that using treatments that have more evidence behind them is better. I think that there are some supplements that have a little bit of evidence, but I do think that they come with their own risks. Because supplements aren’t regulated by the FDA and things like that, I don’t typically recommend them. I think if someone is interested in finding a more naturopathic doctor who might be able to talk to them about those things is reasonable.  Kimberley: Super helpful. Is there anything that you feel like we haven’t covered or that would be important for us to really drill home and make sure we point out here at the end before we finish up? Dr. Katie: I think we’ve covered a lot. I think that the most important thing that I really want to stress is this is a normal part of aging. This is not a disease; this is not a disease state. Also, there are treatments that can be so effective. You don’t have to struggle in silence. It is not something shameful. There are clinicians who are trained, who are able to help if these symptoms are coming up. Just not being afraid to go and talk about it and go reach out for help. I think that that can be so helpful and really life-changing for some people when they get the right treatment. Kimberley: Right. Thank you. Where can we hear about you, get in touch with you, maybe seek out your services? Dr. Katie: You can find me online. I have a website. It’s just www.drkatiemd.com. It’s D-R-K-A-T-I-E-M-D.com. You can follow me on Instagram on the same. If you’re interested to see more of my talks and lectures, I often post those on my LinkedIn page. You can follow me on LinkedIn. I think if you are personally interested in learning more about menopause, there’s a really great book by an OB-GYN, her name is Dr. Jen Gunter, and it’s called The Menopause Manifesto. For anybody who really wants to educate themselves about menopause and understand more about what’s going on in their body and their treatments, I really recommend that book. Kimberley: Amazing. That’s so good to have that resource as well. Thank you. I’m really, really honored. I know you’re doing so many amazing things and running so many amazing programs. I’m so grateful for your time and your expertise on this. Dr. Katie: Of course. I’m so glad that you’re doing a podcast on this. I think this is a topic that we really need more information and education out there. Kimberley: Yeah. Thank you.

Welcome. This is Week 4 of the Sexual Health and Anxiety Series. I have loved your feedback about this so far. I have loved hearing what is right for you, what is not right for you, getting your perspective on what can be so helpful. A lot of people are saying that they really are grateful that we are covering sexual health and anxiety because it’s a topic that we really don’t talk enough about. I think there’s so much shame in it, and I think that that’s something we hopefully can break through today by bringing it into the sunlight and bringing it out into the open and just talking about it as it is, which is just all good and all neutral, and we don’t need to judge. Let’s go through the series so far. In Episode 1 of the series, we did sexual anxiety or sexual performance anxiety with Lauren Fogel Mersy. Number two, we did understanding arousal and anxiety. A lot of you loved that episode, talking a lot about understanding arousal and anxiety. Then last week, we talked about the sexual side effects of anxiety and depression medication or antidepressants with Dr. Sepehr Aziz. That was such a great episode. This week, we’re talking about sexual intrusive thoughts.  The way that I structured this is I wanted to first address the common concerns people have about sexual health and intimacy and so forth. Now I want to talk about some of the medical pieces and the human pieces that can really complicate things. In this case, it’s your thoughts. The thoughts we have can make a huge impact on how we see ourselves, how we judge ourselves, the meaning we make of it, the identity we give it, and it can be incredibly distressing. My hope today is just to go through and normalize all of these experiences and thoughts and presentations and give you some direction on where you can go from there. Because we do know that your thoughts, as we discussed in the second episode, can impact arousal and your thoughts can impact your sexual anxiety.  SEXUAL OCD OBSESSIONS Let’s talk a little bit today about specific sexual intrusive thoughts. Now, sexual intrusive thoughts is also known as sexual obsessions. A sexual obsession is like any other obsession, which is, it is a repetitive, UNWANTED—and let’s emphasize the unwanted piece—sexual thought. There are all different kinds of sexual intrusive thoughts that you can have. For many of you listening, you may have sexual intrusive thoughts and OCD that get together and make a really big mess in your mind and confuse you and bring on doubt and uncertainty, and like I said before, make you question your identity and all of those things.  In addition to these intrusive thoughts, they often can feel very real. Often when people have these sexual intrusive thoughts, again, we all have intrusive thoughts, but if they’re sexual in nature, when they’re accompanied by anxiety, they can sometimes feel incredibly real, so much so that you start to question everything.  SEXUAL SENSATIONS Now, in addition to having sexual intrusive thoughts, some of you have sexual sensations, and we talked a little bit about this in previous episodes. But what I’m really speaking about there is sensations that you would often feel upon arousal. The most common is what we call in the OCD field a groinal response. Some people call it the groinal in and of itself, which is, we know again from previous episodes that when we have sexual thoughts or thoughts that are sexual in nature, we often will feel certain sensations of arousal, whether that be lubrication, swelling, tingling, throbbing. You might simply call it arousal or being turned on. And that is where a lot of people, again, get really confused because they’re having these thoughts that they hate, they’re unwanted, they’re repetitive, they’re impacting their life, they’re associated with a lot of anxiety and uncertainty, and doubt. And then, now you’re having this reaction in your body too, and that groinal response can create a heightened need to engage in compulsions.  As we know—we talk about this in ERP School, our online course for OCD; we go through this extensively—when someone has an obsession, a thought, an intrusive thought, it creates uncertainty and anxiety. And then naturally what we do is we engage in a compulsion to reduce or remove that discomfort to give them a short-term sense of relief. But then what ends up happening is that short-term relief ends up reinforcing the original obsession, which means you have it more, and then you go back through the cycle. You cycle on that cycle over and over again. It gets so big. It ends up impacting your life so, so much. INTRUSIVE SEXUAL URGES Now, let’s also address while we’re here that a lot of you may have intrusive sexual urges. These are also obsessions that we have when you have OCD or OCD-related disorders where you feel like your body is pulling you towards an action to harm someone, to do a sexual act, to some fantasy. You’re having this urge that feels like your body is pulling you like a magnet towards that behavior. Even if you don’t want to do that behavior, or even if that behavior disgusts you and it doesn’t line up with your values, you may still experience these sexual OCD urges that really make you feel like you’re on the cusp of losing control, that you may snap and do that behavior. This is how impactful these sexual intrusive thoughts can be. This is how powerful they can be in that they can create these layers upon layers. You have the thoughts, then you have the feelings, then you have the sensations, you also have the urges. Often there’s a lot of sexual intrusive images as well, like you see in front of you, like a projector, the image happening or the movie scene playing out that really scares you, concerns you, and so forth. And then all of those layers together make you feel absolutely horrible, terrified, so afraid, so unsure of what’s happening in and of yourself.  TYPES OF SEXUAL OCD OBSESSIONS Let’s talk about some specific OCD obsessions and ways in which this plays out. Now, in the OCD field, we call them subtypes. Subtypes are different categories we have of obsessions. They don’t collect all of them. There are people who have a lot of obsessions that don’t fall under these categories, but these subtypes usually include groups of people who experience these subtypes. The reason we do that is, number one, it can be very validating to know that other people are in that subgroup. Number two, it can also really help inform treatment when we have a specific subtype that we know what’s happening, and that can be very helpful and reduce the shame of the person experiencing them.  1. SEXUAL ORIENTATION OBSESSIONS OR SEXUAL ORIENTATION OCD It used to be called homosexual OCD. That was because predominantly people who were heterosexual were reporting having thoughts or sexual intrusive thoughts about their sexual orientation—am I gay, am I straight—and really struggling with having certainty about this. Again, now that we’re more inclusive and that I think a lot more people are talking about sexuality, that we have a lot less shame, a lot more education, we scrapped the homosexual OCD or homosexual obsessions or subtype category. Now we have a more inclusive category, which is called sexual orientation OCD. That can include any body of any sexual orientation who has doubt and uncertainty about that.  Now remember when we started, we talked about the fact that sexual intrusive thoughts are usually unwanted, they’re repetitive and they don’t line up with our values. What we are not talking about here is someone who is actually questioning their sexual orientation. I know a lot of people are. They’re really exploring and being curious about different orientations that appeal to them. That’s way different to the people who have sexual orientation OCD or sexual orientation obsessions. People with OCD are absolutely terrified of this unknown answer, and they feel an incredible sense of urgency to solve it.  If you experience this, you may actually want to listen back. We’ve got a couple of episodes on this in the past. But it’s really important to understand and we have to understand the nuance here that as you’re doing treatment, we are very careful not to just sweep people under the rug and say, “This is your OCD,” because we want to be informed in knowing that, okay, you also do get to question your sexual orientation. But if it is a presentation of sexual orientation OCD, we will treat it like that and we will be very specific in reducing the compulsions that you’re engaging in so that you can get some relief. That is the first one.  2. SEXUAL INTRUSIVE THOUGHTS ABOUT FAMILY OR SEXUAL INTRUSIVE THOUGHTS ABOUT INCEST Incest sexual OCD or that type of subtype is another very common one. But often, again, one that is not talked about enough in fear of being judged, in fear of having too much shame, in fear of being reported. When people have these types of obsessions, they often will have a thought like, “What if I’m attracted to my dad?” Or maybe they’re with their sibling and they experience some arousal for reasons they don’t know. Again, we talked about this in the arousal and anxiety episode, so go back and listen to that if you didn’t. They may experience that, and that is where they will often say, “My brain broke. I feel like I had to solve that answer. I had to figure it out. I need to get complete certainty that that is not the case, and I need to know for sure.”  The important thing to remember here is a lot of my patients, I will see and they may have some of these sexual intrusive thoughts, but their partners will say, “Yeah, I’ve had the same thoughts.” It’s just that for the person without OCD, they don’t experience that same degree of distress. They blow it off. It doesn’t really land in their brain. It’s just like a fleeting thought. Whereas people with OCD, it’s like the record got stuck and it’s just repeating, repeating, repeating. The distress gets higher. The doubt and uncertainty get higher. Therefore, because of all of this bubbling kettle happening, there’s this really strong urgency to relieve it with compulsions.  3. SEXUAL INTRUSIVE THOUGHTS ABOUT GOD OR ABOUT A RELIGIOUS LEADER This is one that’s less common, or should I say less commonly reported. We actually don’t have evidence of how common it is. I think a lot of people have so much shame and are so afraid of sinning and what that means that they may even not report it. But again, this is no different to having thoughts of incest, but this one is particularly focused on having sexual thoughts about God and needing to know what that means and trying to cleanse themselves of their perceived sin, of having that intrusive thought. It can make them question their religion. It can make them feel like they have to stop going to church. They may do a ton of compulsive prayer. They may do a ton of reassurance with certain religious leaders to make sure that they’re not sinning or to relieve them of that uncertainty and that distaste and distress. These are all very common symptoms of people who have sexual intrusive thoughts about God. 4. BESTIALITY OBSESSIONS These are thoughts about pets and animals, and it’s very common. It’s funny, as we speak, I am recording this with a three-pound puppy sitting on my lap. We just got a three-pound puppy. It is a Malti-Poo puppy dog, and he’s the cutest thing you’ve ever seen. But it’s true that when you have a dog, you’re having to take care of its genitals and wipe it up and its feces and its urine and clean and all the things, and it’s common to have sexual intrusive thoughts about your pet or about your dog or your cat. Some people, again, with bestiality obsessions or bestiality OCD, have a tremendous repetitive degree of these thoughts. They’re very distressing because they love their dog. They would never do anything to hurt their dog, but they can’t stop having these thoughts or these feelings or these sensations, or even these urges. Again, all these presentations are the same, it’s just that the content is different. We treat them the same when we’re discussing it, but we’re very careful with addressing the high level of shame and embarrassment, humiliation, guilt that they have for these thoughts. Guilt is a huge one with these sexual obsessions. People often feel incredibly guilty as if they’ve done something wrong for having these obsessions. These are a few.  5. PEDOPHILIA OBSESSIONS Now, for someone who has intrusive sexual thoughts and feelings and sensations and urges about children (POCD), they tend to be, in my experience, the most distressed. They tend to be, when I see them, the ones who come in absolutely completely taken over with guilt and shame. A lot of the time, they will have completely removed themselves from their child. They feel they’re not responsible. They won’t go near the parks. They won’t go to family’s birthday parties. They’re so insistent on trying to never have these thoughts. Again, I understand. I don’t blame them. But as we know, the more you try not to have a thought, what happens? The more you have it. The more you try and suppress a thought, the more you have it. That can get people in a very stuck cycle.  SEXUAL OCD  COMPULSIONS Let’s move on now to really address different sexual OCD compulsions.  Now, for all sexual obsessions, or what I should say is, for all obsessions in general, there are specific categories of compulsions and these are things again that we do to reduce or remove the discomfort and certainty, dread, doubt, and so forth.  1. Trigger Avoidance This is where you avoid the thing that may trigger your obsession or thought. Avoiding your dog, avoiding your child, avoiding your family member, avoiding people of the sexual orientation that you’re having uncertainty about.  2. Actual Sex Avoidance We talked about that in the first episode. We talked a lot about how people avoid sex because of the anxiety that being intimate and sexual causes.  3. Mental Rumination This is a really common one for sexual intrusive thoughts because you just want to solve like why am I having it? What does it mean? You might be ruminating, what could that mean? And going over and over and over that a many, many time.  4. Mental Checking What you can also be doing here is checking for arousal. Next time you’re around, let’s say, a dog and you have bestiality obsessions, you might check to see if you’re aroused. But just checking to see if you’re aroused means that you get aroused. Now that you’re aroused, you’re now checking to see what that means and trying to figure that out and you’re very distressed.  We can see how often the compulsion that the person does actually triggers more and more and more distress. It may provide you a moment or a fleeting moment of relief, but then you actually have more distress. It usually brings on more uncertainty. We know that the more we try and control life, the more out of control we feel. That’s a general rule. That’s very much the case for these types of obsessive thoughts.  5. Pornography Use A lot of people who have sexual orientation OCD in particular, but any of these, they may actually use pornography as a way to get reassurance that they are of a certain sexual orientation, that they are not attracted to the orientation that they’re having uncertainty about, or they’re not attracted to animals or God or a family member because they were aroused watching pornography. That becomes a form of self-reassurance.  There’s two types of reassurance. One is reassurance where we go to somebody else and say, “Are you sure I wouldn’t do that thing? Are you sure that thing isn’t true? Are you sure I don’t have that? I’m not that bad a person?” The other one is really giving reassurance to yourself, and that’s a very common one with pornography use.  SEXUAL INTRUSIVE THOUGHTS PTSD  There are some sexual intrusive thought examples, including specific obsessions and subtypes, and also compulsions. But one sexual intrusive thought example I also wanted to address is not OCD-related; it’s actually related to a different diagnosis, which is called PTSD (post-traumatic stress disorder). Often for people who have been sexually assaulted or molested, they too may experience sexual intrusive thoughts in the form of memories or images of what happened to them or what could have happened to them. Maybe it’s often some version of what happened to them, and that is a common presentation for PTSD. If you are experiencing PTSD, usually, there is a traumatic event that is related to the obsession or the thoughts. They usually are in association or accompanied by flashbacks. There are many other symptoms. I’m not a PTSD specialist, but there’s a high level of distress, many nightmares. You may have flashbacks, as I’ve said. Panic is a huge part of PTSD as well. That is common. If you have had a traumatic event, I would go and see a specialist and help them to make sure that they’ve diagnosed you correctly so that you can get the correct care.  SEXUAL INTRUSIVE THOUGHTS TREATMENT If you have OCD and you’re having some of these sexual intrusive thoughts, the best treatment for you to go and get immediately is Exposure and Response Prevention. This is a particular type of cognitive behavioral therapy where you can learn to change your reaction, break yourself out of that cycle of obsessions, anxiety, compulsions, and then feed yourself back into the loop around and around. You can break that cycle and return back to doing the things you want and have a different reaction to the thoughts that you have. PEOPLE ASK HOW TO STOP SEXUAL INTRUSIVE THOUGHTS?  Often people will come to me and say, “How do I stop these sexual intrusive thoughts?” I will quickly say to them, “You don’t. The more you try and stop them, the more you’re going to have. But what we can do is we can act very skillfully in intervening, not by preventing the thoughts, but by changing how we relate and respond to those thoughts.” For those of you who don’t know, I have a whole course on this called ERP School. ERP is for Exposure and Response Prevention. I’ll show you how you can do this on your own, or you can reach out to me and we can talk about whether if you’re in the states where we’re licensed, one of my associates can help you one-on-one. If you’re not in a state where I belong, reach out to the IOCDF and see if you can find someone who treats OCD using ERP in your area. Because the truth is, you don’t have to suffer having these thoughts. There is a treatment to help you manage these thoughts and help you be much more comfortable in response to those thoughts. Of course, the truth here is you’re never going to like them. Nobody likes these thoughts. The goal isn’t to like them. The goal isn’t to make them go away. The goal isn’t to prove them wrong even; it’s just to change your reaction to one that doesn’t keep that cycle going. That is the key component when it comes to sexual intrusive thoughts treatment or OCD treatment. That’s true for any subtype of OCD because there are many other subtypes as well.  That’s it, guys. I could go on and on and on and on about this, but I want to be respectful of your time. The main goal again is just to normalize that these thoughts happen. For some people, it happens more than others. The goal, if you can take one thing away from today, it would be, try not to assign meaning to the duration and frequency of which you have these thoughts. Often people will say, “I have them all day. That has to mean something.” I’m here to say, “Let’s not assign meaning to these thoughts at all. Thoughts are thoughts. They come and they go. They don’t have meaning and we want to practice not assigning meaning to them so we don’t strengthen that cycle.”  I hope that was helpful for you guys. I know it was a ton of information. I hope it was super, super helpful. I am so excited to continue with this.  Next week, we are talking about menopause and anxiety, which we have an amazing doctor again. I want to talk about things with people who are really skilled in this area. We have a medical doctor coming on talking about menopause and the impact of anxiety. And then we’re going to talk about PMS and anxiety, and that will hopefully conclude our sexual health and anxiety series.  Thank you so much for being here. I love you guys so much. Thank you from me and from Theo, our beautiful little baby puppy. I will see you next week.

Hello and welcome back everybody. We are on Week 3 of the Sexual Health and Anxiety Series. At first, we talked with the amazing Lauren Fogel Mersy about sexual anxiety or sexual performance anxiety. And then last week, I went into depth about really understanding arousal and anxiety, how certain things will increase arousal, certain things will decrease it, and teaching you how to get to know what is what so that you can have a rich, intimate, fulfilling life.  We are now on Week 3. I have to admit, this is an episode that I so have wanted to do for quite a while, mainly because I get asked these questions so often and I actually don’t know the answers. It’s actually out of my scope. In clinical terms, we call it “out of my scope of practice,” meaning the topic we’re talking about today is out of my skill set. It’s out of my pay grade. It’s out of my level of training.  What we’re talking about this week is the sexual side effects of antidepressants or anxiety medications, the common ones that people have when they are anxious or depressed. Now, as I said to you, this is a medical topic, one in which I am not trained to talk about, so I invited Dr. Sepehr Aziz onto the episode, and he does such a beautiful job, a respectful, kind, compassionate approach to addressing sexual side effects of anxiety medication, sexual side effects of depression medication. It’s just beautiful. It’s just so beautiful. I feel like I want to almost hand this episode off to every patient when I first start treating them, because I think so often when we’re either on medication or we’re considering medication, this is a really common concern, one in which people often aren’t game to discuss. So, here we are. I’m actually going to leave it right to the doctor, leave it to the pro to talk all about sexual side effects and what you can do, and how you may discuss this with your medical provider. Let’s do it. Kimberley: Welcome. I have been wanting to do this interview for so long. I am so excited to have with us Dr. Sepehr Aziz. Thank you so much for being here with us today. Dr. Aziz: Thanks for having me. Kimberley: Okay. I have so many questions we’re going to get through as much as we can. Before we get started, just tell us a little about you and your background, and tell us what you want to tell us. Dr. Aziz: Sure. Again, I’m Dr. Sepehr Aziz. I go by “Shepherd,” so you can go ahead and call me Shep if you’d like. I’m a psychiatrist. I’m board certified in general adult psychiatry as well as child and adolescent psychiatry by the American Board of Psychiatry and Neurology. I completed medical school and did my residency in UMass where they originally developed mindfulness-based CBT and MBSR. And then I completed my Child and Adolescent training at UCSF. I’ve been working since then at USC as a Clinical Assistant Professor of Psychiatry there. I see a lot of OCD patients. I do specialize in anxiety disorders and ADHD as well. Kimberley: Which is why you’re the perfect person for this job today. Dr. Aziz: Thank you.  WHAT ARE THE BEST MEDICATIONS FOR PEOPLE WITH ANXIETY & OCD (IN GENERAL)? Kimberley: I thank you so much for being here. I want to get straight into the big questions that I get asked so regularly and I don’t feel qualified to answer myself. What are the best medications for people with anxiety and OCD? Is there a general go-to? Can you give me some explanation on that? Dr. Aziz: As part of my practice, I first and foremost always try to let patients know that the best treatment is always a combination of therapy as well as medications. It’s really important to pursue therapy because medications can treat things and they can make it easier to tolerate your anxiety, but ultimately, in order to have sustained change, you really want to have therapy as well. Now, the first-line medications for anxiety and OCD are the same, and that’s SSRIs or selective serotonin reuptake inhibitors. SNRIs, which are selective norepinephrine reuptake inhibitors, also work generally, but the best research that we have in the literature is on SSRIs, and that’s why they’re usually preferred first. There are other medications that also might work, but these are usually first-line, as we call it. There are no specific SSRIs that might work better. We’ve tried some head-to-head trials sometimes, but there’s no one medication that works better than others. It’s just tailored depending on the patient and the different side effects of the medication. SSRI’S VS ANTIDEPRESSANTS DEFINITION Kimberley: Right. Just so people are clear in SSRI, a lot of people, and I notice, use the term antidepressant. Are they synonymous or are they different? Dr. Aziz: Originally, they were called antidepressants when they first were released because that was the indication. There was an epidemic of depression and we were really badly looking for medications that would work. Started out with tricyclic antidepressants and then we had MAOIs, and then eventually, we developed SSRIs. These all fall under antidepressant treatments. However, later on, we realized that they work very well for anxiety in addition to depression. Actually, in my opinion, they work better for anxiety than they do for depression. I generally shy away from referring to them as antidepressants just to reduce the stigma around them a little bit and also to be more accurate in the way that I talk about them. But yes, they’re synonymous, you could say.  BEST MEDICATION FOR DEPRESSION Kimberley: Sure. Thank you for clearing that up because that’s a question I often get. I know I led you in a direction away but you answered. What is the best medication for people with depression then? Is it those SSRIs or would you go-- Dr. Aziz: Again, these are first-line medications, which means it’s the first medication we would try if we’re starting medication, which is SSRIs. Other medications might also work like SNRIs again. For depression specifically, there are medications called serotonin modulators that are also effective such as vortioxetine or nefazodone, or vilazodone. But SSRIs are generally what people reach for first just because they’ve been around for a long time, they’re available generic, they work, and there’s no evidence that the newer medications or modulators work better. They’re usually first line. Kimberley: Fantastic. Now you brought up the term “generic” and I think that that’s an important topic because the cost of therapy is high. A lot of people may be wondering, is the generic as good as the non-generic options? Dr. Aziz: It really depends on the medication and it also depends on which country you’re in. In the US, we have pretty strict laws as to how closely a generic has to be to a regular medication, a brand name medication, and there’s a margin of error that they allow. The margin of error for generics is, I believe, a little bit higher than for the brand name. However, most of the time, it’s pretty close. For something like Lexapro, I usually don’t have any pressure on myself to prescribe the brand name over the generic. For something like other medications we use in psychiatry that might have a specific way that the brand name is released, a non-anxiety example is Concerta, which is for ADHD. This medication uses an osmotic release mechanism and that’s proprietary. They license it out to one generic company, but that license is expiring. All those patients who are on that generic in the next month or two are going to notice a difference in the way that the medication is released. Unless you’re a physician privy to that information, you might not even know that that’s going to happen. That’s where you see a big change. Otherwise, for most of the antidepressants, I haven’t noticed a big difference between generic and brand names.   Kimberley: Right. Super helpful. Now you mentioned it depends on the person. How might one decide or who does decide what medication they would go on? Dr. Aziz: It’s really something that needs to be discussed between the person and their psychiatrist. There are a number of variables that go into that, such as what’s worked in a family member in the past, because there are genetic factors in hepatic metabolism and things like that that give us some clue as to what might work. Or sometimes if I have a patient with co-occurring ADHD and I know they’re going to be missing their medications a lot, I’m more likely to prescribe them Prozac because it has a longer half-life, so it’ll last longer. If they miss a dose or two, it’s not as big of a deal. If I have a patient who’s very nervous about getting off of the medication when they get pregnant, I would avoid Prozac because it has a long half-life and it would take longer to come off of the medication. Some medications like Prozac and Zoloft are more likely to cause insomnia or agitation in younger people, so I’ll take that into consideration. Some medications have a higher likelihood of causing weight loss versus weight gain. These are all things that would take into consideration in order to tailor it to the specific patient. Kimberley: Right. I think that’s been my experience too. They will usually ask, do you have a sibling or a parent that tried a certain medication, and was that helpful? I love that question. I think it informs a lot of decisions. We’re here really. The main goal of today is really to talk about one particular set of side effects, which is the sexual side effects of medication. In fact, I think most commonly with clients of mine, that tends to be the first thing they’re afraid of having to happen. How common are sexual side effects? Is it in fact all hype or is it something that is actually a concern? How would you explain the prevalence of the side effects? Dr. Aziz: This is a really important topic, I just want to say, because it is something that I feel is neglected when patients are talking to physicians, and that’s just because it can be uncomfortable to talk about these things sometimes, both for physicians and for patients. Oftentimes, it’s avoided almost. But because of that, we don’t know for sure exactly what the incidence rate is. The literature on this and the research on this is not very accurate for a number of reasons. There are limitations. The range is somewhere between 15 to 80% and the best estimate is about 50%. But I don’t even like saying that because it really depends on age, gender, what other co-occurring disorders they have such as depression. Unipolar depression can also cause sexual dysfunction. They don’t always take that into account in these studies. A lot of the studies don’t ask baseline sexual function before asking if there’s dysfunction after starting a medication, so it’s hard to tell. What I can say for sure, and this is what I tell my patients, is that this sexual dysfunction is the number one reason why people stop taking the medication, because of adverse effects.  WHAT MEDICATIONS ARE MORE PRONE TO SEXUAL SIDE EFFECTS?  Kimberley: Right. It’s interesting you say that we actually don’t know, and it is true. I’ve had clients say having anxiety has sexual side effects too, having depression has sexual side effects too, and they’re weighing the pros and cons of going on medication comparative to when you’re depressed, you may not have any sexual drive as well. Are some medications more prone to these sexual side effects? Does that help inform your decision on what you prescribe because of certain meds? Dr. Aziz: Yeah. I mean, the SSRIs specifically are the ones that are most likely to cause sexual side effects. Technically, it’s the tricyclics, but no one really prescribes those in high doses anymore. It’s very rare. They’re the number one. But in terms of the more commonly prescribed antidepressants and anti-anxiety medications among the SSRIs and the SNRIs and the things like bupropion and the serotonin modulators we talked about, the SSRIs are most likely to cause sexual dysfunction. Kimberley: Right. Forgive me for my lack of knowledge here, I just want to make sure I’m understanding this. What about the medications like Xanax and the more panic-related medications? Is that underneath this category? Can you just explain that to me? Dr. Aziz: I don’t usually include those in this category. Those medications work for anxiety technically, but in current standard practice, we don’t start them as an initial medication for anxiety disorders because there’s a physical dependency that can occur and then it becomes hard to come off of the medication. They’re used more for panic as an episodic abortive medication when someone is in the middle of a panic attack, or in certain cases of anxiety that’s not responding well to more conventional treatment, we’ll start it. We’ll start it on top of or instead of those medications. They can cause sexual side effects, but it’s not the same and it’s much less likely.  SEXUAL SIDE EFFECTS OF MEDICATION FOR MEN VS WOMEN  Kimberley: Okay. Very helpful. Is it the same? I know you said we don’t have a lot of data, and I think that’s true because of the stigma around reporting sexual side effects, or even just talking about sex in general. Do we have any data on whether it impacts men more than women? Dr. Aziz: The data shows that women report more sexual side effects, but we believe that’s because women are more likely to be treated with SSRIs. When we’re looking at the per capita, we don’t have good numbers in terms of that. In my own practice, I’d say it’s pretty equal. I feel like men might complain about it more, but again, I’m a man and so it might just be a comfort thing of reporting it to me versus not reporting. Although I try to be good about asking before and after I start medication, which is very important to do. But again, it doesn’t happen all the time. Kimberley: Yeah, it’s interesting, isn’t it? Because from my experience as a clinician, not a psychiatrist, and this is very anecdotal, I’ve heard men because of not the stigma, but the pressure to have a full erection and to be very hard, that there’s a certain masculinity that’s very much vulnerable when they have sexual side effects—I’ve heard that to be very distressing. In my experience. I’ve had women be really disappointed in the sexual side effects, but I didn’t feel that... I mean, that’s not really entirely true because I think there’s shame on both ends. Do you notice that the expectations on gender impacts how much people report or the distress that they have about the sexual side effects?  Dr. Aziz: Definitely. I think, like you said, men feel more shame when it comes to sexual side effects. For women, it’s more annoyance. We haven’t really talked about what the sexual side effects are, but that also differs between the sexes. Something that’s the same between sexes, it takes longer to achieve orgasm or climax. In some cases, you can’t. For men, it can cause erectile dysfunction or low libido. For women, it can also cause low libido or lack of lubrication, which can also lead to pain on penetration or pain when you’re having sex. These are differences between the sexes that can cause different reporting and different feelings, really. Kimberley: Right. That’s interesting that it’s showing up in that. It really sounds like it impacts all the areas of sexual playfulness and sexual activity, the arousal, the lubrication. That’s true for men too, by the sounds of it. Is that correct?  Dr. Aziz: Yeah.  Kimberley: We’ve already done one episode about the sexual performance anxiety, and I’m sure it probably adds to performance anxiety when that’s not going well as well, correct? Dr. Aziz: It’s interesting because in my practice, when I identify that someone is having sexual performance anxiety or I feel like somebody, especially people with anxiety disorders, if I feel like they have vulvodynia, which means pain on penetration—if I see they have vulvodynia and I feel that this is because of the anxiety, oftentimes the SSRI might improve that and cause greater satisfaction from sex. It’s a double-edged sword here. COMMON SEXUAL SIDE EFFECTS OF ANTIDEPRESSANTS Kimberley: Yeah. Can you tell me a little more about What symptoms are they having? The pain? What was it called again? Dr. Aziz: Vulvodynia. Kimberley: Is that for men and women? Just for women, I’m assuming. Dr. Aziz: Just from vulva, it is referring to the outside of the female genitalia. Especially when you have a lack of lubrication or sometimes the muscles, everyone with anxiety knows sometimes you have muscle tension and there are a lot of complex muscles in the pelvic floor. Sometimes this can cause pain when you’re having sex. There are different ways to address that, but SSRIs sometimes can improve that.  Kimberley: Wow. It can improve it, and sometimes it can create a side effect as well, and it’s just a matter of trial and error, would you say? Dr. Aziz: It’s a delicate balance because these side effects are also dose-dependent. It’s not like black or white. I start someone on 5 milligrams, which is a child’s dose of Lexapro. Either they have sexual side effects or don’t. They might not have it on 5, and then they might have it a little bit on 10, and then they get to 20 and they’re like, “Doctor, I can’t have orgasms anymore.” We try to find the balance between improving the anxiety and avoiding side effects. SEXUAL SIDE EFFECTS TREATMENT Kimberley: You’re going right into the big question, which is, when someone does have side effects, is it the first line of response to look at the dose? Or how would you handle a case if someone came to you first and said, “I’m having sexual side effects, what can we do?”  Dr. Aziz: Again, I’m really thorough personally. Before I even seem to start a medication, I’ll ask about libido and erectile dysfunction and ability to climax and things like that, so I have a baseline. That’s important when you are thinking about making a change to someone’s medications. The other thing that’s important is, is the medication working for them? If they haven’t seen a big difference since they started the medication, I might change the medication. If they’ve seen an improvement, now there’s a pressure on me to keep the medication on because it’s working and helping. I might augment it with a second medication that’ll help reverse the sexual side effects or I might think about reducing the dose a little bit while maintaining somewhere in the therapeutic zone of doses or I might recommend, and I always recommend non-pharmacological ways of addressing sexual side effects. You always do that at baseline. Kimberley: What would that be? Dr. Aziz: There’s watchful waiting. Sometimes if you just wait and give it some time, these symptoms can get better. I’m a little more active than that. I’ll say it’s not just waiting, but it’s waiting and practicing, whether that’s solo practice or with your partner. Sometimes planning sex helps, especially if you have low libido. There’s something about the anticipation that can make someone more excited. The use of different aids for sex such as toys, vibrators, or pornography, whether that’s pornographic novels or imagery, can sometimes help with the libido issues and also improve satisfaction for both partners. The other thing which doesn’t have great research, but there is a small research study on this, and not a lot of people know about this, but if you exercise about an hour before sex, you’re more likely to achieve climax. This was specifically studied in people with SSRI-related anorgasmia. Kimberley: Interesting. I’m assuming too, like lubricants, oils, and things like that as well, or? Dr. Aziz: For lubrication issues, yes. Lubricants, oils, and again, you really have to give people psychoeducation on which ones they have to use, which ones they have to avoid, which ones interact with condoms, and which ones don’t. But you would recommend those as well. Kimberley: Is it a normal practice to also refer for sex therapy? If the medication is helping their symptoms, depression, anxiety, OCD, would you ever refer to sex therapy to help with that? Is that a standard practice or is that for specific diagnoses, like you said, with the pain around the vulva and so forth? Dr. Aziz: Absolutely. A lot of the things I just talked about are part of sex therapy and they’re part of the sexual education that you would receive when you go to a sex therapist. I happen to be comfortable talking about these things, and I’ve experienced talking about it. When I write my notes, that would fall under me doing therapy. But a lot of psychiatrists would refer to a sex therapist. Hopefully, there are some in the town nearby where someone is. It’s sometimes hard to find someone that specializes in that. Kimberley: Is there some pushback with that? I mean, I know when I’ve had patients and they’re having some sexual dysfunction and they do have some pushback that they feel a lot of shame around using vibrators or toys. Do you notice a more willingness to try that because they want to stay on the meds? Or is it still very difficult for them to consider trying these additional things? Are they more likely to just say, “No, the meds are the problem, I want to go off the medication”? Dr. Aziz: It really depends on the patient. In my population that I see, I work at USC on campus, so I only see university students in my USC practice. My age group is like 18 to 40. Generally, people are pretty receptive. Obviously, it’s very delicate to speak to some people who have undergone sexual trauma in the past. Again, since I’m a man, sometimes speaking to a woman who’s had sexual trauma can be triggering. It’s a very delicate way that you have to speak and sometimes there’s some pushback or resistance. It can really be bad for the patient because they’re having a problem and they’re uncomfortable talking about it. There might be a shortage of female psychiatrists for me to refer to. We see that. There’s also a portion of the population that’s just generally uncomfortable with this, especially people who are more religious might be uncomfortable talking about this and you have to approach that from a certain angle. I happen to also be specialized in cultural psychiatry, so I deal with these things a lot, approaching things from a very specific cultural approach, culturally informative approach. Definitely, you see resistance in many populations. Kimberley: I think that that’s so true. One thing I want to ask you, which I probably should have asked you before, is what would you say to the person who wants to try meds but is afraid of the potential of side effects? Is there a certain spiel or way in which you educate them to help them understand the risks or the benefits? How do you go about that for those who there’s no sexual side effects, they’re just afraid of the possibility? Dr. Aziz: As part of my practice, I give as much informed consent to my patients as I can. I let them know what might happen and how that’s going to look afterwards. Once it happens, what would we do about it if it happened? A lot of times, especially patients with anxiety, you catastrophize and you feel this fear of some potential bad thing happening, and you never go past that. You never ask yourself, okay, well now let’s imagine that happens. What happens next? I tell my patients, “Yeah, you might have sexual dysfunction, but if that happens, we can reduce the medications or stop them and they’ll go away.” I also have to tell my patients that if they search the internet, there are many people who have sexual side effects, which didn’t go away, and who are very upset about it. This is something that is talked about on Reddit, on Twitter. When my patients go to Dr. Google and do their research, they often get really scared. “Doctor, what if this happens and it doesn’t go away?” I always try to explain to them, I have hundreds of patients that I’ve treated with these medications. In my practice, that’s never happened. As far as I know from the literature, there are no studies that show that there are permanent dysfunctions sexually because of SSRIs.  Now, like I said, the research is not complete, but everything that I’ve read has been anecdotal. My feeling is that if you address these things in the beginning and you’re diligent in asking about the side effects of baseline sexual function beforehand and you are comfortable talking with your patients about it, you can avoid this completely. That’s been my experience. When I explain that to my patients, they feel like I have their back, like they’re protected, like I’m not just going to let them fall through the cracks. That has worked for me very well. Kimberley: Right. It sounds like you give them some hope too, that this can be a positive experience, that this could be a great next step. Dr. Aziz: Yeah, absolutely. Kimberley: Thank you for bringing up Dr. Google, because referring to Reddit for anything psychologically related is not a great idea, I will say. Definitely, when it comes to medications, I think another thing that I see a lot that’s interesting on social media is I often will get dozens of questions saying, “I heard such and such works. Have your clients taken this medication? I heard this medication doesn’t work. What’s your experience?” Or if I’ve told them about my own personal experience, they want to know all about it because that will help inform their decision. Would you agree, do not get your information from social media or online at all? Dr. Aziz: I have patients who come to me and they’re like, “My friend took Lexapro and said it was the worst thing in the world, and it may or not feel any emotions.” I’m explaining to them, I literally have hundreds of patients, hundreds that I prescribe this to, and I go up and down on the dose. I talk to them about their intimate lives all day. But for some reason, and it makes sense, the word of their friend or someone close to them, really, carries a lot of weight. Also, I don’t want to discount Reddit either, because I feel like it’s as a support system and as a support group. I find other people who have gone through what you’ve gone through. It’s very strong. Even pages like-- I don’t want to say the page, but there’s a page that’s against psychiatry, and I peruse this page a lot because I have my own qualms about psychiatry sometimes. I know the pharmaceutical companies have a certain pressure on themselves financially, and I know hospitals have a certain pressure on themselves. I get it. I go on the page and there’s a lot of people who have been hurt in the past, and it’s useful for patients to see other people who share that feeling and to get support. But at the same time, it’s important to find providers that you can trust and to have strong critical thinking skills, and be able to advocate for yourself while still listening to somebody who might have more information than you. Kimberley: I’m so grateful you mentioned that. I do think that that is true. I think it’s also what I try to remember when I am online. The people who haven’t had a bad experience aren’t posting on Reddit. They’re out having a great time because it helped, the medication helped them, and they just want to move on. I really respect those who have a bad experience. They feel the need to educate. But I don’t think it’s that 50% who gave a great experience are on Reddit either. Would you agree? Dr. Aziz: Right. Yeah. The people who are having great outcomes are not creating a Reddit page to go talk about it, right? Kimberley: Yeah. Thank you so much for answering all my questions. Is there a general message that you want to give? Maybe it’s even saying it once over on something you’ve said before. What would be your final message for people who are listening? WHEN SSRIs IMPACTS YOUR SEX LIFE: ADVICE FROM DR AZIZ Dr. Aziz: I just want to say that when SSRI’s impact your sex life, it’s really important for psychiatry, and especially in therapy, that you feel comfortable sharing your experiences in that room. It should be a safe space where you feel comfortable talking about your feelings at home and what’s going on in your intimate life and how things are affecting you. Your feelings, positive or negative towards your therapist or your psychiatrist, whether things they said made you uncomfortable, whether you feel they’re avoiding something, that room should be a safe space for you to be as open as possible. When you are as open as possible, that’s when you’re going to get the best care because your provider, especially in mental health, needs to know the whole picture of what’s going on in your life. Oftentimes, we are just as uncomfortable as you. And so, again, a lot of providers might avoid it because they’re afraid of offending you by asking about your orgasms. As a patient, you take the initiative and you bring it up. It’s going to improve your care. Try not to be afraid of bringing these things up. If you do feel uncomfortable for any reason, always let your provider know.  I always tell my patients, I have a therapist. I pay a lot of money to see my therapist, and sometimes I tell him things I hate about him. He’s a great therapist. He’s psychoanalytic. Every time I bring something up, he brings it back to something about my dad. He’s way older than me. But he’s a great therapist. Every time I’ve brought something like that up, it’s been a breakthrough for me because that feeling means something. That would be my main message to everyone listening. Kimberley: Thank you. I’m so grateful for your time and your expertise. Really, thank you. Can you tell us where people can get in touch with you, seek out your services, read more about you? Dr. Aziz: Sure. I work for OCD SoCal. I’m on the executive board, and that’s the main way I like to communicate with people who see me on programs like this. You can always email me at S, like my first name, Aziz, that’s A-Z-I-Z, @OCDSoCal.org. If you’re a USC student, you can call Student Health and request to see me at the PBHS clinic. That’s the Psychiatry and Behavioral Health Services clinic on campus at USC. Kimberley: They’re lucky to have you. Dr. Aziz: Thank you. Kimberley: Yes. I love that you’re there. Thank you so much for all of your expertise. I am so grateful. This has been so helpful.