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

SUMMARY: In this weeks podcast, we talk with Dr Jon Grayson about managing mental compulsions. Jon talks about how to use Acceptance to manage strong intrusive thoughts and other obsessions. Jon addressed how to use acceptance with OCD, GAD and other Anxiety disorders. Covered in This Episode: What is a Mental Compulsion? What is the difference between Mental Rumination and Mental Compulsions? How to use Acceptance for Mental Compulsions How to practice acceptance when the intrusive thoughts are so strong. Links To Things I Talk About: Jon’s Book Freedom from Obsessive Compulsive Disorder: A Personalized Recovery Program for Living with Uncertainty Jon’s Website https://www.laocdtreatment.com/ ERP School: https://www.cbtschool.com/erp-school-lp Episode Sponsor: This episode of Your Anxiety Toolkit is brought to you by CBTschool.com. CBTschool.com is a psychoeducation platform that provides courses and other online resources for people with anxiety, OCD, and Body-Focused Repetitive Behaviors. Go to cbtschool.com to learn more. Spread the love! Everyone needs tools for anxiety... If you like Your Anxiety Toolkit Podcast, visit YOUR ANXIETY TOOLKIT PODCAST to subscribe free and you'll never miss an episode. And if you really like Your Anxiety Toolkit, I'd appreciate you telling a friend (maybe even two). EPISODE TRANSCRIPTION This is Your Anxiety Toolkit Episode - 285. Welcome back, everybody. We are on episode three of the six-part series. And if you have listened to the previous episodes, I am sure you are just full of information, but hopefully ready to hear some more. Today, we have Dr. Jonathan Grayson. He’s here to talk about his specific way of managing mental compulsions. As you may know, if you’ve listened before, I strongly urge you to start and go in order. So, first, we started with Mental Compulsions 101. That was with yours truly, myself. Then Jon Hershfield came in. He talked about mindfulness and really went in, gave some incredible tools. Shala Nicely, again, gave some lived experience and really the tools that worked for her. And I have just been mind-blown with both of their expertise. And it doesn’t stop there. We have amazing Dr. Jonathan Grayson today talking about all of the ways that he manages mental compulsions and how he brings specific concepts to help a client be motivated and lean into that response prevention and to reduce those mental compulsions. I am again blown away with how amazing and respectful and kind and knowledgeable these experts are. I just am overwhelmed with joy to share this with you. Again, please remember this should not replace professional mental health care. We are here at CBT School, who is the host of this series. We’re here to provide you skills and tools, and resources specifically if you don’t have access to those resources. That is a huge part of our mission. So, even though we have ERP School – and that is an online course, you can take it from your home – we wanted to offer this freely because so many people are seeming to be misunderstanding mental compulsions, and it’s an area I really have been excited to share with you in this free series. So, I’m not going to yammer on anymore. I’m going to let you hear the amazing wisdom of Jonathan Grayson. Have a wonderful day. Kimberley: Welcome. I am so honored to have you here, Jon Grayson. Jonathan: It is always a pleasure. Kimberley: Okay. So, I actually am really, really interested to hear your point of view. As we go through a different episode, I actually am learning things. I thought I knew it all, but I’m learning and learning. So, I’m so excited to get your view on managing mental compulsions or how you address them. My first question is, do you call them mental compulsions, mental rituals, rumination? How do you frame it? Jonathan: I’m never really too big on jargony, but mental compulsions are mental rituals. And I think that’s trying to-- and I think the thing about mental rituals is some people don’t know they have them. I mean, some people know, but some people will describe it as, “I just obsess, I don’t have rituals.” but then when you listen, they do. And the ritual part is trying to reassure themselves or convince themselves that whatever it is they’re worrying about isn’t. So, they have both the fear part like, “Oh my God, what if this is true? But wait, here’s why it’s not true. Now I know that’s not really true. But what if it is true?” So, that is what I would call mental compulsion or rituals. Kimberley: Right. How do you-- let’s say you’re sitting across from a patient or a client they are doing either predominantly mental compulsions or that’s a huge part of the symptoms that they have. How would you address in your own way, teaching somebody how to manage mental compulsions? Jonathan: I think there’s two answers to the question because I never have, and one has to do with what is the content, because I believe every set of mental rituals – I believe it for all forms of OCD, whether there’s a very strong behavioral component or it’s all mental – it has its own set of arguments that we’re going to use. Of course, when I talk about arguments, I know this will be a shock to you, but to me, it always has to do with coping with uncertainty, because I think the purpose of mental compulsions is to deny reality. That is, there is something I don’t want to be true and I keep trying to convince myself it’s not true.  Now often it’s a low probability. But low probability is not no probability. Sometimes I have clients a little confused, saying like, “I tell myself it’s low probability,” and they actually feel better. Is that okay? And the answer is, it depends. If I’m trying to convince myself, I don’t have to worry about it because it’s a low probability, no, that’s a ritual. If I’m just saying it’s a low probability, I mean, way actually with OCD, it’s very easy because people don’t mind saying it’s low prob they. They like saying it’s low probability, but they don’t want the last sentence to be “But it might happen.” So, it’s like, as long as you’re answering “It might happen,” then you’re dealing with reality because everything is a low probability, even if it’s really small.  So, one part has to do with the content. And I think for every set of obsessions, there is, what is the content they’re doing? I think in a more general way, the goal of treatment is basically accepting that low probability things might happen. I was recently saying to people that I hope the probability of nuclear war is no worse than that. It was as bad as likely as a worldwide pandemic. Some people would freak out like, “You think there’s going to be a war?” First of all, I know anything, but they were missing the point. It’s like, no, I really mean it’s as likely as a pandemic, which means it’s not likely. However, the thing about the pandemic, low probability things can happen. So yeah, we’re probably okay. And so, the thing about acceptance that everyone hates is acceptance is second best. We spend so much time talking about how great acceptance is and I really think it’s a disservice in some respects to not point out what acceptance means because it almost always is. Here’s something you don’t want that you might have to live with. If I lose a loved one, we start in denial. And for me, denial is defined as I’m comparing life to a fantasy. I have a woman in a bad relationship and she thinks he really loves the guy, but it’s like, he’d be so good if only he would change X, Y, and Z. And of course, if he changed X, Y, and Z, he would be someone else. So, they’re in love with a fantasy. And when somebody dies, the fantasy is life would be better if they were here. It’s a fantasy because that’s never happening again. So, we have to get them to the point.  And of course, the thing, the reason I mentioned death is it points out a really important thing about acceptance. You don’t get to just decide, “I’m going to accept.” I lose a loved one. I don’t care how or where you are. You’re starting in denial because you’re missing them and you want them there. And after about a year, if you’ve gone through mourning, you accept it. It’s not like you don’t care they’re gone. You can still cry. You can still miss them. But when you’re doing something you’re enjoying and in the present not comparing to what it would be with that person.  So, acceptance, I’m pretty sure, always sucks. However, it’s better than fantasy because the fantasies never happen. So, it doesn’t matter if it’s likely or unlikely. It’s just a matter that this is your fear and the thing that’s hard for people to deal with fear is to cope with it. You’re going to say, “How would I try to live with the worst happening?” And people’s initial response to something is, “Yeah, but I don’t want that.” There are multiple reasons that we need to do acceptance. If I’m correct about denial, that’s comparing reality to fantasy. Well, not acceptance means what I want will never happen. So, for me to want that there’s no possibility something will occur is probably not true. I don’t care if it means that maybe this reality doesn’t exist and I’m going to wake up, and some of the things that discover I’ve created all of reality, there’s nothing. I don’t know that that’s likely, but I can’t prove it’s not likely.  So, I think people go in circles. And you can hear it. The thing about the pandemic, you could hear the regular population denial. Because when I say it’s comparing reality to fantasy, a lot of times that sounds cool. And people don’t quite get what it means, but here are statements of denial early in the pandemic, “Well, this can’t go on more than a few weeks.” Honestly, at the beginning, I was like, “Of course, it’s going on for a few weeks. They have to have a vaccination. They’re telling us that’s two years down the road. This is going on for a long time.” Kimberley: I was in team two weeks. Jonathan: Yeah. “It can’t last. I can’t take it.” Saying “I can’t take it,” although you’re expressing the feeling like “I really hate this,” but including in the words “I can’t take it” is a fantasy as if you have a choice. And in a way, luckily, most people who say they can’t take it didn’t kill themselves. It’s proved that they can’t take it. They took it. They kept going on. It’s like, they didn’t want to imagine continuing to live that way. So, acceptance is like, “Yeah, this is going to happen. Yes, it can keep going.” How will you try to cope with the worst? And go on, I’ll shut up. You look like you want to say something. Kimberley: No, no. I’m following you. I’m really enjoying this. I actually wrote down the word “cope” right at the beginning because I think that that’s such a keyword here. To stay out of the fantasy, would you say that’s true? Jonathan: Well, yes. The worst might-- I mean, I always feel like if I’m doing therapy and if somebody has intolerance of uncertainty, they don’t like uncertainty, I have to treat that problem. And what I mean by that is we have a lot of therapists who impose their own feelings on the client. If I have a therapist that I have somebody who’s socially anxious and saying, “I’m afraid if I go in a room, some people won’t like me.” Almost every therapist is going to say, “Oh, well, that’s the fact, they might not like you.” But that same patient is like, “I’m afraid if I touch the doorknob, I’m going to get sick.” “Oh no, that won’t happen.” Well, that’s not the issue. Now therapist is-- if I have a problem of threat estimation, that’s fine, but that’s not it. I don’t want to know that it’s a low probability, I want no probability. So, we have to deal with the fact that this is what the person’s afraid of. This is what they fear.  Somebody will say, “Well, but they don’t have cancer issue. Why should they worry about it?” But let’s face it. If they did have cancer, the focus would be coping with the fact they’re dying. And if they’re afraid of having cancer, I’d say the treatment is the same. Now, the only great thing is they probably won’t have cancer, so it’s not a fear they will have to probably deal with. They want to have the second part of it like, “And I’m dying.” But to be more prepared-- and I think what you’ve done wisely, like hearing that, yes, what you’ve done wisely is you’re talking about the fact that this is not just a nosy problem. This is a problem for everyone, coping with uncertainty.  I hate to do a plug. It’s okay. It’s a while away. Actually, Liz McIngvale and I, we’re working on a book, talking about-- well, the book is partially-- and we’ll be doing some talks on it. We’re saying that ERP is not the gold standard of treatment for OCD. And we’re going to say that it’s not the gold standard because it’s lacking the gold. It really needs to be ERP plus gold. But that’s awkward because I like to be calling these initials. So, we want to use initials. Do you happen to know the chemical symbol for gold? Kimberley: F-- no. FE is copper.  Jonathan: No, that’s iron.  Kimberley: Iron.  Jonathan: Yeah. AU. Kimberley: AU. Jonathan: The gold standard of treatment-- Kimberley: Like Australia. Jonathan: Well, no. ERP plus AU. AU as in Accepting Uncertainty. Kimberley: Oh, my trap. Jonathan: Yeah. It took me a while to work that around.  Kimberley: Now you sure it’s not Australia.  Jonathan: But our point is what we want to write. We want to write a book that’s not only about helping therapists deal with every presentation of OCD and how you deal with the uncertainty problem, but we’re also arguing that it’s a book for everyone that people can learn from OCD, a disorder that intolerance uncertainty is like the core. Because I always feel that our clients who get better, they’re not normal. They are better than normal because they’re coping with uncertainty, because the average person really doesn’t do that. Well, I mean, in the pandemic, you got to see how bad non-sufferers are. So, I think the core of coping with mental obsessions is this. Well, what if the worst happens? And so many people, “I don’t want to think it,” and that leaves us stuck because we’re not stupid. If you say to somebody-- if you get a phone call from police and they say your spouse has died, your first response is you’re just in this shock and you’re just like frozen. And for a lot of things that are bad, that’s the way people stop thinking. It’s like, “I don’t want to think about it.” The thing is, if the police make that call, something happens next. And life goes on.  And back for clients, I often ask that in a sneaky way. What if this did happen? What would be next? What if he did have-- the doctor says, “Yeah, it can,” so I freak out. What does that look like? “I’d be screaming.” You’re in the doctor’s office, screaming. How long are you going to do that? And then you’re going to go home and you need dinner. What do you do the next day? And even though we’re going through something that sounds terribly scary, people oddly feel better after that. Now, this is first session. It’s not like they’ve done treatment, but they feel better because a statement that is true, you can’t do what you won’t imagine. And I don’t mean this as you would say, in the flowers and unicorns kind of way that you can do anything you can imagine. I do not mean that. But if you won’t even imagine it, you can’t do it. So, what would you do in X situation where it’s like, no. Well, it’s like the world is ending. When we imagine it, it’s not like it’s good. But it’s like, oh, because the feeling that accompanies acceptance is a down, depressing feeling like, “Oh, that could happen.” However, it’s not frantic. Denial is frantic. “That can’t happen. No, no.” Again, everything at least has some low probability. Some things are higher. You could have cancer, yes. Your family could die. Those things are like, they’re there. So, it’s not like I get the choice. So, the statement of denial is frantic. The statement of acceptance is depressing, but it’s not frantic. And so, I don’t care how bad the disaster is. How would you try to cope? Because in most realities, that’s what you’re going to do. And I could pause at this moment because I don’t know if this would be the point where I would then be shifting to, well, what are the mental compulsives we’re talking about here? Because I think again, each one has its own set of arguments. You’ve heard my general thing. In some ways I think I’m reasonably good at applying it to myself. I think there’s some areas I haven’t been tested in. So, that’s nice. I hope I could be-- I know what I want is possible because I’ve seen people do it. Would I be one of those good people? I can only hope. But at least because I know people have done it, I know it’s possible. I like to believe-- go on, you. Yes. Kimberley: What does that look like? Can you paint me a picture of a client who does well using this strategy at managing mental compulsions? Jonathan: A client that I-- there’s a podcast on that, the OC stories, he was afraid of going crazy. And he had had this from age 19 to his late forties. And he had ERP, but ERP was always focused likely and we’re going to focus on going crazy and all this stuff. Know whatever explicit just said to him, the goal of treatment is for you to risk going crazy. I told him that the first session and he began to cry because he’s been spending more than 30 years trying to avoid this. And I’m saying, “Oh yeah, this might happen.” And many people really are able to accept. And I never talk about accepting uncertainty. I talk about learning to accept uncertainty. Because really, if I can talk to you-- if it’s just a decision, we’re done the first session. But most people are convinced of recession. It took about three months to help convince him. And he kept going back and forth. And so, convincing him, we went through a number of things to work on it.  So, I’m describing it quickly, so it sounds simple. But remember, three months. The first reason, and this is true of almost all rituals, mental compulsions, regardless, you don’t have a choice. All your rituals do not prevent you from going crazy. He’s avoiding places because you’ve got an anxiety attack there, so I’m not going to go there. It’s like, sorry, it’s a biological process that you’re going crazy. That’s doing nothing. So, one is, your rituals don’t work. Two, for pretty much anything, you don’t have a choice. Uncertainty is the fact of life. We talked about what it would look like and he went crazy. And we were going-- and we talked about, well, what’s going to happen? Where are you going to go? He went through all these things. And because he’s logical, at some point it’s like, it could happen.  And at that point, he’s then able to spend the other work, which is not fun, which is then imagining going crazy and looking at all the things that scare the heck out of him so he could begin to function again. We wanted to treat going crazy, the way most people do this is not their problem. Treat, getting main paralyzed and disfigured in a car crash. We all know it’s possible. Our brilliant plan is generally, I hope it doesn’t happen. I’m not dealing with it until I’m bleeding out, crushed under the metal. To say, “I’m not going to be in a car accident today,” it’s like, really? I can’t say that. So, our goal is to get whatever uncertainties in life there are to be like that. And it doesn’t matter whether I’m afraid of going crazy. I’m afraid that I’m going to be a pedophile. I’m going to slice and dice my wife tonight. I’m going to flunk the test. These people don’t like me. It doesn’t matter what it is. It’s still always the same. I mean, we can talk about odds, but not as simply reassurance because, again, it’s reassurance if I want to know it’s low odds, but if I want it to not be possible, it’s not reassuring. It’s like, it’s probably not this, but it might be how we deal with it is that way.  The other thing that we look at is, how does it work for you to fight against this uncertainty? What are you losing? And of course, the more pathological the problem is, the worse it is. So, if I have OCD, it could be destroying my life. I’m not only hurting myself, I’m hurting my family. Let’s go how you’re really torturing everybody. And sometimes I think, in that case, we’re looking for reasons to get better. I always like people to look at all the harm they’re doing to themselves and their family. And I think in a brilliant way, just to plug you, I think your book, your new book really partially addresses that because the self-compassion part isn’t just like, okay, be nice to yourself, stop suffering. It’s like, if you’re going to love yourself, what kind of life do you want to make for yourself? What are your values going to be? Because I think we transform this process of coping into something more than simply confronting fear. It becomes something for myself. And secondarily, not as preferable, but sometimes easier to get to – it becomes not only confronting a fear, it becomes an act of love. Because you know what, I’m going to stop being a pain in the ass to my family. I’m now going to put all of us first.  And so, we’re really going to have-- what are my values, and how does this interfere with my values? And again, it doesn’t have to be as major as I’m dysfunctional, torturing my family with something OCD for any worry. Everybody’s going to be happier if I can cope with my worries better. I mean, my family’s going to be happier because they love me. It’s really nice to see me not freaking out because they don’t have-- because you want to help and there’s no way to help. So, for me to be better and calmer and coping is nice for them. It’s certainly nice for me, and isn’t that what I would prefer in life? And so, when, when my life depends on me having a worry that’s not allowed to happen, I don’t get to enjoy things.  Another coping thing I do that’s smaller is I will ask people to notice what they’re enjoying, no matter how, whatever level, even 5%. I think many times people will say, “Everything sucks, I don’t enjoy anything because of this problem.” Now that’s not entirely true because in the course of interviewing them, there are a few times I’ll get them to laugh for three seconds. And I admit if laughing three seconds were the goal, wow, that’d be great. But three seconds of laughter isn’t much compared to a life of misery. But the thing is, they don’t even notice that ever. The entire experience has been horrible and it’s like-- and to get them to notice not what it should be, but what it was.  I once did this with a guy. I sent him to the movies and I said, “Watch the movie, just tell me whatever you enjoyed. I don’t care how little.” And he came back and he said, “It didn’t work. Everything was horrible.” I’m like, “Okay, now tell me about the movie.” So, he was describing the movie to me, it was a war movie, and it is clear, this guy liked the climax. So, I’m like-- Kimberley: Isn’t that funny? The way our brain works? Jonathan: Yeah. And I said, “That was pretty cool, that climax. Are you sorry you saw that?” “No.” I said, “Okay, you didn’t do my assignment. Notice whatever you enjoyed. I don’t care that it’s not as good as it should have been. You clearly like that.” And it makes a difference because it means a two-hour experience that he comes away believing he had nothing. It would be a slight change to go like, “I enjoyed a little bit of that.” I try to tell people, think of it as like a little while of enjoyment that you don’t notice exists, and we want to expand those. And most people would recognize that in a way, what we’re talking about is a little bit of mindfulness. Like, okay, it sucks. I’m not arguing it doesn’t suck, but a lot of mindfulness. It isn’t like, I’m going to put you in a happy land. It’s like, we were trying to do AND, not OR. The beginning of the pandemic, Kathy and I, we’re out on our pandemic walk. And she said to me, “This would be such a great day if all this wasn’t going on.” I said, “You’re wrong, Kathy.” We should let you and your listeners know. You don’t know this, but your husband does. Being married to a psychologist is not necessarily fun. Kimberley: So true. Jonathan: It is a beautiful day. We’re walking together, it’s beautiful. We’re together, it is beautiful. It is a beautiful day AND it sucks that there’s a pandemic.  Kimberley: So true.  Jonathan: Not OR, it’s AND. In a sense, mindfulness is teaching us to live in that world of AND. This is awful AND I can still enjoy stuff, as opposed to it’s either or. And again, some people go like, “Well, that’s awful.” And that’s perfectly true, because we’re going back to what is acceptance. Acceptance sucks. It’s the second-best life. However, what’s really great about the second-best life, the first best doesn’t exist. So, it’s like, yeah, it’s second-best, but it’s this or nothing. So, I think those are a lot of the principles of doing it and I think to do it, it’s like, why would I take this risk? It’s not a risk, but essentially, it’s like, why would I accept living like this, whatever this is? And I don’t have a choice. What am I losing by not living like this? Am I hurting my family? What would life be like if I could be okay with this? Depending who you are, that’s an incredibly amazing change or it’s a minor change. I mean, if I’m a very competent worrier and very successful, we’re talking about way more peace. But if I’m competent, I’m interfering with my life and taking up a lot of time, we’re now making major changes in the quality of life. And as you know, I can obsess or worry about anything from like, “I need to be the best.” And I always ask people, what is so good about best? Because God forbid, you should be mediocre. God forbid, you should be a happy mediocre person than the best person. And so, for some-- Kimberley: Well, that’s still a piece of denial, isn’t it? They have this idea that the best is no pain. Jonathan: Yeah. Kimberley: There’s no pain at the top. Jonathan: Yeah. Right. And generally, there’s some other assumption that-- I don’t know. Somehow, I’m deficient of, I’m not best. So, it’s like the only way I can know. It’s another set of issues. What is it that I fear that I have to cope with? Not being best. Okay, I get you want to be best. Why? Well, best is best. I mean, it’s nice, I guess. When I think about being well-known, I generally think of being well-known as icing. That is, what makes my life great? For me, I love what I’m doing, and what I’m doing is, besides talking a lot because I love talking, but I like working with people, and I just really enjoy it. I have no plans on retiring because I like this too much. That’s almost all year round. Being famous and well-known, that’s about six days a year when I go to conventions. And I say, it’s like icing to indicate I am weak enough. I’ll admit I’m weak enough to really enjoy it. But I also recognize it is nothing. It doesn’t have any substance. And the thing about fame, you’re always going to lose it. You’re never famous enough. And there’s a poem by Shelly that I think really characterizes it. It describes a traveler in an ancient land. It’s come across a huge fallen monument and it’s describing the magnificence of what this had been. And he comes to the base of the statue where these words are written: “My name is Ozymandias, King of Kings; Look on my Works, ye Mighty, and despair!” That’s fame. It’s empty I can gorge, but it doesn’t mean anything because what I enjoy is what I actually do. It’d be sad if my life was like, it’s good six days a year when I can feel it. Kimberley: Right. And I think what’s important, particularly for the sufferer, is you still have uncertainty in your life. Jonathan: I don’t know any way to be certain, so I know nothing. Kimberley: Right. You know what I was reflecting on, and this is just me reflecting, is last year, maybe it was the beginning of this year, I gave myself the exercise to catch the mini toddler tantrums that showed up in my mind. Jonathan: I love that term. Great. Did you make that up? Kimberley: I think I did because it-- Jonathan: Take credit. It’s great. Love it. Kimberley: It feels like a toddler tantrum in my mind. Jonathan: It’s perfect. It’s that “But I don’t want that.” I love it. Oh, I love it. Go on. Kimberley: Yeah. I did a whole podcast about it last year because I was just noticing toddler tantrum after toddler tantrum, and I regulate myself really well. But it was showing up. And then as you’re talking, I’m thinking about how that was me resisting acceptance. That toddler tantrum is probably where I have the option to pull out of rumination and be present when I can catch it and be like, “Okay, you’re totally in denial. You’re in a fantasy land.” And so, that really speaks to me as a way to catch when you’re up in that place of rumination. Jonathan: That’s perfect. Kimberley: Yeah. For me, that was really powerful. I love that you brought that up because I think that is the bridge. I’m totally out of acceptance when I’m in a toddler tantrum. Jonathan: Right. Because when you get better, as you’re describing, you can deal that pull of like, “This is what it is. No, no, no.” You can feel that pull back and forth because you don’t get completely lost and it’s like, ah. Kimberley: Yeah. It was such a visual. I could see it tantruming out. “No, no, no.” And so, I love that you brought that in particularly in this way, like I said, of catching the compulsion. So, thank you. That actually consolidated-- Jonathan: I’m just now obsessing about how I’m going to work this in. We’ll give you credit. Kimberley: You do. The Kimberly Quinlan “toddler tantrum,” I’m very well-known for it now. No, I am so thankful for you for bringing all this up. Is there-- because I want to be respectful of your time, is there anything else that you want to address when it comes to conceptualizing or managing mental compulsions? Jonathan: I think that I’m afraid I have to be patient. Again, thinking about death, I don’t get to accept just because I want to. You have some people who try to accept like, “I’m accepting and I’m accepting it.” It’s like, yeah, sorry. I can be working towards learning it. I think sometimes people have an insight. An insight is not like you suddenly know some new piece of information. Insight is something that you basically knew, suddenly it’s true. I had somebody have that the other day when that’s hurting and they felt like it was trivial trying to explain to me what happened, but I already had this concept. I said, “I know. It’s like, you’ve always known you feel like going wrong.” “No, you don’t get it. It’s really true.” So, it was very cool.  And so, I think it’s a gradual process where I get better at it. And because life is completely uncertain in every which way, there’s always opportunities to practice it, better personal. And you may scare other people. And one client who was very scared of a lot of things, especially of one of their pets dying. As they got uncertain and told, and then they could talk about it pretty calmly with people, “Oh yeah, I think she’s going to die at some point.” And people would be horrified. She could sound so calm, but she was like, not that she likes it and she really doesn’t want it to happen, but she could also think about it and think about life after that. And I think some people mistakenly will say something like, “Oh my God, you’re making life complete miserable. All you’re thinking about is all these nightmares that can happen all the time. That’s terrible.” That’s crazy because-- I thought I’d use a clinical term. Because what happens when I accept uncertainty?  Somebody else has said this. Unfortunately, I haven’t made it up. I become, in a positive way, hopeless future. And what I mean by hopeless is the way most people who aren’t scared of the car crash, or it’s not like, I’m okay with a car crash. It’s like, what can I do? And when I become hopeless about control, that is when I get to live in the present because I’m no longer in the past or the future. Let’s face it. The truth is that’s all we have. The past of great memories or terrible memories, the future’s hopes, all we have is the present, this moment, my entire life and your entire life with each other. Everything else we like might not be there at this moment. So, I get to have the only thing there is, which is the present. And again, I can’t just decide because you see people do this, “I’m going to live in the present. I’m going to enjoy the present now. Enjoy the present.” It’s like, I have to learn to give things up.  To steal from this woman who wrote this book of compassion: “To be kind to myself, to let myself learn, to not expect it all at once.” Again, if we were talking OCD, I don’t know why we were talking about that. If we were talking about OCD, every particular variation has its own uncertainties to cope with. Scrupulosity, how do I learn to believe in a God and simultaneously admit I might be wrong? How do I live in a world where probably I’m not going to slice and dice Kathy tonight? But if I do, how would I try to-- what would I do the next step? When my son was 16 and going out on dates. And of course, he would never be home on time. And Kathy always wanted to call him. And I wouldn’t let her call him not to be nice to him, but I knew as she knew, his cell phone would be on. So, calling somebody you’re worried about in their cell phone on is not going to be comforting. So, she’d go like, “Well, when can I call him?” So, I’d make this mental calculation. Okay, he should be home now. I think he’ll be home in these many minutes. And let me add another half hour and say, you can call him dead. And she could for some reason, which is unusual, she would then go to sleep. And I would go there and I think, “Huh, he’s probably okay. He’s probably not doing anything terrible. Probably nothing terrible is happening to him. But tonight could be the night that our lives change and everything is screwed up forever.” And then I would go to sleep. That’s just the truth. Kimberley: Yeah. It’s powerful. I’ll be calling you, and my kids are teenagers, saying “Coach me, coach me.” Jonathan: Yeah. And I will give you the following advice. It gets so much easier when they’re 23.  Kimberley: Yes, I know. Jonathan: Until your acceptance is, “Oh yeah,” you’re screwed till then. Kimberley: It’s true. I’m so grateful for you and your time and all your wisdom. I feel like I’m sitting and just absorbing it all for myself, which I’m loving.  Jonathan: Thank you. Kimberley: Tell us, I know you’ve been on the podcast before, but tell us where people can hear more about you and your work. You obviously have a new book, which I did not know about. Jonathan: Well, we are working on it and we’re at the stage of working it, not procrastinating. We’re at the stage of doing a bunch of presentations on the idea, because I’ve just seen so many treatments fail because it didn’t address uncertainty. Although I always focus on certainty, it really is-- the bottom part of dealing with that is coping with life. It transcends OCD. So, I don’t know. What would you like to know about me? Kimberley: Where can people find you? Jonathan: Where can people find me? Easily on the internet. Website is a laocdtreatment.com. But I think my name plus OCD tends to come up a lot.  Kimberley: Your book? Jonathan: I have a book. It’s Freedom From OCD. I think there are a lot of good OCD books. Of course, I like mine because I agree with it most. But it’s a little scary when people read it before they see me because it is almost my entire repertoire minus maybe about 40 minutes. I feel like I’m going to be repeating myself, but somehow that doesn’t seem to be a problem. Apparently, hearing it out loud is different than reading it.  Kimberley: Well, and that’s the whole point, right? I have the same situation as people need to hear it more than once too, in some cases. Not as a form of reassurance, but I think we all need to hear it. Even me today having a little light bulb moment I think is really cool, even though I’ve heard that before. So, I will have your website and your work in the show notes. Jonathan: Very kind. Kimberley: Thank you so much for being here and sharing. Jonathan: I don’t know if you figured it out yet. I know I’ve told you this, but I’ll just repeat it. Probably if you asked me to come on, the answer will always be yes. So, thank you. Kimberley: I’m so happy. No, I remember you saying that last time. Like I said to you, before we started recording, I have wanted to do this series for quite a while. And I had you right there going. I already put you on the list because I already knew. You told me you would say yes. Jonathan: And so, apparently, I’m not dishonest or not that dishonest. Kimberley: Not at all. When I texted to ask you, I actually already had you on the list and scheduled you in. Jonathan: It was a confidence that you could well have. Kimberley: Yeah. I’m so grateful. And yes, we will definitely have you on. It’s always a pleasure. Jonathan: All right. Okay. Take care. Thank you very much.

SUMMARY:  In this weeks podcast, we have my dearest friend Shala Nicely talking about how she manages mental compulsions.  In this episode, Shala shares her lived experience with Obsessive Compulsive Disorder and how she overcomes mental rituals. In This Episode: How to reduce mental compulsions for OCD and GAD. How to use Flooding Techniques with Mental Compulsions Magical Thinking and Mental Compulsions BDD and Mental Compulsions Links To Things I Talk About: Shalanicely.com Book: Is Fred in the Refridgerator? Book: Everyday Mindfulness for OCD ERP School: https://www.cbtschool.com/erp-school-lp Episode Sponsor: This episode of Your Anxiety Toolkit is brought to you by CBTschool.com.  CBTschool.com is a psychoeducation platform that provides courses and other online resources for people with anxiety, OCD, and Body-Focused Repetitive Behaviors.  Go to cbtschool.com to learn more. Spread the love! Everyone needs tools for anxiety... If you like Your Anxiety Toolkit Podcast, visit YOUR ANXIETY TOOLKIT PODCAST to subscribe free and you'll never miss an episode. And if you really like Your Anxiety Toolkit, I'd appreciate you telling a friend (maybe even two). EPISODE TRANSCRIPTION This is Your Anxiety Toolkit - Episode 284. Welcome back, everybody. We are on the third video or the third part of this six-part series on how to manage mental compulsions. Last week’s episode with Jon Hershfield was bomb, like so good. And I will say that we, this week, have Shala Nicely, and she goes for it as well. So, I am so honored to have these amazing experts talking about mental compulsions, talking about what specific tools they use.  So, I’m not going to take too much time of the intro this time, because I know you just want to get to the content. Again, I just want to put a disclaimer. This should not replace professional mental health care. This series is for educational purposes only. My job at CBT School is to give you as much education as I can, knowing that you may or may not have access to care or treatment in your own home. So, I’m hoping that this fills in a gap that maybe we’ve missed in the past in terms of we have ERP School, that’s an online course teaching you everything about ERP to get you started if you’re doing that on your own. But this is a bigger topic. This is an area that I’d need to make a complete new course. But instead of making a course, I’m bringing these experts to you for free, hopefully giving you the tools that you need.  If you’re wanting additional information about ERP School, please go to CBTSchool.com. With that being said, let’s go straight over to this episode with Shala Nicely.  Kimberley: Welcome, Shala. I am so happy to have you here. Shala: I am so happy to be here. Thank you for having me. Kimberley: Okay. So, I have heard a little bit of your views on this, but I am actually so excited now to get into the juicy details of how you address mental compulsions or mental rituals. First, I want to check in with you, do you call them mental compulsions, rituals, rumination? How do you address them? Shala: Yeah. All those things. I also sometimes call it mental gymnastics up in your head, it’s all sorts of things you’re doing in your head to try to get some relief from anxiety. Kimberley: Right. So, if you had a patient or a client who really was struggling with mental compulsions, whether or not they were doing other compulsions as well, how might you address that particular part of their symptomology? Shala: So, let me answer that by stepping back a little bit and telling you about my own experience with this, because a lot of the way I do it is based on what I learned, trying to manage my own mental rituals. I’ve had OCD probably since I was five or six, untreated until I was 39. Stumbled upon the right treatment when I went to the IOCDF Conference and started doing exposure mostly on my own. I went to Reid Wilson’s two-day group, where I learned how to do it. But the rest of the time, I was implementing on my own. And even though I had quite a few physical compulsions, I would’ve considered myself a primary mental ritualizer, meaning if we look at the majority, my compulsions were up in my head. And the way I think about this is I think that sometimes if you have OCD for long enough, and you’ve got to go out and keep functioning in the world and you can’t do all these rituals so that people could see, because then people will be like, “What’s wrong with you? What are you doing?” you take them inward. And some mental compulsions can take the place of physical compulsions that you’re not able to do for whatever reason because you’re trying to function. And I’d had untreated OCD for so long that most of my rituals were up in my head, not all, but the great majority of them.  Exposure & Response Prevention for Mental Compulsions So, when I started to do exposure, what I found was I could do exposure therapy, straight up going and facing my fears, like going and being around things that might be triggering all I wanted, but I wasn’t necessarily getting better because I wasn’t addressing the mental rituals. So, basically, I’m doing exposure without response prevention or exposure with partial response prevention, which can make things either worse or just neutralize your efforts. So, what I did was I figured out how to be in the presence of triggers and not be up in my head, trying to do analyzing, justifying, figuring it out, replaying the situation with a different ending, all the sorts of things that I would do over and over in my head. And the way I did this was I took something I learned from Jonathan Grayson and his book, Freedom From OCD. I know you’re having him on for this series too. And he talked about doing all this ERP scripting, where you basically write out the worst-case scenario, what you think your OCD thinks is going to happen and you write it in either a worst-case way or an uncertainty-focused way. And what I did was after reading his book, I took that concept and I just shortened it down, and anything that my OCD was afraid of, I would just wrap may or may not surround it.  So, for instance, an example that I use in Is Fred in the Refrigerator?, my memoir, Taming OCD and Reclaiming My Life was that I used to-- when I was walking through stores like Target, if I saw one of those little plastic price tags that had fallen on the ground, if I didn’t pick it up and put it out of harm’s way, I was afraid somebody was going to slip and fall and break their neck. And it would be on some security camera that I just walked on past it and didn’t do anything. So, a typical scrupulosity obsession. And so, going shopping was really hard because I’m cleaning up the store as I’m shopping. And so, what I would do is I would either go to Target, walk past the price tag. And then as I’m just passing the price tag, I would say things. And in Target, I obviously couldn’t do this really out loud, mumble it out loud as best, but I may or may not cause somebody to kill themselves by they’re going to slip and fall on that price tag because I didn’t pick it up. I may or may not be an awful, terrible rotten human being. They may or may not catch me and throw me into jail. I may or may not rot in prison. People may or may not find out what a really bad person I really am. This may or may not be OCD, et cetera, et cetera, et cetera.  And that would allow me to be present with the obsessions, all the what-ifs – those are basically what-ifs turned into ‘may or may nots’ – without compulsing with them, without doing anything that would artificially lower my anxiety. So, it allowed me to be in the presence of those obsessive thoughts while interrupting the pattern of the mental rituals. And that’s really how I use ‘may or may nots’ and how I teach my clients to use ‘may or may nots’ today is using them to really be mindfully present of what the OCD is worried about while not interacting with that content in a way that’s going to make things worse. So, that’s how I developed it for myself. And I think that-- and that is a tool that I would say is an intermediary tool. So, I use that now in my own recovery. I don’t have to use ’may or may nots’. It’s very often at all. If I get super triggered, which doesn’t happen too terribly often, but if I get super triggered and I cannot get out of my head, I’ll use ’may or may nots’.  But I think the continuum is that you try to do something to interrupt the mental rituals, which for me is the ’may or may nots’. You can also-- people can write down the scripts, they can do a worst-case scenario. But eventually, what you’re trying to get to is you’re trying to be able to hear the OCD, what-ifs in your head and completely ignore it. And I call that my shoulders back, the way of thinking about things. Just put your shoulders back and you move on with your day. You don’t acknowledge it.  What I’ll do with clients, I’ll say, “If you had the thought of Blue Martian is going to land on my head, I mean, you wouldn’t even do anything with that thought. That thought would just go in and go out and wouldn’t get any of your attention.” That’s the way we want to treat OCD, is just thoughts can be there. I’m not going to say, “Oh, that’s my OCD.” I’m not going to say, “OCD, I’m not talking to you.” I’m not going to acknowledge it at all. I’m just going to treat it like any other weird thought that we have during the day and move on.  Your question was, how would you help somebody who comes in with mental rituals? Well, first, I want to understand where are they in their OCD recovery? How long have they been doing these mental rituals? What percentage of their compulsions are mental versus physical? What are the kind of things that their OCD is afraid of? Basically, make a list or a hierarchy of everything they’re afraid of. And then we start working on exposure therapy. And when I have them do exposures, the first exposure I do with people, we’ll find something that’s-- I start in the middle of the hierarchy. You don’t have to, but I try. And I will have them face the fear. But then I’ll immediately ask them, what is your OCD saying right now? And they’ll tell me, and I’ll say, “I want you to repeat after me.” I have them do this, and everyone that I see hates this, but I have them do it. Standing up with their shoulders back like Wonder Woman, because this type of power pose helps them. It changes the chemistry of your body and helps you feel more powerful.  OCD thinks it’s very powerful. So, I want my clients to feel as powerful as they can. So, I have them stand like Wonder Woman and they repeat after me. Somebody could-- let’s just say we are standing near something red on the floor. And I’ll say, “Well, what is your OCD saying right now?” And they’ll say, “Well, that’s blood and it could have AIDS in it, and I’m going to get sick.” I’ll say, “Well, that may or may not be a spot of blood on the floor. I may or may not get sick and I may or may not get AIDS, but I want to do this. I’m going to stay here. OCD, I want to be anxious, so bring it on.”  And that’s how we do the exposure, is I ask them what’s in their head. I have them repeat it to me until they understand what the process is. And then I’m having them be in the presence of this and just script, script, script away. That’s what I call it scripting, so that they are in the presence of whatever’s bothering them, but they’re not up in their head. And anytime something comes in their head, I teach them to pull it down into the script. Never let something be circulating in your head without saying it out loud and pulling it into the script.  I will work on this technique with clients as we’re working on exposures, because eventually what we’ll want to do is instead of going all over the place, “That may or may not be blood, I may or may not get AIDS, I may or may not get sick,” I’ll say, “Okay, of all the things you’ve just said, what does your OCD-- what is your OCD scared of the most? Let’s focus on that.” And so, “I may or may not get AIDS. I may or may not get AIDS. I may or may not have HIV. I may or may not get AIDS,” over again until people start to say, “Oh, okay. I guess I don’t have any control over this,” because what we’re trying to do is help the OCD habituate to the uncertainty. Habituate, I know that’d be a confusing word. You don’t have to habituate in order for exposure to work due to the theory of inhibitory learning, but we’re trying to help your brain get used to the uncertainty here. Kimberley: And break into a different cycle instead of doing the old rumination cycle.  Shala: Yes. And so then, I’ll teach people to just find their scariest fear. They say that over and over and over again. Then let’s hit the next one. “Well, my family may or may not survive if I die because if I get a fatal disease and I die and my family may or may not be left destitute,” and then over and over. “My family may or may not be left destitute. My family may or may not be left destitute, whatever,” until we’re hitting all the things that could be circulating in your head.  Now, some people really don’t need to do that scripting because they’re not up in their head that much. But that’s the minority of people. I think most people with OCD are doing something in their head. And a lot of people aren’t aware of what they’re doing because these mental rituals are incredibly subtle at times. And so, as people, as my clients go out and work on these exposures, I’ll have them tell me how it’s going. I have people fill out forms on my website each day as they’re doing exposures so I can see what’s going on. And if they’re not really up in their head and they don’t really need to do the ‘may or may nots’, great. That’s better. In fact, just go do the exposure and go on with your life. If they’re up in their head, then I have them do the ’may or may nots’. And so, that’s how I would start with somebody.  And so, what I’m trying to do is I’m giving them what I call a bridge tool. Because people who have been mental ritualizing for a long time, I have found it’s virtually impossible to just stop because that’s what your mind is used to doing. And so, what I’m doing is I’m giving them a competing response. And I’m saying here, instead of mental ritualizing, I’d like you to say a bunch of ’may or may nots’ statements while standing up and say them out loud while looking like Wonder Woman. Everybody rolls their eyes like, “Really?” But that’s what we do as a bridge tool. And so, they’ve lifted enough mental weights, so to speak, with this technique that they can hear the OCD and start to disengage and not interact with it at all. Then we move to that technique. Flooding Techniques for Mental Rumination Kimberley: Is there a reason why-- and for some of the listeners, they may have learned this before, but is there a reason why you use ’may or may nots’ instead of worst-case scenarios? Shala: For me, for my personal OCD recovery journey, what I found with worst-case scenario is I got too lost in the content. I remember doing-- I had had a mammogram, it had come back with some abnormal findings. I spent the whole weekend trying to do scripting about what could happen, and I was using worst-case scenario. Well, I end up in the hospital, I end up with breast cancer, I end up dead. And by the end of the weekend, I was completely demoralized. And I’m like, “Well, I don’t bother because I’m going to be dead, because I have breast cancer.” That’s where my mind took it because I’ve had OCD long enough that if I get a really scary and I start and I play around in the content, I’m going to start losing insight and I’m going to start doing depression as a compulsion, which is the blog we did talk about, where you start acting depressed because you’re believing what the OCD says like, “Oh, well, I might as well just give up, I have breast cancer,” and then becoming depressed, and then acting like it’s true. And then that’s reinforcing the whole cycle.  So, for me, worst-case scenario scripting made things worse. So, when I stayed in the uncertainty realm, the ‘may or may nots’ that helped because I was trying to help my brain understand, “Well, I may or may not have breast cancer. And if I do, I mean, I’ll go to the doctor, I’ll do what I need to do, but there’s nothing I can do about it right now in my head other than what I’m doing.” Some people like worst-case scenario and it works fine for them. And I think that works too. I mostly use ’may or may nots’ with clients unless they are unable through numbing that they might be doing. If they’re unable to actually feel what they’re saying, because they’re used to turning it over in their head and pulling the anxiety down officially, and so I can’t get a rise out of the OCD because there’s a lot of really little subtle mental compulsions going on, then I’ll insert some worst-case scenario to get the anxiety level up, to help them really feel the fear, and then pull back into ’may or may nots’. But there’s nothing wrong with worst-case scenario. But for me, that was what happened. And I think if you are prone to depression, if you’re prone to losing insight into your OCD when you’ve got a really big one, I think that’s a risk factor for using that particular type of scripting.  Magical Thinking and Mental Compulsions  Kimberley: Right. And I found that they may or may not have worked just as well, except the one thing, and I’m actually curious on your opinion on this and I have not had this conversation, is I find that people who have a lot of magical thinking benefit by worst-case scenario, like their jinxing compulsions and so forth, like the fear of saying it means it will happen. So, saying the worst-case is the best exposure. Is that true for you? Shala: I have not had to use it much on my own magically. I certainly had a lot of magical thinking. Like, if I don’t hit this green light, then somebody’s going to die. But I think the worst-case scenario, I could actually work well in that, because if you use the worst-case scenario, it can make it seem so ridiculous that it helps people let go of it more easily. And I think you can do that with ’may or may nots’ too. I’ll try to encourage people to use the creativity that they have because everybody with OCD has a ton of creativity. And we know that because the OCD shares your brain and it’s certainly the creative stuff And to one-up the OCD, you use the scripting to be like, “Gosh, I may or may not get some drug-disease and give it to my entire neighborhood. I may or may not kill off an entire section of my county. We may or may not infect the entire state of Georgia. The entire United States may or may not blow up because I got this one disease. So, they may or may not have to eject me off the earth and make me live on Mars because I’m such a bad person.” This ‘may or may not’ is in all this crazy stuff too, because that’s how to win, is to one up the OCD. It thinks that’s scary, let’s go even scarier. But the scary you get, it also gets a little bit ridiculous after a while. And then the whole thing seems to be a little bit ridiculous. So, I think you can still use that worst-case stuff with may or may not. Kimberley: Right. Okay. So, I mean, I will always sort of-- I know you really well. I’ve always held you so high in my mind in just how resilient and strong you are in doing this. How might you, or how do you help people who feel completely powerless at even addressing this? For you to say it, it sounds very like you’re just doing it and it’s so powerful. But for those who are really struggling with this idea of like, you said, coming out of your head, can you speak to how you address that in session if someone’s really struggling to engage in ’may or may nots’ and so forth? Shala: Yeah. Well, thank you for the kind words, first off. I think that it’s really common for people with OCD by the time they get to a therapist to feel completely demoralized, especially if they’ve been to multiple therapists before they get to somebody who does ERP. And so, they feel like they’re the victim at the hands of a very cruel abuser that they can’t get away from. And so, they feel beaten down and they don’t know how to get out of their heads. They feel like they’re trapped in this mental prison. They can’t get out. And if somebody is struggling like that, and they’re doing the ’may or may nots’ and the OCD is reacting, which of course, it will, and coming back at them stronger, which I always warn people, this is going to happen. When you start poking at this, the OCD is going to poke back and poke back even harder, because it wants to get you back in line so it can keep you prisoner.  So, what I’ll often do in those situations, if I see somebody is really feeling like they have been so victimized, that they’re never going to be able to get over this, is the type of script I have them do is more of an empowerment script, which could sound like this: “OCD, I’m not listening to you anymore. I’m not doing what you want. I am strong. I can do this.” And I might add some ’may or may nots’ in there. “And I want to be anxious. Come on, bring it on. You think that’s scary? Give me something else.”  I know you’re having Reid Wilson on as part of this too. I learned all that “bring it on” type stuff and pushing for the anxiety from him. And I think helping people say that out loud can be really transformative. I’ve seen people just completely break down in tears of sort of, “Oh my gosh, I could do this,” like tears of empowerment from standing up and yelling at their OCD.  If people like swearing, I also just have them swear at it, like they would really swear at somebody who had been abusing them if they had a chance, because swearing actually can make you feel more powerful too, and I want to use all the tools we can. So, I think scripting comes in a number of forms. It’s all about really taking what’s in your head, turning it into a helpful self-talk and saying it out loud. And the reason out loud is important for any type of scripting is that if you’re saying it in your head, it’s going to get mixed up with all the jumble of mental ruminating that’s going on. And saying it out loud makes it hard for you to ruminate. It’s not impossible, but it’s hard because you’re saying it. Your brain really is only processing one thing at a time. And so, if you’re talking and really paying attention to what you’re saying, it’s much harder to be up in your head spinning this around.  And so, adding these empowerment scripts in with the ’may or may nots’ helps people both accept the uncertainty and feel like they can do this, feel like they can stand up to the OCD and say, “You’ve beaten me enough. No more. This is my life. I’m not letting you ruin it anymore. I am taking this back. I don’t care how long it takes. I don’t care what I have to do. I’m going to do this.” And that builds people up enough where they can feel like they can start approaching these exposures. Kimberley: I love that. I think that is such-- I’ve had that same experience of how powerful empowerment can be in switching that behavior. It’s so important. Now, one thing I really want to ask you is, do you switch this method when you’re dealing with other anxiety disorders – health anxiety, social anxiety, panic disorder? What is your approach? Is there a difference or would you say the tools are the same? Shala: There’s a slight difference between disorders. I think health anxiety, I treat exactly like OCD. Even some of the examples I gave here were really health anxiety statements. With panic disorder-- and again, I learned this from Reid and you can ask him more about this when you interview him. But with pain disorder, it’s all about, I want to feel more shorter breath, more like their elephant standing on my chest. I want my heart to be faster. But I’m doing this while I’m having people do exercises that would actually create those feelings, like breathing through a little bit of cocktail straw, jogging, turning up a space heater, and blowing it on themselves. So, we’re trying to create those symptoms and then talk out loud and say, “Come on, I want more of this. I want to feel more anxious. Give me the worst panic attack you’ve ever had.” So, it’s all about amping up the symptoms.  With social anxiety, it’s a little bit different because with social anxiety, I would work on the cognitions first. Whereas with OCD, we don’t work on the cognitions at all, other than I want you to have a different cognitive relationship with your disorder and your anxiety. I want you to want the anxiety. I want you to want the OCD to come and bother you because that gives you an opportunity to practice. That’s the cognitive work with OCD. I do not work on the cognitive work on the content. I’m not going to say to somebody, “Well, the chance you’re going to get AIDS from that little spot of blood is very small.” That’s not going to be helpful  With social anxiety, we’re actually working on those distorted cognitions at the beginning. And so, a lot of the work with social anxiety is going to be going out and testing those new cognitions, which really turns the exposures into what we call behavioral experiments. It’s more of a cognitive method. We’re going out and saying, “Gosh, my new belief, instead of everybody’s judging me, is, well, everybody is probably thinking about themselves and I’m going to go do some things that my social anxiety wouldn’t want me to do and test out that new belief.” I might have them use that new belief, but also if their anxiety gets really high and they’re having a hard time saying, “Well, that person may or may not be judging me. They may or may not be looking at me funny. They may or may not go home and tell people about me.” But really, we’re trying to do something a little bit different with social anxiety. Kimberley: And what about with generalized anxiety? With the mental, a lot of rumination there, do you have a little shift in how you respond? Shala: Yeah. So, it’s funny that the talk that Michelle Massi and others gave at IOCDF-- I think it was at IOCDF this year about what’s the difference between OCD and GAD is they’re really aligned there. I mean, I treat GAD very similarly the way I treat OCD in that people are up in their heads trying to do things. They’re also doing other types of safety behaviors, compulsive safety behaviors, but a lot of people GAD are just up in their head. They’re just worried about more “real-life” things. But again, a lot of OCD stuff can be real-life things. I mean, look at COVID. That was real life. And people’s OCD could wrap itself around that. So, I treat GAD and OCD quite similarly. There are some differences, but in terms of scripting, we call it “worry time” in GAD. It’s got a different name, but it’s basically the same thing. Kimberley: Right. Okay. Thank you for answering that because I know some folks here listening will be not having OCD and will be curious to see how it affects them. So, is that the practice for you or is there anything else you feel like people need to know going in, in terms of like, “Here is my strategy, here is my plan to target mental rituals”? What would you say? Shala: So, as I mentioned, I think the ’may or may nots’ are bridge tool that are always available to you throughout your entire recovery. My goal with anybody that I’m working with is to help them get to the point where they can just use shoulders back. And the way that I think about this is what I call my “man in the park” metaphor. So, we’ve all probably been in a park where somebody is yelling typically about the end of the world and all that stuff. And even if you were to agree with some of the things that the person might say from a spiritual or religious standpoint, you don’t run home and go, “Oh my gosh, we got to pack all our things up because it’s the end of the world. We have to get with all of our relatives and be together because we’re all going to die.” We don’t do that. We hear what this guy’s saying, and then we go on with our days, again, even if you might agree with some of the content. Now, why do we do that? We do that because it’s not relevant in our life. We realize that person probably, unfortunately, has some problems. But it doesn’t affect us. We hear it just like when we might hear birds in the background or a car honking, and we just go on with our day. That’s how we want to treat OCD. What we do when we have untreated OCD is we run up to the man in the park and we say, “Oh my gosh, can I have a pamphlet? Let me read the pamphlet. Oh my gosh, you’re right. Tell me more, tell me more.” And we’re interacting with him, trying to get some reassurance that maybe he’s wrong, that maybe he does really mean the end of the world is coming soon. Maybe it’s going to be like in a hundred years. Eventually, we get to the point where we’re handing out pamphlets for him. “Here, everybody, take one of these.” What we’re doing with ’may or may nots’ is we’re learning how to walk by the man in the park and go, “The world may or may not be ending. The world may or may not be ending. I’m not taking a pamphlet. The world may or may not be ending.” So, we’re trying to not interact with him. We’re trying to take what he’s saying and hold it in our heads without doing something compulsive that’s going to make our anxiety higher. What we’re trying to do is practice that enough till we can get to the point where we can be in the park with the guy and just go on with our day. We hear him speaking, but we’re really-- it’s just not relevant. It’s just not part of our life. So, we just move on. And we’re not trying to shove him away. It’s just like any other noise or sound or activity that you would just-- it doesn’t even register in your consciousness. That’s what we’re trying to do.  Now I think another way to think about this is if you think-- say you’re in an art gallery. Art galleries are quiet and there are lots of people standing around, and there’s somebody in there that you don’t like or who doesn’t like you or whatever. You’re not going to walk up to that person and tap on their shoulder and say, “Excuse me, I’m going to ignore you.” You’re just going to be like, “I know that person is there. I’m just going to do what I’m doing.” And I think that’s-- I use that to help people understand this transition, because we’re basically going from ’may or may nots’ where we’re saying, “OCD, I’m not letting you do this to me anymore,” so we are being really aggressive with it, to this being able to be in the same space with it, but we’re not talking to it at all because we don’t need to, because we can be in the presence with the intrusive thoughts that the OCD is reacting to, just like the presence of all the other thousands of thoughts we have each day without interacting with them. Kimberley: That’s so interesting. I’ve never thought of it that way.  Shala: And so, that’s where I’m trying to get people because that is the strongest, strongest recovery, is if you can go do the things that you want to do, be in the presence of the anxiety and not do compulsions physical or mental, you don’t give anything for OCD to work with. I have a whole chapter in my memoir about this after I heard Reid say at one of the conferences, “We need to act as though what OCD is saying doesn’t matter.” And that was revolutionary to me to hear that. And that’s what we’re trying to do both physically and mentally. Because if you can have an obsession and focus on what you want to focus on, do what you want to do, you’re not giving OCD anything to work with. And typically, it’ll just drain away. But this takes time. I mean, it has taken me years to learn how to do this, but I went untreated for 35 years too. It may not take you years, but it may. And that’s okay. It’s a process. And I think if you have trouble trying to do shoulders back, man in the park, use ’may or may nots’. You can use the combination. But I think we’re trying to get to the point where you can just be with the OCD and hear it flipping out and just go on with your day. OCD, BDD, and Mental Rituals  Kimberley: In your book, you talk about the different voices. There is a BDD voice and an OCD voice. Was it harder or easier depending on the voice? Was that a component for you in that-- because the words and the voice sound a little different. I know in your memoir you give them different names and so forth, which if anyone hasn’t read your memoir, they need to go right now and read it. Do you have any thoughts on that in terms of the different voices or the different ways in which the disorders interact? Shala: That’s a really great question because yes, I think OCD does shift its voice and shift its persona based on how scared it is. So, if it’s a little bit scared, it’s probably going to speak to you. It’s still going to be not a very nice voice. It might be urgent and pleading. But if it’s super scared, I talk about mine being like the triad of hell, how my OCD will personify into different things based on how scared it is. And if it’s super scared and it’s going to get super big and it’s going to get super loud in your head because it’s trying desperately to help you understand you’ve got to save it because it thinks it’s in danger. That’s all its content. Then I think-- and if you have trouble ignoring it because it’s screaming in your head, like the man in the park comes over with his megaphone, puts it right up against your ear and starts talking, that’s hard to ignore. That’s hard to act like that’s not relevant because it hurts. There’s so much noise.  That’s when you might have to use a may or may not type approach because it’s just so loud, you can’t ignore it, because it’s so scared. And that’s okay. And again, sometimes I’ll have to use that. Not too terribly often just because I’ve spent a long time working on how to use the shoulder’s back, man in the park, but if I have to use it, I use it. And so, I think your thought about how do I interact with the OCD based on how aggressive it’s being also plays into this. Kimberley: I love all this. I think this is really helpful in terms of being able to be flexible. I know sometimes we want just the one rule that’s going to work in all situations, but I think you’re right. I think that there needs to be different approaches. And would you say it depends on the person? Do you give them some autonomy over finding what works for them, or what would you say?  Shala: Absolutely. If people are up in their heads and they don’t want to use ’may or may nots’, I’ll try to use some other things. If I really, really think that that’s what we need right now, is we need scripting, I’ll try to sell them on why. But at the end of the day, it’s always my client’s choice and I do it differently based on every client. For some clients, it might be just more empowering statements. For some clients where it’s more panicky focused, it might be more about bringing on your anxiety. Sometimes it might be pulling self-compassion in and just saying the self-compassion statements out loud. So, it really does vary by person. There’s no one-size-fits-all, but I think, I feel that people need to have something to replace the mental ritualizing with at the beginning that they’ve been doing it for a long time, just because otherwise, it’s like, I’m giving them a bicycle, they’ve never ridden a bicycle before and I won’t give them any training wheels. And that’s really, really hard. Some people can do it. I mean, some people can just be like, “Oh, I’m to stop doing that in my head? Okay, well, I’ll stop doing that in my head.” But most people need something to help them bridge that gap to get to the point where they can just be in the presence with it and not be talking to it in their heads. Kimberley: Amazing. All right. Any final statements from you as we get close to the end? Shala: I think that it’s important to, as you’re working on this, really think about what you’re doing in your head that might be subtle, that could be making the OCD worse. And I think talking and being willing to talk about this to therapists about putting it all out there, “Hey, I’m saying this to myself in my head, is that helpful or harmful?” Because OCD therapy can be pretty straightforward. I mean, ERP, go out and face your fears, don’t do rituals. It sounds pretty straightforward. But there is a lot of subtlety to this. And the more that you can root out these subtle mental rituals, the better that your recovery is going to be.  And know too that if you’ve had untreated OCD for a long time, you can uncover mental rituals, little bitty ones, for years after you get out of therapy. And that’s okay. It doesn’t mean you’re not in recovery. It just means that you are getting more and more insightful and educated about what OCD is. And the more that you can pick those little things out, just the better your recovery will be. But we also don’t want to be perfectionistic about that like, “I must eliminate every single mental ritual that I have or I’m not going to be in a good recovery.” That’s approaching your ERP like OCD would do. And we don’t want to do that. But we do want to be mindful about the subtleties and make sure to try to pull out as many of those subtle things that we might be doing in our heads as possible.  Kimberley: Amazing. Thank you. Tell us-- again, first, let me just say, such helpful information. And your personal experience, I think, is really validating and helpful to hear on those little nuances. Tell us where people can hear about you and the amazing projects you’ve got going on. Shala: You can go to ShalaNicely.com and I have lots of free blog posts I’ve written on this. So, there are two blog posts, two pretty extensive blog posts on ’may or may nots’. So, if you go on my website and just search may or may not, it’ll bring up two blog posts about that. If you search on shoulders back or man in the park, you’ll find two blog posts on how to do that technique. I also have a blog post I wrote in the last year or so called Shower Scripting, which is how to do ERP, like just some touch-up scripting in the shower, use that time. So, I would say go to my website and you can find all sorts of free resources. I’ve got two books. You can find on Amazon, Everyday Mindfulness for OCD, Jon Hershfield and I co-wrote. And we talk about ‘may or may nots’ and shoulders back and some of the things in there just briefly. And then my memoir, Is Fred in the Refrigerator?: Taming OCD and Reclaiming My Life, is also on Amazon or bookstores, Audible, and that kind of thing.  Kimberley: I wonder too, if we could-- I’m going to put links to all these in the show note. I remember you having a word with your OCD, a video? Shala: Oh yes, that’s true. Kimberley: Can we link that too? Shala: Yes. And that one I have under my COVID resources, because I’m so glad you brought that up. When the pandemic started, my OCD did not like it, as many people who have contamination OCD can relate to. And it was pretty scary all the time. And it was making me scared all the time. And eventually, I just wrote it a letter and I’m like, “Dude, we’re not doing this anymore.” And I read it out loud and I recorded it out loud so that people could hear how I was talking to it.  Kimberley: It was so powerful. Shala: Well, thank you. And it’s fun to do. I think the more that you can personify your OCD, the more you can think of it as an entity that is within you but is not you, and to recognize that your relationship with it will change over time. Sometimes you’re going to be compassionate with it. “Gosh, OCD, I’m so sorry,” You’re scared we’re doing this anyway. Sometimes you’re going to be aggressive with it. Sometimes you just ignore it. And that changes as you go through therapy, it changes through your life. And I think that recognizing that it’s okay to have OCD and to have this little thing, I think of like an orange ball with big feet and sunglasses is how I think about it when it’s behaving – it makes it less of an adversarial relationship over time and more like I have an annoying little sibling that, gosh, it’s just not going to ever not be there, but it’s fine. We can live together and live in this uncertainty and be happy anyway. Kimberley: I just love it. Thank you so much for being here and sharing your experience and your knowledge. It’s so wonderful. Shala: Thank you so much for having me.

SUMMARY:  In this weeks podcast, we have my dearest friend Shala Nicely talking about how she manages mental compulsions.  In this episode, Shala shares her lived experience with Obsessive Compulsive Disorder and how she overcomes mental rituals. In This Episode: How to reduce mental compulsions for OCD and GAD. How to use Flooding Techniques with Mental Compulsions Magical Thinking and Mental Compulsions BDD and Mental Compulsions Links To Things I Talk About: Shalanicely.com Book: Is Fred in the Refridgerator? Book: Everyday Mindfulness for OCD ERP School: https://www.cbtschool.com/erp-school-lp Episode Sponsor: This episode of Your Anxiety Toolkit is brought to you by CBTschool.com.  CBTschool.com is a psychoeducation platform that provides courses and other online resources for people with anxiety, OCD, and Body-Focused Repetitive Behaviors.  Go to cbtschool.com to learn more. Spread the love! Everyone needs tools for anxiety... If you like Your Anxiety Toolkit Podcast, visit YOUR ANXIETY TOOLKIT PODCAST to subscribe free and you'll never miss an episode. And if you really like Your Anxiety Toolkit, I'd appreciate you telling a friend (maybe even two). EPISODE TRANSCRIPTION This is Your Anxiety Toolkit - Episode 284. Welcome back, everybody. We are on the third video or the third part of this six-part series on how to manage mental compulsions. Last week’s episode with Jon Hershfield was bomb, like so good. And I will say that we, this week, have Shala Nicely, and she goes for it as well. So, I am so honored to have these amazing experts talking about mental compulsions, talking about what specific tools they use.  So, I’m not going to take too much time of the intro this time, because I know you just want to get to the content. Again, I just want to put a disclaimer. This should not replace professional mental health care. This series is for educational purposes only. My job at CBT School is to give you as much education as I can, knowing that you may or may not have access to care or treatment in your own home. So, I’m hoping that this fills in a gap that maybe we’ve missed in the past in terms of we have ERP School, that’s an online course teaching you everything about ERP to get you started if you’re doing that on your own. But this is a bigger topic. This is an area that I’d need to make a complete new course. But instead of making a course, I’m bringing these experts to you for free, hopefully giving you the tools that you need.  If you’re wanting additional information about ERP School, please go to CBTSchool.com. With that being said, let’s go straight over to this episode with Shala Nicely.  Kimberley: Welcome, Shala. I am so happy to have you here. Shala: I am so happy to be here. Thank you for having me. Kimberley: Okay. So, I have heard a little bit of your views on this, but I am actually so excited now to get into the juicy details of how you address mental compulsions or mental rituals. First, I want to check in with you, do you call them mental compulsions, rituals, rumination? How do you address them? Shala: Yeah. All those things. I also sometimes call it mental gymnastics up in your head, it’s all sorts of things you’re doing in your head to try to get some relief from anxiety. Kimberley: Right. So, if you had a patient or a client who really was struggling with mental compulsions, whether or not they were doing other compulsions as well, how might you address that particular part of their symptomology? Shala: So, let me answer that by stepping back a little bit and telling you about my own experience with this, because a lot of the way I do it is based on what I learned, trying to manage my own mental rituals. I’ve had OCD probably since I was five or six, untreated until I was 39. Stumbled upon the right treatment when I went to the IOCDF Conference and started doing exposure mostly on my own. I went to Reid Wilson’s two-day group, where I learned how to do it. But the rest of the time, I was implementing on my own. And even though I had quite a few physical compulsions, I would’ve considered myself a primary mental ritualizer, meaning if we look at the majority, my compulsions were up in my head. And the way I think about this is I think that sometimes if you have OCD for long enough, and you’ve got to go out and keep functioning in the world and you can’t do all these rituals so that people could see, because then people will be like, “What’s wrong with you? What are you doing?” you take them inward. And some mental compulsions can take the place of physical compulsions that you’re not able to do for whatever reason because you’re trying to function. And I’d had untreated OCD for so long that most of my rituals were up in my head, not all, but the great majority of them.  Exposure & Response Prevention for Mental Compulsions So, when I started to do exposure, what I found was I could do exposure therapy, straight up going and facing my fears, like going and being around things that might be triggering all I wanted, but I wasn’t necessarily getting better because I wasn’t addressing the mental rituals. So, basically, I’m doing exposure without response prevention or exposure with partial response prevention, which can make things either worse or just neutralize your efforts. So, what I did was I figured out how to be in the presence of triggers and not be up in my head, trying to do analyzing, justifying, figuring it out, replaying the situation with a different ending, all the sorts of things that I would do over and over in my head. And the way I did this was I took something I learned from Jonathan Grayson and his book, Freedom From OCD. I know you’re having him on for this series too. And he talked about doing all this ERP scripting, where you basically write out the worst-case scenario, what you think your OCD thinks is going to happen and you write it in either a worst-case way or an uncertainty-focused way. And what I did was after reading his book, I took that concept and I just shortened it down, and anything that my OCD was afraid of, I would just wrap may or may not surround it.  So, for instance, an example that I use in Is Fred in the Refrigerator?, my memoir, Taming OCD and Reclaiming My Life was that I used to-- when I was walking through stores like Target, if I saw one of those little plastic price tags that had fallen on the ground, if I didn’t pick it up and put it out of harm’s way, I was afraid somebody was going to slip and fall and break their neck. And it would be on some security camera that I just walked on past it and didn’t do anything. So, a typical scrupulosity obsession. And so, going shopping was really hard because I’m cleaning up the store as I’m shopping. And so, what I would do is I would either go to Target, walk past the price tag. And then as I’m just passing the price tag, I would say things. And in Target, I obviously couldn’t do this really out loud, mumble it out loud as best, but I may or may not cause somebody to kill themselves by they’re going to slip and fall on that price tag because I didn’t pick it up. I may or may not be an awful, terrible rotten human being. They may or may not catch me and throw me into jail. I may or may not rot in prison. People may or may not find out what a really bad person I really am. This may or may not be OCD, et cetera, et cetera, et cetera.  And that would allow me to be present with the obsessions, all the what-ifs – those are basically what-ifs turned into ‘may or may nots’ – without compulsing with them, without doing anything that would artificially lower my anxiety. So, it allowed me to be in the presence of those obsessive thoughts while interrupting the pattern of the mental rituals. And that’s really how I use ‘may or may nots’ and how I teach my clients to use ‘may or may nots’ today is using them to really be mindfully present of what the OCD is worried about while not interacting with that content in a way that’s going to make things worse. So, that’s how I developed it for myself. And I think that-- and that is a tool that I would say is an intermediary tool. So, I use that now in my own recovery. I don’t have to use ’may or may nots’. It’s very often at all. If I get super triggered, which doesn’t happen too terribly often, but if I get super triggered and I cannot get out of my head, I’ll use ’may or may nots’.  But I think the continuum is that you try to do something to interrupt the mental rituals, which for me is the ’may or may nots’. You can also-- people can write down the scripts, they can do a worst-case scenario. But eventually, what you’re trying to get to is you’re trying to be able to hear the OCD, what-ifs in your head and completely ignore it. And I call that my shoulders back, the way of thinking about things. Just put your shoulders back and you move on with your day. You don’t acknowledge it.  What I’ll do with clients, I’ll say, “If you had the thought of Blue Martian is going to land on my head, I mean, you wouldn’t even do anything with that thought. That thought would just go in and go out and wouldn’t get any of your attention.” That’s the way we want to treat OCD, is just thoughts can be there. I’m not going to say, “Oh, that’s my OCD.” I’m not going to say, “OCD, I’m not talking to you.” I’m not going to acknowledge it at all. I’m just going to treat it like any other weird thought that we have during the day and move on.  Your question was, how would you help somebody who comes in with mental rituals? Well, first, I want to understand where are they in their OCD recovery? How long have they been doing these mental rituals? What percentage of their compulsions are mental versus physical? What are the kind of things that their OCD is afraid of? Basically, make a list or a hierarchy of everything they’re afraid of. And then we start working on exposure therapy. And when I have them do exposures, the first exposure I do with people, we’ll find something that’s-- I start in the middle of the hierarchy. You don’t have to, but I try. And I will have them face the fear. But then I’ll immediately ask them, what is your OCD saying right now? And they’ll tell me, and I’ll say, “I want you to repeat after me.” I have them do this, and everyone that I see hates this, but I have them do it. Standing up with their shoulders back like Wonder Woman, because this type of power pose helps them. It changes the chemistry of your body and helps you feel more powerful.  OCD thinks it’s very powerful. So, I want my clients to feel as powerful as they can. So, I have them stand like Wonder Woman and they repeat after me. Somebody could-- let’s just say we are standing near something red on the floor. And I’ll say, “Well, what is your OCD saying right now?” And they’ll say, “Well, that’s blood and it could have AIDS in it, and I’m going to get sick.” I’ll say, “Well, that may or may not be a spot of blood on the floor. I may or may not get sick and I may or may not get AIDS, but I want to do this. I’m going to stay here. OCD, I want to be anxious, so bring it on.”  And that’s how we do the exposure, is I ask them what’s in their head. I have them repeat it to me until they understand what the process is. And then I’m having them be in the presence of this and just script, script, script away. That’s what I call it scripting, so that they are in the presence of whatever’s bothering them, but they’re not up in their head. And anytime something comes in their head, I teach them to pull it down into the script. Never let something be circulating in your head without saying it out loud and pulling it into the script.  I will work on this technique with clients as we’re working on exposures, because eventually what we’ll want to do is instead of going all over the place, “That may or may not be blood, I may or may not get AIDS, I may or may not get sick,” I’ll say, “Okay, of all the things you’ve just said, what does your OCD-- what is your OCD scared of the most? Let’s focus on that.” And so, “I may or may not get AIDS. I may or may not get AIDS. I may or may not have HIV. I may or may not get AIDS,” over again until people start to say, “Oh, okay. I guess I don’t have any control over this,” because what we’re trying to do is help the OCD habituate to the uncertainty. Habituate, I know that’d be a confusing word. You don’t have to habituate in order for exposure to work due to the theory of inhibitory learning, but we’re trying to help your brain get used to the uncertainty here. Kimberley: And break into a different cycle instead of doing the old rumination cycle.  Shala: Yes. And so then, I’ll teach people to just find their scariest fear. They say that over and over and over again. Then let’s hit the next one. “Well, my family may or may not survive if I die because if I get a fatal disease and I die and my family may or may not be left destitute,” and then over and over. “My family may or may not be left destitute. My family may or may not be left destitute, whatever,” until we’re hitting all the things that could be circulating in your head.  Now, some people really don’t need to do that scripting because they’re not up in their head that much. But that’s the minority of people. I think most people with OCD are doing something in their head. And a lot of people aren’t aware of what they’re doing because these mental rituals are incredibly subtle at times. And so, as people, as my clients go out and work on these exposures, I’ll have them tell me how it’s going. I have people fill out forms on my website each day as they’re doing exposures so I can see what’s going on. And if they’re not really up in their head and they don’t really need to do the ‘may or may nots’, great. That’s better. In fact, just go do the exposure and go on with your life. If they’re up in their head, then I have them do the ’may or may nots’. And so, that’s how I would start with somebody.  And so, what I’m trying to do is I’m giving them what I call a bridge tool. Because people who have been mental ritualizing for a long time, I have found it’s virtually impossible to just stop because that’s what your mind is used to doing. And so, what I’m doing is I’m giving them a competing response. And I’m saying here, instead of mental ritualizing, I’d like you to say a bunch of ’may or may nots’ statements while standing up and say them out loud while looking like Wonder Woman. Everybody rolls their eyes like, “Really?” But that’s what we do as a bridge tool. And so, they’ve lifted enough mental weights, so to speak, with this technique that they can hear the OCD and start to disengage and not interact with it at all. Then we move to that technique. Flooding Techniques for Mental Rumination Kimberley: Is there a reason why-- and for some of the listeners, they may have learned this before, but is there a reason why you use ’may or may nots’ instead of worst-case scenarios? Shala: For me, for my personal OCD recovery journey, what I found with worst-case scenario is I got too lost in the content. I remember doing-- I had had a mammogram, it had come back with some abnormal findings. I spent the whole weekend trying to do scripting about what could happen, and I was using worst-case scenario. Well, I end up in the hospital, I end up with breast cancer, I end up dead. And by the end of the weekend, I was completely demoralized. And I’m like, “Well, I don’t bother because I’m going to be dead, because I have breast cancer.” That’s where my mind took it because I’ve had OCD long enough that if I get a really scary and I start and I play around in the content, I’m going to start losing insight and I’m going to start doing depression as a compulsion, which is the blog we did talk about, where you start acting depressed because you’re believing what the OCD says like, “Oh, well, I might as well just give up, I have breast cancer,” and then becoming depressed, and then acting like it’s true. And then that’s reinforcing the whole cycle.  So, for me, worst-case scenario scripting made things worse. So, when I stayed in the uncertainty realm, the ‘may or may nots’ that helped because I was trying to help my brain understand, “Well, I may or may not have breast cancer. And if I do, I mean, I’ll go to the doctor, I’ll do what I need to do, but there’s nothing I can do about it right now in my head other than what I’m doing.” Some people like worst-case scenario and it works fine for them. And I think that works too. I mostly use ’may or may nots’ with clients unless they are unable through numbing that they might be doing. If they’re unable to actually feel what they’re saying, because they’re used to turning it over in their head and pulling the anxiety down officially, and so I can’t get a rise out of the OCD because there’s a lot of really little subtle mental compulsions going on, then I’ll insert some worst-case scenario to get the anxiety level up, to help them really feel the fear, and then pull back into ’may or may nots’. But there’s nothing wrong with worst-case scenario. But for me, that was what happened. And I think if you are prone to depression, if you’re prone to losing insight into your OCD when you’ve got a really big one, I think that’s a risk factor for using that particular type of scripting.  Magical Thinking and Mental Compulsions  Kimberley: Right. And I found that they may or may not have worked just as well, except the one thing, and I’m actually curious on your opinion on this and I have not had this conversation, is I find that people who have a lot of magical thinking benefit by worst-case scenario, like their jinxing compulsions and so forth, like the fear of saying it means it will happen. So, saying the worst-case is the best exposure. Is that true for you? Shala: I have not had to use it much on my own magically. I certainly had a lot of magical thinking. Like, if I don’t hit this green light, then somebody’s going to die. But I think the worst-case scenario, I could actually work well in that, because if you use the worst-case scenario, it can make it seem so ridiculous that it helps people let go of it more easily. And I think you can do that with ’may or may nots’ too. I’ll try to encourage people to use the creativity that they have because everybody with OCD has a ton of creativity. And we know that because the OCD shares your brain and it’s certainly the creative stuff And to one-up the OCD, you use the scripting to be like, “Gosh, I may or may not get some drug-disease and give it to my entire neighborhood. I may or may not kill off an entire section of my county. We may or may not infect the entire state of Georgia. The entire United States may or may not blow up because I got this one disease. So, they may or may not have to eject me off the earth and make me live on Mars because I’m such a bad person.” This ‘may or may not’ is in all this crazy stuff too, because that’s how to win, is to one up the OCD. It thinks that’s scary, let’s go even scarier. But the scary you get, it also gets a little bit ridiculous after a while. And then the whole thing seems to be a little bit ridiculous. So, I think you can still use that worst-case stuff with may or may not. Kimberley: Right. Okay. So, I mean, I will always sort of-- I know you really well. I’ve always held you so high in my mind in just how resilient and strong you are in doing this. How might you, or how do you help people who feel completely powerless at even addressing this? For you to say it, it sounds very like you’re just doing it and it’s so powerful. But for those who are really struggling with this idea of like, you said, coming out of your head, can you speak to how you address that in session if someone’s really struggling to engage in ’may or may nots’ and so forth? Shala: Yeah. Well, thank you for the kind words, first off. I think that it’s really common for people with OCD by the time they get to a therapist to feel completely demoralized, especially if they’ve been to multiple therapists before they get to somebody who does ERP. And so, they feel like they’re the victim at the hands of a very cruel abuser that they can’t get away from. And so, they feel beaten down and they don’t know how to get out of their heads. They feel like they’re trapped in this mental prison. They can’t get out. And if somebody is struggling like that, and they’re doing the ’may or may nots’ and the OCD is reacting, which of course, it will, and coming back at them stronger, which I always warn people, this is going to happen. When you start poking at this, the OCD is going to poke back and poke back even harder, because it wants to get you back in line so it can keep you prisoner.  So, what I’ll often do in those situations, if I see somebody is really feeling like they have been so victimized, that they’re never going to be able to get over this, is the type of script I have them do is more of an empowerment script, which could sound like this: “OCD, I’m not listening to you anymore. I’m not doing what you want. I am strong. I can do this.” And I might add some ’may or may nots’ in there. “And I want to be anxious. Come on, bring it on. You think that’s scary? Give me something else.”  I know you’re having Reid Wilson on as part of this too. I learned all that “bring it on” type stuff and pushing for the anxiety from him. And I think helping people say that out loud can be really transformative. I’ve seen people just completely break down in tears of sort of, “Oh my gosh, I could do this,” like tears of empowerment from standing up and yelling at their OCD.  If people like swearing, I also just have them swear at it, like they would really swear at somebody who had been abusing them if they had a chance, because swearing actually can make you feel more powerful too, and I want to use all the tools we can. So, I think scripting comes in a number of forms. It’s all about really taking what’s in your head, turning it into a helpful self-talk and saying it out loud. And the reason out loud is important for any type of scripting is that if you’re saying it in your head, it’s going to get mixed up with all the jumble of mental ruminating that’s going on. And saying it out loud makes it hard for you to ruminate. It’s not impossible, but it’s hard because you’re saying it. Your brain really is only processing one thing at a time. And so, if you’re talking and really paying attention to what you’re saying, it’s much harder to be up in your head spinning this around.  And so, adding these empowerment scripts in with the ’may or may nots’ helps people both accept the uncertainty and feel like they can do this, feel like they can stand up to the OCD and say, “You’ve beaten me enough. No more. This is my life. I’m not letting you ruin it anymore. I am taking this back. I don’t care how long it takes. I don’t care what I have to do. I’m going to do this.” And that builds people up enough where they can feel like they can start approaching these exposures. Kimberley: I love that. I think that is such-- I’ve had that same experience of how powerful empowerment can be in switching that behavior. It’s so important. Now, one thing I really want to ask you is, do you switch this method when you’re dealing with other anxiety disorders – health anxiety, social anxiety, panic disorder? What is your approach? Is there a difference or would you say the tools are the same? Shala: There’s a slight difference between disorders. I think health anxiety, I treat exactly like OCD. Even some of the examples I gave here were really health anxiety statements. With panic disorder-- and again, I learned this from Reid and you can ask him more about this when you interview him. But with pain disorder, it’s all about, I want to feel more shorter breath, more like their elephant standing on my chest. I want my heart to be faster. But I’m doing this while I’m having people do exercises that would actually create those feelings, like breathing through a little bit of cocktail straw, jogging, turning up a space heater, and blowing it on themselves. So, we’re trying to create those symptoms and then talk out loud and say, “Come on, I want more of this. I want to feel more anxious. Give me the worst panic attack you’ve ever had.” So, it’s all about amping up the symptoms.  With social anxiety, it’s a little bit different because with social anxiety, I would work on the cognitions first. Whereas with OCD, we don’t work on the cognitions at all, other than I want you to have a different cognitive relationship with your disorder and your anxiety. I want you to want the anxiety. I want you to want the OCD to come and bother you because that gives you an opportunity to practice. That’s the cognitive work with OCD. I do not work on the cognitive work on the content. I’m not going to say to somebody, “Well, the chance you’re going to get AIDS from that little spot of blood is very small.” That’s not going to be helpful  With social anxiety, we’re actually working on those distorted cognitions at the beginning. And so, a lot of the work with social anxiety is going to be going out and testing those new cognitions, which really turns the exposures into what we call behavioral experiments. It’s more of a cognitive method. We’re going out and saying, “Gosh, my new belief, instead of everybody’s judging me, is, well, everybody is probably thinking about themselves and I’m going to go do some things that my social anxiety wouldn’t want me to do and test out that new belief.” I might have them use that new belief, but also if their anxiety gets really high and they’re having a hard time saying, “Well, that person may or may not be judging me. They may or may not be looking at me funny. They may or may not go home and tell people about me.” But really, we’re trying to do something a little bit different with social anxiety. Kimberley: And what about with generalized anxiety? With the mental, a lot of rumination there, do you have a little shift in how you respond? Shala: Yeah. So, it’s funny that the talk that Michelle Massi and others gave at IOCDF-- I think it was at IOCDF this year about what’s the difference between OCD and GAD is they’re really aligned there. I mean, I treat GAD very similarly the way I treat OCD in that people are up in their heads trying to do things. They’re also doing other types of safety behaviors, compulsive safety behaviors, but a lot of people GAD are just up in their head. They’re just worried about more “real-life” things. But again, a lot of OCD stuff can be real-life things. I mean, look at COVID. That was real life. And people’s OCD could wrap itself around that. So, I treat GAD and OCD quite similarly. There are some differences, but in terms of scripting, we call it “worry time” in GAD. It’s got a different name, but it’s basically the same thing. Kimberley: Right. Okay. Thank you for answering that because I know some folks here listening will be not having OCD and will be curious to see how it affects them. So, is that the practice for you or is there anything else you feel like people need to know going in, in terms of like, “Here is my strategy, here is my plan to target mental rituals”? What would you say? Shala: So, as I mentioned, I think the ’may or may nots’ are bridge tool that are always available to you throughout your entire recovery. My goal with anybody that I’m working with is to help them get to the point where they can just use shoulders back. And the way that I think about this is what I call my “man in the park” metaphor. So, we’ve all probably been in a park where somebody is yelling typically about the end of the world and all that stuff. And even if you were to agree with some of the things that the person might say from a spiritual or religious standpoint, you don’t run home and go, “Oh my gosh, we got to pack all our things up because it’s the end of the world. We have to get with all of our relatives and be together because we’re all going to die.” We don’t do that. We hear what this guy’s saying, and then we go on with our days, again, even if you might agree with some of the content. Now, why do we do that? We do that because it’s not relevant in our life. We realize that person probably, unfortunately, has some problems. But it doesn’t affect us. We hear it just like when we might hear birds in the background or a car honking, and we just go on with our day. That’s how we want to treat OCD. What we do when we have untreated OCD is we run up to the man in the park and we say, “Oh my gosh, can I have a pamphlet? Let me read the pamphlet. Oh my gosh, you’re right. Tell me more, tell me more.” And we’re interacting with him, trying to get some reassurance that maybe he’s wrong, that maybe he does really mean the end of the world is coming soon. Maybe it’s going to be like in a hundred years. Eventually, we get to the point where we’re handing out pamphlets for him. “Here, everybody, take one of these.” What we’re doing with ’may or may nots’ is we’re learning how to walk by the man in the park and go, “The world may or may not be ending. The world may or may not be ending. I’m not taking a pamphlet. The world may or may not be ending.” So, we’re trying to not interact with him. We’re trying to take what he’s saying and hold it in our heads without doing something compulsive that’s going to make our anxiety higher. What we’re trying to do is practice that enough till we can get to the point where we can be in the park with the guy and just go on with our day. We hear him speaking, but we’re really-- it’s just not relevant. It’s just not part of our life. So, we just move on. And we’re not trying to shove him away. It’s just like any other noise or sound or activity that you would just-- it doesn’t even register in your consciousness. That’s what we’re trying to do.  Now I think another way to think about this is if you think-- say you’re in an art gallery. Art galleries are quiet and there are lots of people standing around, and there’s somebody in there that you don’t like or who doesn’t like you or whatever. You’re not going to walk up to that person and tap on their shoulder and say, “Excuse me, I’m going to ignore you.” You’re just going to be like, “I know that person is there. I’m just going to do what I’m doing.” And I think that’s-- I use that to help people understand this transition, because we’re basically going from ’may or may nots’ where we’re saying, “OCD, I’m not letting you do this to me anymore,” so we are being really aggressive with it, to this being able to be in the same space with it, but we’re not talking to it at all because we don’t need to, because we can be in the presence with the intrusive thoughts that the OCD is reacting to, just like the presence of all the other thousands of thoughts we have each day without interacting with them. Kimberley: That’s so interesting. I’ve never thought of it that way.  Shala: And so, that’s where I’m trying to get people because that is the strongest, strongest recovery, is if you can go do the things that you want to do, be in the presence of the anxiety and not do compulsions physical or mental, you don’t give anything for OCD to work with. I have a whole chapter in my memoir about this after I heard Reid say at one of the conferences, “We need to act as though what OCD is saying doesn’t matter.” And that was revolutionary to me to hear that. And that’s what we’re trying to do both physically and mentally. Because if you can have an obsession and focus on what you want to focus on, do what you want to do, you’re not giving OCD anything to work with. And typically, it’ll just drain away. But this takes time. I mean, it has taken me years to learn how to do this, but I went untreated for 35 years too. It may not take you years, but it may. And that’s okay. It’s a process. And I think if you have trouble trying to do shoulders back, man in the park, use ’may or may nots’. You can use the combination. But I think we’re trying to get to the point where you can just be with the OCD and hear it flipping out and just go on with your day. OCD, BDD, and Mental Rituals  Kimberley: In your book, you talk about the different voices. There is a BDD voice and an OCD voice. Was it harder or easier depending on the voice? Was that a component for you in that-- because the words and the voice sound a little different. I know in your memoir you give them different names and so forth, which if anyone hasn’t read your memoir, they need to go right now and read it. Do you have any thoughts on that in terms of the different voices or the different ways in which the disorders interact? Shala: That’s a really great question because yes, I think OCD does shift its voice and shift its persona based on how scared it is. So, if it’s a little bit scared, it’s probably going to speak to you. It’s still going to be not a very nice voice. It might be urgent and pleading. But if it’s super scared, I talk about mine being like the triad of hell, how my OCD will personify into different things based on how scared it is. And if it’s super scared and it’s going to get super big and it’s going to get super loud in your head because it’s trying desperately to help you understand you’ve got to save it because it thinks it’s in danger. That’s all its content. Then I think-- and if you have trouble ignoring it because it’s screaming in your head, like the man in the park comes over with his megaphone, puts it right up against your ear and starts talking, that’s hard to ignore. That’s hard to act like that’s not relevant because it hurts. There’s so much noise.  That’s when you might have to use a may or may not type approach because it’s just so loud, you can’t ignore it, because it’s so scared. And that’s okay. And again, sometimes I’ll have to use that. Not too terribly often just because I’ve spent a long time working on how to use the shoulder’s back, man in the park, but if I have to use it, I use it. And so, I think your thought about how do I interact with the OCD based on how aggressive it’s being also plays into this. Kimberley: I love all this. I think this is really helpful in terms of being able to be flexible. I know sometimes we want just the one rule that’s going to work in all situations, but I think you’re right. I think that there needs to be different approaches. And would you say it depends on the person? Do you give them some autonomy over finding what works for them, or what would you say?  Shala: Absolutely. If people are up in their heads and they don’t want to use ’may or may nots’, I’ll try to use some other things. If I really, really think that that’s what we need right now, is we need scripting, I’ll try to sell them on why. But at the end of the day, it’s always my client’s choice and I do it differently based on every client. For some clients, it might be just more empowering statements. For some clients where it’s more panicky focused, it might be more about bringing on your anxiety. Sometimes it might be pulling self-compassion in and just saying the self-compassion statements out loud. So, it really does vary by person. There’s no one-size-fits-all, but I think, I feel that people need to have something to replace the mental ritualizing with at the beginning that they’ve been doing it for a long time, just because otherwise, it’s like, I’m giving them a bicycle, they’ve never ridden a bicycle before and I won’t give them any training wheels. And that’s really, really hard. Some people can do it. I mean, some people can just be like, “Oh, I’m to stop doing that in my head? Okay, well, I’ll stop doing that in my head.” But most people need something to help them bridge that gap to get to the point where they can just be in the presence with it and not be talking to it in their heads. Kimberley: Amazing. All right. Any final statements from you as we get close to the end? Shala: I think that it’s important to, as you’re working on this, really think about what you’re doing in your head that might be subtle, that could be making the OCD worse. And I think talking and being willing to talk about this to therapists about putting it all out there, “Hey, I’m saying this to myself in my head, is that helpful or harmful?” Because OCD therapy can be pretty straightforward. I mean, ERP, go out and face your fears, don’t do rituals. It sounds pretty straightforward. But there is a lot of subtlety to this. And the more that you can root out these subtle mental rituals, the better that your recovery is going to be.  And know too that if you’ve had untreated OCD for a long time, you can uncover mental rituals, little bitty ones, for years after you get out of therapy. And that’s okay. It doesn’t mean you’re not in recovery. It just means that you are getting more and more insightful and educated about what OCD is. And the more that you can pick those little things out, just the better your recovery will be. But we also don’t want to be perfectionistic about that like, “I must eliminate every single mental ritual that I have or I’m not going to be in a good recovery.” That’s approaching your ERP like OCD would do. And we don’t want to do that. But we do want to be mindful about the subtleties and make sure to try to pull out as many of those subtle things that we might be doing in our heads as possible.  Kimberley: Amazing. Thank you. Tell us-- again, first, let me just say, such helpful information. And your personal experience, I think, is really validating and helpful to hear on those little nuances. Tell us where people can hear about you and the amazing projects you’ve got going on. Shala: You can go to ShalaNicely.com and I have lots of free blog posts I’ve written on this. So, there are two blog posts, two pretty extensive blog posts on ’may or may nots’. So, if you go on my website and just search may or may not, it’ll bring up two blog posts about that. If you search on shoulders back or man in the park, you’ll find two blog posts on how to do that technique. I also have a blog post I wrote in the last year or so called Shower Scripting, which is how to do ERP, like just some touch-up scripting in the shower, use that time. So, I would say go to my website and you can find all sorts of free resources. I’ve got two books. You can find on Amazon, Everyday Mindfulness for OCD, Jon Hershfield and I co-wrote. And we talk about ‘may or may nots’ and shoulders back and some of the things in there just briefly. And then my memoir, Is Fred in the Refrigerator?: Taming OCD and Reclaiming My Life, is also on Amazon or bookstores, Audible, and that kind of thing.  Kimberley: I wonder too, if we could-- I’m going to put links to all these in the show note. I remember you having a word with your OCD, a video? Shala: Oh yes, that’s true. Kimberley: Can we link that too? Shala: Yes. And that one I have under my COVID resources, because I’m so glad you brought that up. When the pandemic started, my OCD did not like it, as many people who have contamination OCD can relate to. And it was pretty scary all the time. And it was making me scared all the time. And eventually, I just wrote it a letter and I’m like, “Dude, we’re not doing this anymore.” And I read it out loud and I recorded it out loud so that people could hear how I was talking to it.  Kimberley: It was so powerful. Shala: Well, thank you. And it’s fun to do. I think the more that you can personify your OCD, the more you can think of it as an entity that is within you but is not you, and to recognize that your relationship with it will change over time. Sometimes you’re going to be compassionate with it. “Gosh, OCD, I’m so sorry,” You’re scared we’re doing this anyway. Sometimes you’re going to be aggressive with it. Sometimes you just ignore it. And that changes as you go through therapy, it changes through your life. And I think that recognizing that it’s okay to have OCD and to have this little thing, I think of like an orange ball with big feet and sunglasses is how I think about it when it’s behaving – it makes it less of an adversarial relationship over time and more like I have an annoying little sibling that, gosh, it’s just not going to ever not be there, but it’s fine. We can live together and live in this uncertainty and be happy anyway. Kimberley: I just love it. Thank you so much for being here and sharing your experience and your knowledge. It’s so wonderful. Shala: Thank you so much for having me.

SUMMARY: Covered in This Episode: What is a Mental Compulsion?  What is the difference between Mental Rumination and Mental Compulsions?  How to use Mindfulness for Mental Compulsions How to “Label and Abandon” intrusive thoughts and mental compulsions  How to use Awareness logs to help reduce mental rituals and mental rumination  Links To Things I Talk About: Links to Jon’s Books https://www.amazon.com/ Work with Jon https://www.sheppardpratt.org/care-finder/ocd-anxiety-center/ Episode Sponsor: This episode of Your Anxiety Toolkit is brought to you by CBTschool.com.  CBTschool.com is a psychoeducation platform that provides courses and other online resources for people with anxiety, OCD, and Body-Focused Repetitive Behaviors.  Go to cbtschool.com to learn more.  To learn about our Online Course for OCD, visit https://www.cbtschool.com/erp-school-lp. Spread the love! Everyone needs tools for anxiety... If you like Your Anxiety Toolkit Podcast, visit YOUR ANXIETY TOOLKIT PODCAST to subscribe free, and you'll never miss an episode. And if you really like Your Anxiety Toolkit, I'd appreciate you telling a friend (maybe even two). EPISODE TRANSCRIPTION I want you to go back and listen to that. That is where I walk you through Mental Compulsions 101. What is a mental compulsion, the types of mental compulsions, things to be looking out for. The reason I stress that you start there is there may be things you’re doing that are mental compulsions and you didn’t realize. So, you want to know those things before you go in and listen to the skills that you’re about to receive. Oh my goodness. This is just so, so exciting. I’m mind-blown with how exciting this is all for me. First of all, let’s introduce the guest for today. Today, we have the amazing Jon Hershfield. Jon has been on the episode before, even talking about mental compulsions. However, I wanted him to status off. He was so brave. He jumped in, and I wanted him to give his ideas around what is a mental compulsion, how he uses mental compulsion treatment with his clients, what skills he uses. Little thing to know here, he taught me something I myself didn’t know and have now since implemented with our patients over at my clinic of people who struggle with mental compulsions. I’ve also uploaded that and added a little bit of that concept into ERP School, which is our course for OCD, called ERP School. You can get it at CBTSchool.com.  Jon is amazing. So, you’re going to really feel solid moving into this. He gives some solid advice. Of course, he’s always so lovely and wise. And so, I am just so excited to share this with you. Let’s just get to the show because I know you’re here to learn. This is episode two of the series. Next week we will be talking with Shala Nicely and she will be dropping major truth bombs and major skills as well, as will all of the people on the series. So, I am so, so excited.  One thing to know as you move into it is there will be some things that really work for you and some that won’t. So, I’m going to say this in every episode intro. So, all of these skills are top-notch science-based skills. Each person is going to give their own specific nuanced way of managing it. So, I want you to go in knowing that you can take what you need. Some things will really be like, yes, that’s exactly what I needed to hear. Some may not. So, I want you to go in with an open mind knowing that the whole purpose of this six-part series is to give you many different approaches so that you can try on what works for you. That’s my main agenda here, is that you can feel like you’ve gotten all the ideas and then you can start to put together a plan for yourself. Let’s go over to the show. I’m so happy you’re here. ----- Kimberley: Welcome, Jon. I’m so happy to have you back. Jon: Hi, Kimberley. Thanks for having me back. Difference Between Mental Compulsions and Mental Rumination  Kimberley: Okay. So, you’re first in line and I purposely had you first in line. I know we’ve had episodes similar to this in the past, but I just wanted to really get your view on how you’re dealing with mental compulsions. First, I want to check in, do you call them “mental compulsions” or do you call it “mental rumination”? Do you want to clarify your own idea? Jon: Yeah. I say mental compulsions or mental rituals. I use the terms pretty interchangeably. It comes up at the first, usually in the assessment, if not then in the first post-assessment session, when I’m explaining how OCD works and I get to the part we say, and then there’s this thing called compulsions. And what I do is I describe compulsions as anything that you do physically or mentally to reduce distress, and this is the important part, specifically by trying to increase certainty about the content of the obsession.  Why that’s important is I think we need to get rid of this myth that sometimes shows up in the OCD community that when you do exposures or when you’re triggered, you’re just supposed to freak out and deal with it, and hopefully, it’ll go away on its own. Actually, there are many things you can do to reduce distress that aren’t compulsive, because what makes it compulsive is that it’s acting on the content of the obsession. I mean, there might be some rare exceptions where your specific obsession has to do with an unwillingness to be anxious or something like that. But for the most part, meditation, breathing exercises, grounding exercises, DBT, certain forms of distraction, exercise – these can all reduce your physical experience of distress without saying anything in particular about whether or not the thought that triggered you is true or going to come. So, once I’ve described that, then hopefully, it opens people up to realize, well, it could really be anything and most of those things are going to be mental. So then, we go through, “Well, what are the different mental ways?” We know the physical ways through washing hands and checking locks and things like that. But what are all the things you’re doing in your mind to convince yourself out of the distress, as opposed to actually working your way through the distress using a variety of distress tolerance skills, including acceptance? Kimberley: Right. Do you do the same for people with generalized anxiety or social anxiety or other anxiety disorders? Would you conceptualize it the same way? Mental Compulsions for General Anxiety Disorder vs OCD  Jon: Yeah. I think for the most part, I mean, I do meet people. Some people who I think are better understood as having generalized anxiety disorder than OCD, and identifying with that concept actually helps them approach this problem that they have of dealing with uncertainty and dealing with worry and dealing with anxiety on close to home, regular everyday issues like finance and work and health and relationships and things like that. And there’s a subsection of that people who, if you treat it like OCD, it’s really helpful. And there’s a subsection if you treat it like OCD, they think, “Oh no, I have some other psychiatric problem I have to worry about right now.” I’m a fan of treating the individual that the diagnostic terms are there to help us. Fundamentally, the treatment will be the same. What are you doing that’s sending the signal to your brain, that these ideas are threats as opposed to ideas, and how can we change that signal? Exposure & Response Prevention for Mental Compulsions  Kimberley: Right. I thank you for clarifying on that. So, after you’ve given that degree of psychoeducation, what do you personally do next? Do you want to share? Do you go more into an exposure option? Do you do more response prevention? Tell me a little bit about it, walk me through how you would do this with a client. Jon: The first thing I would usually do is ask them to educate me on what it’s really like to be them. And so, that involves some thought tracking. So, we’ll use a trigger and response log. So, I keep it very simple. What’s setting you off and what are you doing? And I’ll tell them in the beginning, don’t try too hard to get better because I want to know what your life is really like, and I’ll start to see the patterns. It seems every time you’re triggered by this, you seem to do that. And that’s where they’ll start to reveal to me things like, “Well, I just thought about it for an hour and then it went away.” And that’s how I know that they’re engaging in mental review and rumination, other things like that. Or I was triggered by the thought that I could be sick and I repeated the word “healthy” 10 times. Okay. So, they’re doing thought neutralization. Sometimes we’ll expand on that. One of the clinicians in my practice took our thought records and repurposed them as a mental behavior log. So, it’s what set you off. What did you do? What was the mental behavior that was happening at that time? And in some cases, what would’ve been more helpful? Again, I rely more on my patients to tell me what’s going on than on me to tell them “Here’s what’s going on,” so you get the best information. Logging Mental Rituals  Kimberley: Right. I love that. I love the idea of having a log. You’re really checking in for what’s going on before dropping everything down. Does that increase their distress? How do they experience that? Jon: I think a lot of people find it very helpful because first of all, it’s an act of mindfulness to write this stuff down because it’s requiring you to put it in front of you and see it, which is different than having it hit you from inside your head. And so, that’s helpful. They’re seeing it as a thought process. And I think it also helps people come to terms with a certain reality about rumination that it’s not a hundred percent compulsion in the sense that there’s an element of rumination that’s habitual. Your mind, like a puppy, is conditioned to respond automatically to certain things that it’s been reinforced to do. And so, sometimes people just ruminate because they’re alone or sitting in a particular chair. It’s the same reason why people sometimes struggle with hair-pulling disorder, trichotillomania or skin picking. It’s these environmental cues. And then the brain says, “Oh, we should do this now because this is what we do in this situation.” People give themselves a really hard time for ruminating because they’ve been told to stop, but they can’t stop because they find themselves doing it.  So, what I try to help people understand is like, “Look, you can only control what you can control. And the more that you are aware of, the more you can control. So, this is where you can bring mindfulness into it.” So, maybe for this person, there’s such a ruminator. They’re constantly analyzing, figuring things out. It’s part of their identity. They’re very philosophical. They’re not thinking of it as a compulsion, and many times they’re not thinking of it at all. It’s just happening. And then we increased their awareness, like, “Oh, okay. I got triggered. I left the building for a while. And then suddenly, I realized I was way down the rabbit hole, convinced myself that’s something terrible. So, in that moment I realized I’m supposed to stop, but so much damage has been done because I just spent a really long time analyzing and compulsing and trying to figure it out.”  So, strategies that increase our awareness of what the mind is doing are extraordinarily helpful because imagine catching it five seconds into the process and being able to say, “Oh, I’m ruminating. Okay, I don’t need to do that right now. I’m going to return my attention to what I was doing before I got distracted.” Kimberley: Right. I love the idea of this, the log for awareness, because a lot of people say, “Oh, maybe for half an hour a day.” Once they’ve logged it, they’re like, “Wow, it’s four hours a day.” I think it’s helpful to actually recognize this, like how impactful it is on their life. So, I love that you’re doing that piece. You can only control what you can control. What do you do with the stuff you can’t control? Jon: Oh, you apply heavy doses of self-criticism until you hate yourself enough to never do it again. That’s the other mental ritual that usually happens and people realize, “Oh, I’ve been ruminating,” and they’re angry at themselves. “I should know better.” So, they’re angry at themselves for something they didn’t know they were doing, which is unfair. So, I use the term, I say, “label and abandon.” That’s what you do with all mental rituals. The moment you see it, you give it a name and you drop it. You just drop it on the floor where you were, you don’t finish it up real quick. You don’t analyze too much about it and then drop it. You’re just like, “Oh, I’m holding this thing I must not hold,” and you drop it. Label and abandon. What people tend to do is criticize then label, then criticize some more and then abandon. And the real problem with that is that the self-criticism is in and of itself another mental ritual. It’s a strategy for reducing distress that’s focused on increasing certainty about the content of the obsession. The obsession, in this case, is “I’m never going to get better.” Now I know I’m going to get better because I’ve told myself that I’m being fooled and that I’ll never do that again. It’s not true. But then you wash your hands. They aren’t really clean either. So, none of our compulsions really work. Self-Compassion for Mental Compulsions  Kimberley: Doesn’t have to make sense.  Jon: Yeah. So, I think bringing self-compassion in the moment to be able to recognize it and recognize the urge to self-criticize and really just say like, “Oh, I’m not going to do that. I caught myself ruminating. Well done.” Same thing we do when we meditate. Some people think that meditation has something to do with relaxation or something to do with controlling your mind. It’s actually just a noticing exercise. Your mind wanders, you notice it. “Oh, look at that, I’m thinking.” Back to the breath. That’s a good thing that you noticed that you wandered. Not, “Oh, I wandered, I can’t focus. I’m bad at meditating.” So, it’s really just changing the frame for how people are relating to what’s going on inside.  One, eliminating self-criticism just makes life a lot easier. Two, eliminating the self-criticism and including that willingness to just label the thought pattern or the thought process and drop it right where it is. You can start to catch that earlier and earlier and earlier. So, you’re reducing compulsions. And you’ll see that the activity, the neutralizing, the figuring it out, the using your mental strength against yourself instead of in support of yourself, you could see how that’s sending the signal to the brain. “Wait, this is very important. I need to keep pushing it to the forefront.” There’s something to figure out here. This isn’t a cold case in a box, on a shelf somewhere. This is an ongoing investigation and we have to figure it out. How do we know? Because they’re still trying to figure it out. Kimberley: Right. How much do you think insight has to play here or how much of a role does it play? Jon: Insight plays a role in all forms of OCD. I mean, it plays a role in everything – insight into our relationships, insight into our career aspirations. I think one of the things I’ve noticed, and this is just anecdotal, is that the higher the distress and the poorer the distress regulation skills, often the lower the insight. Not necessarily the other way around. Some people have low insight and aren’t particularly distressed by what’s going on, but if the anxiety and the distress and the discomfort and disgust are so high that the brain goes into a brownout, I noticed that people switch from trying to get me to reassure them that their fears are untrue to trying to convince me that their fears are true. And to me, that represents an insight drop and I want to help them boost up their insight. And again, I think becoming more aware of your mental activity that is voluntary – I’m choosing to put my mind on this, I’m choosing to figure it out, it didn’t just happen. But in this moment, I’m actually trying to complete the problem, the puzzle – becoming more aware that that’s what you’re doing, that’s how you develop insight. And that actually helps with distress regulation. Kimberley: Right. Tell me, I love you’re using this word. So, for someone who struggles with distress regulation, what kind of skills would you give a client or use for yourself? Jon: So, there are many different skills a person could use. And I hesitate to say, “Look, use this skill,” because sometimes if you’re always relying on one skill and it’s not working for you, you might be resistant to using a different skill. In DBT, they have something called tip skills. So, changing in-- drastic changes in temperature, intense exercise, progressive muscle relaxation, pace breathing. These are all ways of shifting your perspective. In a more global sense, I think the most important thing is dropping out of the intellectualization of what’s happening and into the body. So, let’s say the problem, the way you know that you’re anxious is that your muscles are tense and there’s heat in your body and your heart rate is elevated. But there are lots of circumstances in your life where your muscles would be tense and your heart rate will be up and you’ll feel hot, and you might be exercising, for example.  So, that experience alone isn’t threatening. It’s that experience press plus the narrative that something bad is going to happen and it’s because I’m triggered and it’s because I can’t handle the uncertainty and all this stuff. So, it’s doing two things at once. It’s dropping out of the thought process, which is fundamentally the same thing as labeling and abandoning the mental ritual, and then dropping into the body and saying, “What’s happening now is my hands are sweaty,” and just paying attention to it. Okay, alright, sweaty hands. I can be with sweaty hands. Slowing things down and looking at things the way they are, which is not intellectual, as opposed to looking at things the way they could be, or should be, or might have been, which again is a mental ruminative process. Kimberley: Right. Do you find-- I have found recently actually with several clients that they have an obsession. They start to ruminate and then somewhere through there, it’s hard to determine what’s in control and what’s not. So, we want to preface it with that. But things get really out of control once they start to catastrophize even more. So, would you call the catastrophization a mental rumination, or would you call it an intrusive thought? How would you conceptualize that with a client? They have the obsession, they start ruminating, and then they start going to the worst-case scenario and just staying there. Jon: Yeah. There’s different ways to look at it. So, catastrophizing is predicting a negative future and assuming you can’t cope with it, and it’s a way of thinking about a situation. So, it’s investing in a false project. The real project is there’s something unknown about the future and it makes you uncomfortable and you don’t like it. How do you deal with that? That’s worth taking a look at. The false project is, my plane is going to crash and I need to figure out how to keep the plane from crashing. But that’s how the OCD mind tends to work. So, one way of thinking about catastrophizing is it’s a tone it’s a way-- if you can step back far enough and be mindful of the fact that you’re thinking, you can also be mindful of the fact that there is a way that you’re thinking. And if the way that you’re thinking is catastrophizing, you could say, “Yeah, that’s catastrophizing. I don’t need to do that right now.”  But I think to your point, it is also an act. It’s something somebody is doing. It’s like, I’m going to see this through to the end and the hopes that it doesn’t end in catastrophe, but I’m also going to steer it into catastrophe because I just can’t help myself. It’s like a hot stove in your head that you just want to touch and you’re like, “Ouch.” And in that case, I would say, yeah, that’s a mental ritual. It’s something that you’re doing.  I like the concept of non-engagement responses. So, things that you can do to respond to the thought process that aren’t engaging it directly, that are helping you launch off. Because like I said, before you label and abandon. But between the label and abandon, a lot of people feel like they need a little help. They need something to drive a wedge between them and the thought process. Simply dropping it just doesn’t feel enough, or it’s met with such distress because whenever you don’t do a compulsion, it feels irresponsible, and they can’t handle that distress. So, they need just a little boost.  What do we know about OCD? We know that the one thing you can’t do effectively is defend yourself because then you’re getting into an argument and you can’t win an argument against somebody who doesn’t care what the outcome of the argument is. The OCD just wants to argue. So, any argument, no matter how good it is, the OCD is like, “Great, now we’re arguing again.” How to Manage Mental Compulsions  Kimberley: Yeah. “I got you.” Jon: Yeah. So, what are our options? What are our non-engagement response options? One, which I think is completely undersold, is ignoring it. Just ignoring it. Again, none of these you want to only focus on because they could all become compulsive. And then you’re walking around going, “I’m ignoring it, I’m ignoring it.” And then you’re just actually avoiding it. But it’s completely okay to just choose not to take yourself seriously. You look at your email and it’s things that you want. And then in there is a junk mail that just accidentally got filtered into the inbox instead of the spam box, and mostly what you do is ignore it. You don’t even read the subject of it. You recognize that in the moment, it’s spam and you move on as if it wasn’t even there. Then there’s being mindful of it. Mindful noting. Just acknowledging it. You take that extra beat to be like, “Oh yeah, there’s that thought.” In act, they would call this diffusion. I’m having a thought that something terrible is going to happen. And then you’re dropping it. So, you’re just stepping back and be like, “Oh, I see what’s going on here. Okay, cool. But I’m not going to respond to it.” And then as we get into more ERP territory, we also have the option of agreeing with the uncertainty that maybe, maybe not. “What do I know? Okay. Maybe the plane is going to crash. I can’t be bothered with this.” But you have to do it with attitude because if you get too involved in the linguistics of it, then it’s like, well, what’s the potential that it’ll happen? And you can’t play that game, the probability game.  But it is objectively true that any statement that begins with the word “maybe” has something to it. Maybe in the middle of this call, this computer is going to explode or something like that. It would be very silly for me to worry about that, but you can’t deny that the statement is true because it’s possible. It’s maybe. So, just acknowledging that, be like, “Okay, fine. Maybe.” And then dropping it the way you would if you had some thought that you didn’t find triggering and yet was still objectively true.  And then the last one, which can be a lot of fun, can also be overdone, can also become compulsive, but if done well can make life a little bit more fun, is agreeing with the thought in an exaggerated humorous, sarcastic way. Just blowing it up. So, you’re out doing the OCD. The OCD is very creative, but you’re more creative than the OCD. Kimberley: Can you give me examples? Jon: Well, the OCD says your plane is going to crash. He said, your plane is going to crash into a school. Just be done with it, right? And that kind of shock where the bully is expecting you to defend yourself and instead, you just punched yourself in the face. He’s like, “Yeah, you’re weird. I’m not going to bother you anymore.” That’s the relationship one wants with their OCD. Kimberley: That’s true. I remember in a previous episode we had with, I think it was when you had brought out your team book about saying “Good one bro,” or “brah.” Jon: “Cool story, brah.” Yeah.  Kimberley: Cool story brah. And I’ve had many of my patients say that that was also really helpful, is there’s a degree of attitude that goes with that, right? Jon: Yeah. And because again, it’s just a glitch in the system that, of course, you’re conditioned to respond to it like it’s serious. But once you realize it is, once you get the hint that it’s OCD, you have to shift out of that, “Oh, this is very important, very serious,” and into this like, “This is junk mail.” And if you actually look at your junk mail, none of it is serious. It sounds serious. It sounds like I just inherited a billion dollars from some prince in Nigeria. That sounds very important. I Kimberley: I get that email every day pretty much.  Jon: Yeah. But I look at it and immediately I know that it’s not serious, even though the words in it sound very important.  Kimberley: Yeah. So, for somebody, I’m sitting in the mind of someone who has OCD and is listening right now, and I’m guessing, to those who are listening, you’re nodding and “Yes, this is so helpful. This is so helpful.” And then we may finish the episode and then the realization that “This is really hard” comes. How much coaching, how much encouragement? How do you walk someone through treatment who is finding this incredibly difficult? Jon: I want to live in your mind. In my mind, let that same audience member is like, “This guy sucks.” Kimberley: My mind isn’t so funny after we start the recording. So, you’re cool. Jon: Who is this clown? Again, it’s back to self-compassion. I’m sure people are tired of hearing about it, but it’s simply more objective. It is hard. And if you’re acting like it shouldn’t be hard or you’re doing something wrong as a function, it’s hard because you’re doing something wrong, you’re really confused. How could that be? You could not have known better than to end up here. Everything that brought you here was some other thought or some other feeling, and you’re just responding to your environment. The question is right now where you have some control, what are you going to do with your attention? Right now, you’re noticing, “Oh man, it’s really hard to resist mental rituals. It’s hard to catch them. It’s hard to let go of them. It’s hard to deal with the anxiety of thinking because I didn’t finish the mental ritual. Maybe I missed something and somebody’s going to get hurt or something like that because I didn’t figure it out.”  It is really hard. I don’t think we should pretend that it’s easy. We should acknowledge that it’s hard. And then we should ask, “Okay, well, I made a decision that I’m going to do this. I’m going to treat my OCD and it looks like the treatment for OCD is I’m going to confront this uncertainty and not do compulsions. So, I have to figure out what to do with the fact that it’s hard.” And then it’s back to the body. How do you know that it’s hard? “Well, I could feel the tension here and I could feel my heart rate and my breath.” So, let’s work with that. How can I relate to that experience that’s coming up in a way that’s actually helpful? The thing that I’ve been thinking about a lot lately is this idea that the brain is quick to learn that something is dangerous. Something happens and it hurts, and your brain is like, “Yeah, let’s not do that again.” And you might conclude later that that thing really wasn’t as dangerous as you thought. And so, you want to re-engage with it. And you might find that’s really hard to do, which is why exposure therapy is really hard because it’s not like a one-and-done thing. You have to practice it because the brain is very slow to learn that something is safe, especially after it’s been taught that it’s dangerous.  But that’s not a bad thing. You want a brain that does that. You don’t want a brain that’s like, “Yeah, well, I got bit by one dog, but who cares? Let’s go back in the kennel.” You want a brain that’s like, “Hold on. Are you sure about this?” That whole process of overcoming your fears, I think people, again, they’re way too hard on themselves. It should take some time and it should be slow and sluggish. You look like you’re getting better, and then you slip back a little bit, because it’s really just your brain saying, “Listen, I’m here to keep you safe, and I learned that you weren’t, and you are not following rules. So, I’m pulling you back.” That’s where that is coming from. So, that’s the hard feeling. That’s the hard feeling right there. It’s your brain really trying to get you to say, “No, go back to doing compulsions. Compulsions are keeping you safe.” You have to override that circuit and say, “I appreciate your help. But I think I know something that you don’t. So, I’m going to keep doing this.” And then you can relate to that hard feeling with like, “Good, my brain works. My brain is slow and sluggish to change, but not totally resistant. Over time, I’m going to bend it to my will and it will eventually let go, and either say this isn’t scary anymore or say like, ‘Well, it’s still scary, but I’m not going to keep you from doing it.’” Kimberley: Right. I had a client at the beginning of COVID I think, and the biggest struggle-- and this was true for a lot of people, I think, is they would notice the thought, notice they’re engaging in compulsions and drop it, to use your language, and then go, “Yay, I did that.” And then they would notice another thought in the next 12 seconds or half a second, and then they would go, “Okay, notice it and drop it.” And then they’d do it again. And by number 14, they’re like, “No, this is--” or it would either be like, “This is too hard,” or “This isn’t working.” So, I’m wondering if you could speak to-- we’ve talked about it being “too hard.” Can you speak to your ideas around “this isn’t working”? Jon: Yeah. That’s a painful thought. I think that a lot of times, people, when they say it isn’t working, I ask them to be more specific because their definition of working often involves things like, “I was expecting not to have more intrusive thoughts,” or “I was expecting for those thoughts to not make me anxious.” And when you let go of those expectations, which isn’t lowering them at all, it’s just shifting them, asking, well, what is it that you really want to do in your limited time on this earth? You’re offline for billions of years. Now you’re online for, I don’t know, 70 to 100 if you’re lucky, and then you’re offline again. So, this is the time you have. So, what do you want to do with your attention? And if it’s going to be completely focused on your mental health, well, that’s a bummer. You need to be able to yes, notice the thought, yes, notice the ritual, yes, drop them both, and then return to something.  In this crazy world we’re living in now where we’re just constantly surrounded by things to stimulate us and trigger us and make us think, we have lots of things to turn to that aren’t necessarily healthy, but they’re not all unhealthy either. So, it’s not hard to turn your attention away from something and into a YouTube video or something like that. It is more challenging to shift your attention away from something scary and then bring it to the flavor of your tea. That’s a mindfulness issue. That’s all that is. Why is one thing easier than the other? It’s because you don’t think the flavor of your tea is important. Why? Because you’re just not stimulated by the firing off of neurons in your tongue and the fact that we’re alive on earth and that we’ve evolved over a million years to be able to make and taste tea. That’s not as interesting as somebody dancing to a rap song. I get that, but it could be if you’re paying a different kind of attention. So, it’s just something to consider when you’re like, “Well, I can’t return to the present because it doesn’t engage me in there.” Something to consider, what would really engage you and what is it about the present that you find so uninteresting? Maybe you should take another look. Kimberley: Right. For me, I’m just still so shocked that gravity works. Whenever I’m really stuck, I will admit, my rumination isn’t so anxiety-based. I think it’s more when I’m angry, I get into a ruminative place. We can do that similar behavior. So, when I’m feeling that, I have to just be like, “Okay, drop away from, that’s not helpful. Be aware and then drop it.” And then for me, it’s just like, “Wow, the gravity is pulling me down. It just keeps blowing my mind.” Jon: Yeah. That’s probably a better use of your thought process than continuing to ruminate. But you bring up another point. I think this speaks more closely to your question about when people say it’s not working. I’m probably going to go to OCD jail for this, but I think to some extent, when you get knocked off track by an OCD trigger, because you made me think of it when you’re talking about anger. Like, someone says something to you and makes you angry and you’re ruminating about it. But it’s the same thing in OCD. Something happens. Something triggers you to think like, “I’m going to lose my job. I’m a terrible parent,” or something like that. You’re just triggered. This isn’t just like a little thought, you’re like, “Oh, that’s my OCD.” You can feel it in your bones. It got you. It really got you.  Now, you can put off ruminating as best you can, but you’re going to be carrying that pain in your bones for a while. It could be an hour, could be a day, could be a couple of days. Now, if it’s more than a couple of days, you have to take ownership of the fact that you are playing a big role in keeping this thing going and you need to change if you want different results. But if it’s less than a couple of days and you have OCD, sometimes all you can do is just own it. “All right, I’m just going to be ruminating a lot right now.” And I’m not saying like, hey, sit there and really try to ruminate. But it’s back to that thing before, like your brain is conditioned to take this seriously, and no matter how much you tell yourself it’s not serious, your brain is going to do what your brain is going to do. And so, can you get your work done? Try to show up for your family, try to laugh when something funny happens on TV, even while there’s this elephant sitting on your chest. And every second that you’re not distracted, your mind is like, “Why did they say that? Why did I do that? What’s going to happen next?” And really just step back from it and say like, “You know what, it’s just going to have to be like this for now.” What I see people do a lot is really undersell how much that is living with OCD. “I’m not getting better.” I had this happen actually just earlier today. Somebody was telling me, walking me through this story that was just full of OCD minds that they kept stepping on and they kept exploding and they were distressed and everything. And yet, throughout the whole process, the only problem was they were having OCD and they were upset. But they weren’t avoiding the situation. They weren’t asking for reassurance and they weren’t harming themselves in any way. They were just having a rough time because they just had their buttons pushed. It was frustrating because they wouldn’t acknowledge that that is a kind of progress that is living with this disorder, which necessarily involves having symptoms.  I don’t want people to get confused here and say like, “This is as good as it gets,” or “You should give up hope for getting better.” It’s not about that. Part of getting better is really owning that this is how you show up in the world. You have your assets and your liabilities, and sometimes the best thing to do is just accept what’s going on and work through it in a more self-compassionate way. Kimberley: Right. I really resonate with that too. I’ve had to practice that a lot lately too of accepting my humanness. Because I think there are times where you catch yourself and you’re like, “No, I should be performing way up higher.” And then you’re like, “No, let’s just accept these next few days are going to be rough.” I like that. I think that that’s actually more realistic in terms of what recovery really might look like. This is going to be a rough couple of days or a rough couple of hours or whatever it may be. Jon: Yeah. If you get punched hard enough in the stomach and knock the wind out of you, that takes a certain period of time before you catch your breath. And if you get punched in the OCD brain, it takes a certain amount of time before you catch your breath. So, hang on. It will get better. And again, this isn’t me saying, just do as many compulsions as you want. It’s just, you’re going to do some, especially rumination and taking ownership of that, “Oh man, it’s really loud in there. I’ve been ruminating a lot today. I’ll just do the best I can.” That’s going to be a better approach than like, “I’m going to sit and track every single thought and I’m going to burn it to the ground. I’m going to do it every five seconds.” Really, you’re just going to end up ruminating more that way. Kimberley: Right. And probably beating yourself up more. Jon: Exactly. Kimberley: Right. Okay. I feel like that is an amazing place for us to end. Before we do, is there anything you feel like we’ve missed that you just want people to know before we finish up? Jon: I guess what’s really important to know since we’re talking about mental compulsions is that it’s not separate from the rest of OCD and it’s not harder to treat. People have this idea that, well, if you’re a compulsive hand-washer, you can just stop washing your hands or you can just remove the sink or something like that. But if you’re a compulsive ruminator about whether or not you’re going to harm someone or you’re a good person or any of that stuff, somehow that’s harder to treat. I’ve not found this to be the case. Anecdotally, I haven’t seen any evidence that this is really the case in terms of research. You might be harder on yourself in some ways, and that might make your symptoms seem more severe, but that’s got nothing to do with how hard you are to treat or the likelihood of you getting better. Most physical rituals are really just efforts to get done what your mental rituals are not doing for you. So, many people who are doing physical rituals are also doing mental rituals and those who aren’t doing physical rituals. Again, some people wash their hands. Some people wash their minds. Many people do both. A lot of this stuff, it has to do with like, “I expect my mind to be one way, and it’s another.” And that thing that’s making it another is a contaminant, “I hate it and I want to go away and I’m going to try to get it to go away.” And that’s how this disorder works. Kimberley: Right. It’s really, really wonderful advice. I think that it’s actually really great that you covered that because I think a lot of people ask that question of, does that mean that I’m going to only have half the recovery of someone who does physical compulsions or just Googles or just seeks reassurance? So, I think it’s really important. Do you feel like someone can overcome OCD if their predominant compulsion is mental? Jon: Absolutely. They may even have assets that they are unaware of that makes them even more treatable. I mean, only one way to find out. Kimberley: Yeah. I’m so grateful to you. Thank you for coming on. This is just filling my heart so much. Thank you. Jon: Thank you. I always love speaking with you. Kimberley: Do you want to share where people can find you and all your amazing books and what you’re doing? Jon: My hub is OCDBaltimore.com. That’s the website for the Center for OCD and Anxiety at Sheppard Pratt, and also the OCD program at The Retreat at Sheppard Pratt. And I’m on Instagram at OCDBaltimore, Twitter at OCDBaltimore. I don’t know what my Facebook page is, but it’s out there somewhere. I’m not hard to find. Falling behind a little bit on my meme game, I haven’t found anything quite funny or inspiring enough. I think I’ve toured through all of my favorite movies and TV shows. And so, I’m waiting for some show that I’m into to inspire me. But someone asked me the other day, “Wait, you stopped with the memes.” Kimberley: They’re like, nothing’s funny anymore. Jon: I try not to get into that headspace. Sometimes I do think that way, but yeah, the memes find me. I don’t find them. Kimberley: I love it. And your books are all on Amazon or wherever you can buy books, I’m imagining. Jon: Yes. The OCD Workbook For Teens is my most recent one and the second edition of the Mindfulness Workbook for OCD is also a relatively recent one. Kimberley: Amazing. You’re amazing. Thank you so much. Jon: Thank you.

SUMMARY: Welcome to the first week of this 6-part series on Mental Compulsions.  This week is an introduction to mental compulsions.   Ove the next 6 weeks, we will hear from many of the leaders in our feild on how to manage mental compulsions using many different strategies and CBT techniques.  Next week, we will have Jon Hershfield to talk about how he using mindfulness to help with mental compulsions and mental rituals. In This Episode: What is a mental compulsion? Is there a different between a mental compulsion and mental rumination and mental rituals? What is a compulsion? Types of Mental Compulsions Links To Things I Talk About: How to reach Jon https://www.sheppardpratt.org/care-finder/ocd-anxiety-center/ ERP School: https://www.cbtschool.com/erp-school-lp Episode Sponsor: This episode of Your Anxiety Toolkit is brought to you by CBTschool.com. CBTschool.com is a psychoeducation platform that provides courses and other online resources for people with anxiety, OCD, and Body-Focused Repetitive Behaviors. Go to cbtschool.com to learn more. Spread the love! Everyone needs tools for anxiety... If you like Your Anxiety Toolkit Podcast, visit YOUR ANXIETY TOOLKIT PODCAST to subscribe free and you'll never miss an episode. And if you really like Your Anxiety Toolkit, I'd appreciate you telling a friend (maybe even two). EPISODE TRANSCRIPTION This is Your Anxiety Toolkit - Episode 282 and the first part of a six-part series that I am overwhelmed and honored to share with you – all on mental compulsions. I have wanted to provide a free resource on mental compulsions for years, and I don’t know why, but I finally got enough energy under my wings and I pulled it off and I could not be more excited. Let me tell you why. This is a six-part series. The next six episodes will be dedicated to managing mental compulsions, mental rituals, mental rumination. I will be presenting today the first part of the training, which is what we call Mental Compulsions 101. It will talk to you about all the different types of mental compulsions, give you a little bit of starter training. And then from there, it gets exciting. We have the most incredible experts in the field, all bringing their own approach to the same topic, which is how do we manage mental compulsions? We don’t talk about mental compulsions enough. Often, it’s not addressed enough in treatment. It’s usually very, very difficult to reduce or stop mental compulsion. I thought I would bring all of the leaders, not all of them, the ones I could get and the ones that I had the time to squeeze into this six-part series, the ones that I have found the most beneficial for my training and my education for me and my stuff. I asked very similar questions, all with the main goal of getting their specific way of managing it, their little take, their little nuance, fairy tale magic because they do work magic. These people are volunteering their time to provide this amazing resource. Welcome to number one of a six-part series on mental compulsions. I hope you get every amazing tool from it. I hope it changes your life. I hope you get out your journal and you write down everything that you think will help you and you put it together and you try it and you experiment with it and you practice and you practice because these amazing humans are so good and they bring such wisdom. I’m going to stop there because I don’t want to go on too much. Of course, I will be starting. And then from there, every week for the next five weeks after this one, you will get a new take, a new set of tools, a new way of approaching it. Hopefully, it’s enough to really get you moving in managing your mental compulsion so you can go and live the life that you deserve, so that you can go and do the things you want without fear and anxiety and mental compulsions taking over your time. Let’s do this. I have not once been more excited, so let’s do this together. It is a beautiful day to do hard things and so let’s do it together. Welcome, everybody. Welcome to Mental Compulsions 101. This is where I set the scene and teach you everything you need to know to get you started on understanding mental compulsions, understanding what they are, different kinds, what to do, and then we’re going to move over and let the experts talk about how they personally manage mental compulsions. But before they shared their amazing knowledge and wisdom, I wanted to make sure you all had a good understanding of what a mental compulsion is and really get to know your own mental compulsions so you can catch little, maybe nuanced ways that maybe you’re doing mental compulsions. I’m going to do this in a slideshow format. If you’re listening to this audio, there will be a video format that you can access as well here very soon. I will let you know about that. But for right now, let’s go straight into the content. Who is Kimberley Quinlan? First of all, who am I? My name is Kimberley Quinlan. A lot of you know who I am already. If you don’t, I am a marriage and family therapist in the State of California. I am an Australian, but I live in America and I am honored to say that I am an OCD and Anxiety Specialist. I treat all of the anxiety disorders. I also treat body-focused repetitive behaviors, and we specialize in eating disorders as well. The reason I tell you all that is you probably will find that many different disorders use mental compulsions as a part of their disorder. My hope is that you all feel equally as included in this series. Now, as well as a therapist, I’m also a mental health educator. I am the owner, the very proud owner of CBTSchool.com. It is an online platform where we offer free and paid resources, educational resources for people who have anxiety disorder orders or want to just improve their mental health. I am also the host of Your Anxiety Toolkit Podcast. You may be watching this in a video format, or you may actually be listening to this because it will also be released. All of this will be offered for free on Your Anxiety Toolkit Podcast as well. I wanted to just give you all of that information before we get started so that you know that you can trust me as we move forward. Here we go. What is a Mental Compulsion? First of all, what is a mental compulsion? Well, a mental compulsion is something that we do mentally. The word “compulsion” is something we do, but in this case, we’re talking about not a physical behavior, but a mental behavior. We do it in effort to reduce or remove anxiety, uncertainty, some other form of discomfort, or maybe even disgust. It’s a behavior, it’s a response to a discomfort and you do that response in a way to remove or resist the discomfort that you’re feeling. Now, we know that in obsessive-compulsive disorder, there are a lot of physical compulsions. A lot of us know these physical compulsions because they’ve been shown in Hollywood movies. Jumping over cracks, washing our hands, moving objects – these are very common physical compulsions – checking stoves, checking doors. Most people are very understanding and acknowledge that as being a part of OCD. But what’s important to know is that a lot of people with OCD don’t do those physical compulsions at all. In fact, 100% of their compulsions are done in their head mentally. Now, this is also very true for people with generalized anxiety. It’s also very true for some people with health anxiety or an eating disorder, many disorders engage in mental compulsions. Mental Compulsion Vs Mental Ritual? For the sake of this series, we use the word “mental compulsion,” but you will hear me, as we have guests, you will hear me ask them, do you call them “mental compulsions”? Some people use the word “mental ritual.” Some people use the word “mental rumination.” There are different ways, but ultimately throughout this series, we’re going to mostly consider them one and the same. But again, just briefly, a mental compulsion is something you do inside of your mind to reduce, remove, or resist anxiety, uncertainty, or some form of discomfort that you experience. Let’s keep moving from here. What is a Compulsion Now, who does mental compulsions? I’ve probably answered that for you already. Lots of people do mental compulsions. Again, it ranges over a course of many different anxiety disorders and other disorders, including eating disorders. But again, generalized anxiety, social anxiety, phobias, health anxiety, post-traumatic stress disorder. Some of the people with that mental disorder also engage in mental compulsions. Predominantly, we talk a lot about the practice of mental compulsions for people with obsessive-compulsive disorder. The thing to remember is it’s more common than you think, and you’re probably doing more of them than you guessed. I’m hoping that this 101 training will help you to be able to identify the compulsions you’re doing so that when we go through this series, you have a really good grasp of where you could practice those skills. Now, often when people find out they’re doing mental compulsions, they can be very hard on themselves and berate and criticize themselves for doing them. I really want to make this a judgment-free and punish-free zone where you’re really gentle with yourself as you go through this series. It’s very important that you don’t use this information as a reason to beat yourself up even more. So let’s make a deal. We’re going to be as kind and non-judgmental as we can, as we move through this process. Compassion is always number one. Do we have a deal? Good. Types of Mental Compulsions Here is the big question: Are there different types of mental compulsions? Now, I’m going to proceed with caution here because there is no clear differentiation between the different compulsions. I did a bunch of research. I also wrote a book called The Self-Compassion Workbook For OCD. There is no specific way in which all of the psychological fields agree on what is different types of mental compulsions. There are some guidelines, but there’s no one list. I want to proceed with caution first by letting you know this list that we use with our patients. Now, as you listen, you may have different names for them. Your therapist may use different terminology. That’s all fine. It doesn’t mean what you have done is wrong or what we are doing is wrong. To be honest with you, this would be a 17-hour training if I were to be as thorough as listing out every single one. For the sake of clarity and simplicity, I’ve put them into 10 different types of mental compulsions. If you have ones that aren’t listed, that doesn’t mean it’s not a mental compulsion. I encourage you to just check in. If you have additional or you have a different name, that’s totally okay. Totally okay. We’re just using this again for the sake of clarity and simplicity. Here we go. 1. Mental Repeating The first mental compulsion that we want to look at is mental repeating. This is where you repeat or you make a list of individual items or categories. It can also involve words, numbers, or phrases. Often people will do this for two reasons or more, like I said, is they may repeat them for reassurance. They may be repeating to see whether they have relief. They may be repeating them to see if they feel okay. They may be repeating them to see if any additional obsessions arise, or they may be repeating them to unjinx something. Now, that’s not a clinical term, so let’s just put that out there. What I mean by this is some people will repeat things because they feel like the first time something happened, it was jinx. Like it will mean something bad will happen. It’s been associated with something bad, so they repeat it to unjinx it. We’ll talk more about neutralizing compulsions here in a second, but that’s in regards to mental repeating. You may do it for a completely different reason. Don’t worry too much as we go through this on why you do it. Just get your notepad out and your pencil out and just take note. Do I do any mental repeating compulsions? Not physical. Remember, we’re just talking about mental in this series. 2. Mental Counting This is where you either count words, count letters, count numbers, or count objects. Again, you will not do this out loud. Well, sometimes you may do it out loud in addition to mental, but we’re mostly talking about things you would do silently in your head. Again, you may do this for a multitude of reasons, but again, we want to just keep tabs. Am I doing any mental counting or mental counting rituals? 3. Neutralization Compulsions or Neutralizing Compulsions What we’re talking about here is you’re replacing an obsession with a different image or word. Let’s say you are opening your computer. As you opened the computer, you had an intrusive thought that you didn’t like. And so in effort to neutralize that thought, you would have the opposite thought. Let’s say you had a thought, a number. Let’s say you’ve had the number that you feel is a bad number. You may neutralize it by then repeating a positive number, a number that you like, or a safe number. Or you may do a behavior, you may see something being done and you have a negative thought. So then, you recall a different thought or a prayer, it could be also a prayer, to undo that bad feeling or thought or sensation. Now, when it comes to compulsive prayer, that could be done as a neutralization. In fact, I almost wanted to make prayer its own category, because a lot of people do engage in compulsive prayer, particularly those who have moral and scrupulous obsessions. Again, not to say that all prayer is a compulsion at all, but if you are finding that you’re doing prayer to undo a bad thought or a bad feeling or a bad sensation or a bad urge – when I say bad, I mean unwanted – we would consider that a neutralization or a neutralizing compulsion. 4. Hypervigilance Compulsions Now again, this is the term we use in my practice. Remember here before we proceed that hypervigilance is an obsession, meaning it can be automatic, unwanted, intrusive, but it can also be a compulsive behavior. It could be both or it could be one. But when I talk about the term “hypervigilance compulsions,” this is also true for people with post-traumatic stress disorder, is it’s a scanning of the environment. It’s a scanning, like looking around. I always say with my clients, it’s like this little set of eyes that go doot, doot, doot, doot really quick, and they’re scanning for danger, scanning for potential fear or potential problems. They also do that when we’re in a hypervigilance compulsion. We may do that with our thoughts. We’re scanning thoughts or we’re scanning sensations like, is this coming? What’s happening? Where am I feeling things? You may be scanning and doing hypervigilance in regards to feeling like, am I having a good thought or a bad thought or a good feeling or a bad feeling? And then making meaning about that. You may actually also be hypervigilant about your reaction. If let’s say you saw something that usually you would consider concerning and this time you didn’t, you might become very hypervigilant. What does that mean? I need to make sure I always have this feeling because this feeling would mean I’m a good person or only good things will happen. The last one again is emotions, which emotions and feelings can sometimes go in together. Hypervigilant compulsion is something to keep an eye out. It could be simple as you just being hypervigilant, looking king around. Often this is true for people with driving obsessions or panic disorder. They’re constantly looking for when the next anxiety attack is coming. 5. Mental Reassurance We can do physical reassurance, which is looking at Google, asking a friend like, are you sure nothing bad will happen? We can do physical, but we can also do mental reassurance, which is mentally checking to confirm an obsession is not or will not become a threat. This is true for basic like we already talked about and some checking and repeating behaviors. You may mentally stare at the doorknob to make sure it is locked. You may mentally check and check for reassurance once, twice, five times, ten times, or more. If the stove is off or that you are not having arousal is another one, or that you are not going to panic. You may be checking to get reassurance mentally that your fear is not going to happen. Again, some people’s fear is fear itself. The fear of having a panic attack is very common as well. Again, we’re looking for different ways that mentally we are on alert for potential danger or perceived danger. 6. Mental Review We’ve talked a lot about behaviors that we’re doing in alert of anxiety. Mental review is reviewing and replaying past situations, figuring out the meaning of internal experiences, such as, what is the meaning of the thought I had? What is the meaning of the feeling I had? What is the meaning of that sensation? What does that mean? What is the meaning of an image that just showed up intrusively and repetitively in my mind? What is the meaning of an urge I have? This is very true for people with harm obsessions or sexual obsessions. When they feel an urge, they may review for hours, what did that mean? What does that mean about me? Why am I having those? And so the review piece can be very painful. All of these are very painful and take many, many hours, because not only are you reviewing the past, which can be hard because it’s hard to get mental clarity of the past, but then you’re also trying to figure out what does that mean about me or the world or the future. So, just things to think about. To be honest, mental review could cover all of the categories that we’ve covered, because it’s all review in some way. But again, for the sake of clarity and simplicity, I’ve tried to break them up. You may want to break them up in different ways yourself. That is entirely okay. I just wanted to give you a little category here on its own. 7. Mental Catastrophization This is where you dissect and scrutinize past situations with potential catastrophic scenarios. Now, I made an error here because a lot of people do this about the future as well. But we’ll talk about that here in a little bit. Mental catastrophization, if you have reviewed the past and you’re going over all of the potential terrible situations. This is very true for people who review like, what did I say? Was that a silly thing to say? Was that a good thing to say? What would they think about me? Mental catastrophization is reviewing the past, but is also the future and reviewing every possible catastrophic scenario or opportunity that happened. Whether it happened or not, it doesn’t really matter when it comes to mental compulsions. Usually, when someone does a mental compulsion, they’re reviewing maybe’s, the just in case it does happen, I better review it. 8. Mental Solving Very similar, again, which is anticipating future situations with or without potential what-if scenarios. Very similar to catastrophization compulsions. This is where you’re looking into the future and going, “What if this happens? What if that happens? What if this happens? Well, what if that happens?” and going through multiple, sometimes dozens of scenarios of the worst-case scenarios on what may or may not happen. Again, it usually involves a lot of catastrophizing. But again, these are all safety behaviors. None of this means there’s anything wrong with you or that you’re bad or that you’re not strong. Remember, our brain is just trying to survive. In the moment when we are doing these, our brain actually thinks it’s coming up with solutions, but what we have to do, and all of the guests will talk about this, is recognize. Most of the time, the problem isn’t actually happening. We’re just having thoughts that it’s happening. Again, this is reviewing thoughts of potential what-if scenarios. 9. Mental Self-Punishment I talk a lot about this in my book, The Self-Compassion Workbook For OCD. Mental self-punishment is a compulsion, a mental compulsion that is not talked about enough. One is criticizing, withholding pleasure, harshly disciplining yourself for your obsessions or even the compulsions that you’ve done. Often, we do this as a compulsion, meaning we think that if we punish ourselves, that will prevent us from having the obsession or the compulsion in the future. The fact here is beating yourself up actually doesn’t reduce your chances of having thoughts and feelings and sensations and behaviors or urges. But that is why we do them. It’s to catch when you are engaging in criticizing or withholding or punishing compulsions. 10. Mental Comparison Again, not a very common use of compulsions, but this is one I like to talk about a lot. Most of my patients with OCD and with anxiety will say that they know for certain that they compare more than their friends and family members who do not have anxiety disorders. I’ve put it here just so that you can catch when you are engaging in mental comparison, which is comparing your own life with other people’s life, or comparing your own life with the idea that you thought you should have had for your life. So, an idea of how your life was supposed to be. This is a compulsive behavior because it’s done again to reduce or remove a feeling or a sensation or a discomfort of anxiety or uncertainty you have around your current situation. It’s really important to catch that as well because there’s a lot of damage that can be done from comparing a lot with other people or from a fantasy that you had about the way your life should or shouldn’t look. Again, we will talk about this in episodes, particularly with Jonathan Grayson. He talks a lot about this one. I just wanted to add that one in as well. They’re the main top 10 mental compulsions. Again, I want to stress, these are not a conclusive list that is the be-all and end-all. A lot of clinicians may not agree and they may have different ways of conceptualizing them. That is entirely okay. I’m never going to pretend to be the knower of all things. That is just one way that we conceptualize it here at our center with our staff and our clients to help patients identify ways in which they’re behaving mentally. Something to think about here, though, is you may find some of your compulsions are in more than one category. You might say, “Well, I do mental comparison, but it’s also a self-punishment,” or “I do mental checking, but it’s also a form of reassurance.” That’s okay too. Don’t worry too much about what section it should be under. Again, it’s very fluid. We want you just to be able to document. It doesn’t matter what category it is particularly. I really just wanted this 101 for you to do an inventory and see, “Oh, wow, maybe I’m doing more compulsions than I thought.” Because sometimes they’re very habitual and we are doing them before we even know we’re doing them. I just want to keep reminding you guys it’s okay if it looks a little messy and it’s okay if your list is a little different. The main question here as we conclude is: How do I stop? Well, the beauty is I have the honor of introducing to you some of the absolute, most amazing therapists and specialists in the planet. I fully wholeheartedly agree with that. While I wish I could have done 20 people, I picked six people who I felt would bring a different perspective, who have such amazing wisdom to share with you on how to manage mental compulsions. Now, why did I invite more than one person? Because I have learned as a clinician and as a human being, there is not one way to treat something. When I first started CBT School, I was under the assumption that there is only one way to do it and it’s the right way or the wrong way. From there, I have really grown and matured into recognizing that what works for one person may not work for the next person. As we go through this series, I may be asking very, very similar questions to each person. You will be so amazed and in awe of the responses and how they bring about a small degree of nuance and a little flare of passion and some creativity of each person and bring in a different theme. I’m so honored to have these amazing human beings who are so kind to offer their time, to offer this series, and help you find what works for you. As you go through, I will continue reminding you, please keep asking yourself, would this work for me? Am I willing to try this? The truth is, all of them are doable for everybody, but you might find for your particular set of compulsions specific tools work better. So trial them, see what works, be gentle, experiment. Don’t give up. It may require multiple tries to really find some little win. Please, just listen, enjoy, take as many notes as you can, because literally, the wisdom that is dropped here is mind-blowing. I’ve been treating OCD for over a decade and I actually stopped a few things after I learned this and went straight to my staff and said, “We have to make a new plan. Let’s implement this. This is an amazing skill for our clients. Let’s make sure we do it.” Even I, I’m a student of some of these amazing, amazing people. How do I stop? Stay tuned, listen, learn, take notes, and most importantly, put it into practice. Apply. That’s where the real change happens. Now, before we finish, please do note this series should not replace professional healthcare. This or any product provided by CBT School should be used for education purposes only, so please take as much as you can. If you feel that you need more support, please reach out to a therapist in your area who can help you use these tools and maybe pick a part. Maybe there’s a few things that you need additional help with, and that is okay. Thank you, guys. I am so excited to share this with you. Have a wonderful day.

SUMMARY:  This episode addresses some common questions people have about anxiety and arousal. Oftentimes, we are too afraid to talk about anxiety and arousal, so I thought I would take this opportunity to address some of the questions you may have and take some of the stigma and shame out of discussing anxiety and how it impacts arousal, orgasm, intimacy, and sexual interactions. In This Episode: How anxiety and arousal impact each other (its a cycle) Arousal Non-Concordance and how it impacts people with anxiety and OCD How to take the shame out of arousal struggles Understanding why anxiety impacts orgasms and general intimacy Links To Things I Talk About: Article I wrote about OCD and Arousal Non-Concordance https://www.madeofmillions.com/articles/whats-going-ocd-arousal Come as You are By Emily Nagoski, PhD Come as You Are Workbook By Emily Nagoski, PhD ERP School: https://www.cbtschool.com/erp-school-lp Episode Sponsor: This episode of Your Anxiety Toolkit is brought to you by CBTschool.com. CBTschool.com is a psychoeducation platform that provides courses and other online resources for people with anxiety, OCD, and Body-Focused Repetitive Behaviors. Go to CBTschool.com to learn more. Spread the love! Everyone needs tools for anxiety... If you like Your Anxiety Toolkit Podcast, visit YOUR ANXIETY TOOLKIT PODCAST to subscribe free and you'll never miss an episode. And if you really like Your Anxiety Toolkit, I'd appreciate you telling a friend (maybe even two). EPISODE TRANSCRIPTION This is Your Anxiety Toolkit - Episode 281. Welcome back, everybody. How are you? It is a beautiful sunny day here in California. We’re actually in the middle of a heatwave. It is April when I’m recording this and it is crazy how hard it is, but I’m totally here for it. I’m liking it because I love summer. Talking about heat, let’s talk about anxiety and arousal today. Shall we? Did you get that little pun? I’m just kidding really. Today, we’re talking about anxiety and arousal. I don’t know why, but lately, I’m in the mood to talk about things that no one really wants to talk about or that we all want to talk about and we’re too afraid to talk about. I’m just going to go there. For some reason, I’m having this strong urge with the podcast to just talk about the things that I feel we’re not talking about enough. And several of my clients actually were asking like, “What resources do you have?” And I have a lot of books and things that I can give people. I was like, “All right, I’m going to talk about it more.” So, let’s do it together. Before we do that, let’s quickly do the review of the week. This one is from, let’s see, Jessrabon621. They said: “Amazing podcast. I absolutely love everything about this podcast. I could listen to Kimberley talk all day and her advice is absolutely amazing. I highly recommend this podcast to anyone struggling with anxiety or any other mental health professional that wants to learn more.” Thank you so much, Jess. This week’s “I did a hard thing” is from Anonymous and they say: “I learned it’s okay to fulfill my emotions and just allow my thoughts and it gave me a sense of peace. Learning self-compassion is my hard thing and I’m learning to face OCD and realize that it’s not my fault. I’m learning to manage and live my life for me like I deserve, and I refuse to let this take away my happiness.” This is just so good. I talk about heat. This is seriously on fire right here. I love it so much. The truth is self-compassion practice is probably my hard thing too. I think that me really learning how to stand up for myself, be there for myself, be tender with myself was just as hard as my eating disorder recovery and my anxiety recovery. I really appreciate Anonymous and how they’ve used self-compassion as their hard thing. Let’s get into the episode. Let me preface the episode by we’re talking about anxiety and arousal. If I could have one person on the podcast, it would be Emily Nagoski. I have been trying to get her on the podcast for a while. We will get her on eventually. However, she’s off doing amazing things. Amazing things. Netflix specials, podcasts, documentaries. She’s doing amazing things. So, hopefully, one day. But until then, I want to really highlight her as the genius behind a lot of these concepts. Emily Nagoski is a doctor, a psychology doctor. She is a sex educator. She has written two amazing books. Well, actually, three or four. But the one I’m referring to today is Come as You Are. It’s an amazing book. But I’m actually in my hand holding the Come as You Are Workbook. I strongly encourage you after you listen to this podcast episode to go and order that book. It is amazing. It’s got tons of activities. It might feel weird to have the book. You can get it on Kindle if you want to have it be hidden, but it’s so filled with amazing information. I’m going to try and give you the pieces that I really want you to take away. If you want more, by all means, go and get the workbook. The workbook is called The Come as You Are Workbook: A Practical Guide to the Science of Sex. The reason I love it is because it’s so helpful for those who have anxiety. It’s like she’s speaking directly to us. She’s like, it’s so helpful to have this context. Here’s the thing I want you to consider starting off. A lot of people who have anxiety report struggles with arousal. We’re going to talk about two different struggles that are the highlight of today. Either you have no arousal because of your anxiety, or you’re having arousal at particular times that concern you and confuse you and alarm you. You could be one or both of those camps. So let’s first talk about those who are struggling with arousal in terms of getting aroused. So the thing I want you to think about is commonly-- and this is true for any mental health issue too, it’s true for depression, anxiety disorders, eating disorders, dissociative disorders, all of them really. But the thing I want you to remember, no matter who you are and what your experience is, even if you have a really healthy experience of your own sexual arousal and you’re feeling fine about it, we all have what’s called inhibitors and exciters. Here is an example. An inhibitor is something that inhibits your arousal. An exciter is something that excites your arousal. Now you’re probably already feeling a ton of judgment here like, “I shouldn’t be aroused by this and I should be aroused by this. What if I’m aroused by this? And I shouldn’t be,” and so forth. I want us to take all the judgment out of this and just look at the content of what inhibits our arousal or excites our arousal. Because sometimes, and I’ll talk about this more, sometimes it’s for reasons that don’t make a lot of sense and that’s okay. Let’s talk about an inhibitor, something that pumps the brakes on arousal or pleasure. It could be either. There’s exciters, which are the things that really like the gas pedal. They just really bring on arousal, bring on pleasure, and so forth. We have the content. The content may be first mental or physical, and this includes your health, your physical health. For me, I know when I am struggling with POTS, arousal is just barely a thing. You’re just so wiped out and you’re so exhausted and your brain is foggy. It’s just like nothing. That would be, in my case, an inhibitor. I’m not going to talk about myself a lot here, but I was just using that as an example. You might say your anxiety or your obsession is an inhibitor. It pumps the brakes on arousal. It makes it go away. Worry is one. It could also be other physical health, like headaches or tummy aches, or as we said before, depression. It could be hormone imbalances, things like that. It’s all as important. Go and speak with your doctor. That’s super important. Make sure medically everything checks out if you’re noticing a dip or change in arousal that’s concerning you. The next one in terms of content that may either excite you or inhibit you is your relationship. If your relationship is going well, you may or may not have an increase in arousal depending on what turns you on. If your partner smells of a certain smell or stench that you don’t like, that may pump the brakes. But if they smell a certain way that you do really like and really is arousing to you, that may excite your arousal. It could also be the vibe of the relationship. A lot of people said at the beginning of COVID, there was a lot of fear. That was really, really strong on the brakes. But then all of a sudden, no one had anything to do and there was all this spare time. All of a sudden, the vibe is like, that’s what’s happening. Now, this could be true for people who are in any partnership or it could be just you on your own too. There are things that will excite you and inhibit your arousal if you’re not in a relationship as well, and that’s totally fine. This is for all relationships. There’s no specific kind. Setting is another thing that may pump the brakes or hit the gas for arousal, meaning certain places, certain rooms, certain events. Did your partner do something that turned you on? Going back to physical, it could also depend on your menstrual cycle. People have different levels of arousal depending on different stages of their menstrual cycle. I think the same is true for men, but I don’t actually have a lot of research on that, but I’m sure there are some hormonal impacts on men as well. There’s also ludic factors which are like fantasy. Whether you have a really strong imagination, that either pumps the brakes or puts the gas pedal in terms of arousal. It could be like where you’re being touched. Sometimes there’s certain areas of your body that will set off either the gas pedal or the brakes. It could be certain foreplay. Really what I’m trying to get at here isn’t breaking it down according to the workbook, but there’s so many factors that may influence your arousal. Another one is environmental and cultural and shame. If arousal and the whole concept of sex is shamed or is looked down on, or people have a certain opinion about your sexual orientation, that too can impact your gas pedal and your brakes pedal. So, I want you to explore this, not from a place of pulling it apart really aggressively and critically, but really curiously and check in for yourself, what arouses me? What presses my brakes? What presses my gas? And just start to get to know that. Again, in the workbook, there’s tons of worksheets for this, but you could also just consider this on your own. Write it down on your own, be aware over the next several days or weeks, just jot down in a journal what you’re noticing. Now, before we move on, we’ve talked about a lot of people who are struggling with arousal, and they’ve got a lot of inhibitors and brake pushing. There are the other camp who have a lot of gas pedal pushing. I speak here directly to the folks who have sexual obsessions because often if you have sexual obsessions, the fact that your sexual obsession is sexual in nature may be what sets the gas pedal off, and all of a sudden, you have arousal for reasons that you don’t understand, that don’t make sense to you, or maybe go against your values. I’ve got a quote that I took from the book and from the workbook of Emily Nagoski. Again, none of this is my personal stuff. I’m quoting her and citing her throughout this whole podcast. She says, “Bodies do not say yes or no. They say sex-related or not sex-related.” Let me say it again. “Bodies do not say yes or no. They say sex-related or not sex-related.” This is where I want you to consider, and I’ve experienced this myself, is just because something arouses you doesn’t mean it brings you pleasure. Main point. We’ve got to pull that apart. Culture has led us to believe that if you feel some groinal response to something, you must love it and want more of it. An example of this is for people with sexual obsessions, maybe they have OCD or some other anxiety disorder, and they have an intrusive thought about a baby or an animal. Bestiality is another very common obsession with OCD or could be just about a person. It could be just about a person that you see in the grocery store. When you have a thought that is sex-related, sometimes because the context of it is that it’s sex-related, your body may get aroused. Our job, particularly if you have OCD, is not to try and figure out what that means. It’s not to try and resolve like, does that mean I like it? Does that mean I’m a terrible person? What does that mean? I want you to understand the science here to help you understand your arousal, to help you understand how you can now shift your perspective towards your body and your mind and the pleasure that you experience in the area of sexuality. Again, the body doesn’t say yes or no, they say it’s either sex-related or not sex-related. Here’s the funny thing, and I’ve done this experiment with my patients before, is if you look at a lamp post or it could be anything, you could look at the pencil you’re holding and then you bring to mind a sexual experience, you may notice arousal. Again, it doesn’t mean that you’re now aroused by pencils or pens. It’s that it was labeled as sex-related, so often your brain will naturally press the accelerator. That’s often how I educate people, particularly who are having arousal that concerns it. It’s the same for a lot of people who have sexual trauma. They maybe are really concerned about the fact that they do have arousal around a memory or something. And then that concerns them, what does that mean about me? And the thing to remember too is it’s not your body saying yes or no, it’s your body saying sex-related or not sex-related. It’s important to just help remind yourself of that so that you’re not responding to the content so much and getting caught up in the compulsive behaviors. A lot of my patients in the past have reported, particularly during times when they’re stressed, their anxiety is really high, life is difficult, any of this content we went through, is they may actually have a hard time being aroused at all. Some people have reported not getting an erection and then it completely going for reasons they don’t understand. I think here we want to practice again non-Judgment. Instead, move to curiosity. There’s probably some content that impacted that, which is again, very, very, normal. this is why when I’m talking with patients – I’ve done episodes on this in the past, and we’ve in fact had sex therapists on the podcast in the past – is they’ve said, if you’ve lost arousal, it doesn’t mean you give up. It doesn’t mean you say, “Oh, well, that’s that.” What you do is you move your attention to the content that pumps the gas. When I mean content, it’s like touch, smell, the relationship, the vibe, being in touch with your body, bringing your attention to the dance that you’re doing, whether it’s with a partner or by yourself, or in whatever means that works for you. You can bring that back. There’s another amazing book called Better Sex Through Mindfulness, and it talks a lot about bringing your attention to one or two sensations. Touch, smell being two really, really great ones. Again, if your goal is to be aroused, you might find it’s very hard to be aroused because the context of that is pressure. I don’t know about you, but I don’t really find pressure arousing. Some may, and again, this is where I want this to be completely judgment-free. There’s literally no right and wrong. But pressure is usually not that arousing. Pressure is not that pleasurable in many cases, particularly when it’s forceful and it feels like you have to perform a certain way. Again, some people are at their best in performance mode, but I want to just remind you, the more pressure you put on yourself on this idea of ending it well is probably going to make some anxiety. Same with test anxiety. The more pressure you put on yourself to get an A, the more you’re likely to spin out with anxiety. It’s really no different. So, here is where I want you to catch and ask yourself, is the pressure I put on myself or is the agenda I put on myself actually pumping the brakes for me when it comes to arousal? Is me trying not to have a thought actually in the context of that, does that actually pump the brakes? Because I know you’re trying not to have the thought so that you can be intimate in that moment and engaged in pleasure. But the act of trying not to have the thought can actually pump the brakes. I hope that makes sense. I want you to get really close to understanding what’s going on for you. Everyone is different. Some things will pump the brakes, some things will pump the accelerator. A lot of the times, thought suppression pumps the brakes. A lot of the times, beating yourself up pumps the brakes. A lot of the time, the more goal, like I have to do it this way, that often pumps the brakes. So, keep an eye out for that. Engage in the exciters and get really mindful and present. A couple of things here. We’ve talked about erections, that’s for people who struggle with that. It’s also true for women or men with lubrication. Some people get really upset about the fact that there may or may not be a ton of lubrication. Again, we’ve been misled to believe that if you’re not lubricated, you mustn’t be aroused or that you mustn’t want this thing, or that there must be something wrong with you, and that is entirely true. A lot of women, when we study them, they may be really engaged and their gas pedal is going for it, but there may be no lubrication. And it doesn’t mean something is wrong. In those cases, often a sex therapist or a sex educator will encourage you to use lubrication, a lubricant. Again, some people, I’ve talked to clients and they’re so ashamed of that. But I think it’s important to recognize that that’s just because somebody taught us that, and sadly, it’s a lot to do with patriarchy and that it was pushed on women in particular that that meant they’re like a good woman if they’re really lubricated. And that’s not true. That’s just fake, false. No science. It has no basis in reality. Now we’ve talked about lubrication. We’ve talked about erection. Same for orgasm. Some people get really frustrated and disheartened that they can’t reach orgasm. If for any reason you are struggling with this, please, I urge you, go and see a sex therapist. They are the most highly trained therapists. They are so sensitive and compassionate. They can talk with you about this and you can target the specific things you want to work on. But orgasm is another one. If you put pressure on yourself to get there, that pumps the brakes often. What I want you to do, and this is your homework, is don’t focus on arousal. Focus on pleasure. Focus on the thing that-- again, it’s really about being in connection with your partner or yourself. As soon as you put a list of to-dos with it is often when things go wrong. Just focus on being present as much as you can, and in the moment being aware of, ooh, move towards the exciters, the gas pedal things. Move away from the inhibitors. Be careful there. Again, for those of you who have anxiety, that doesn’t mean thought suppress. That doesn’t mean judge your thoughts because that in and of itself is an inhibitor often. I want to leave you with that. I’m going to in the future do a whole nother episode about talking more about this idea of arousal non-concordance, which is that quote I use like “The bodies don’t say yes or no, they say sex-related or not sex-related.” I’ll do more of that in the future. But for right now, I want it to be around you exploring your relationship with arousal, understanding it, but then putting your attention on pleasure. Being aware of both, being mindful of both. Most people I know that I’ve talked to about this-- and I’m not a sex therapist. Again, I’m getting all of this directly from the workbook, but most of the clients I’ve talked to about this and we’ve used some worksheets and so forth, they’ve said, when I put all the expectations away and I just focus on this touch and this body part and this smell and this kiss or this fantasy, or being really in touch with your own body, when I just make it as simple as that and I bring it down to just engaging in what feels good – sort of use it as like a north star. You just keep following. That feels good. Okay, that feels good. That doesn’t feel so great. I’ll move towards what feels good – is moving in that direction non-judgmentally and curiously that they’ve had the time of their lives. I really just want to give you that gift. Focus on pleasure. Focus on non-judgmentally and curiously, being aware of what’s current and present in your senses. That’s all I got for you for today. I think it’s enough. Do we agree? I think it’s enough. I could talk about this all day. To be honest, and I’ve said this so many times, if I had enough time, I would go back and I would become a sex therapist. It is a huge training. Sex therapists have the most intensive, extensive training and requirements. I would love to do it. But one day, I’ll probably do it when I’m 70. And that will be awesome. I’ll be down for that, for sure. I just love this content. Now, again, I want to be really clear. I’m not a sex therapist. I still have ones to learn. I still have. Even what we’ve covered today, there’s probably nuanced things that I could probably explain better. Again, which is why I’m going to stress to you, go and check out the book. I’m just here to try and get you-- I was thinking about this. Remember, I just recently did the episode on the three-day silent retreat and I was sitting in a meditation. I remember this so clearly. I’m just going to tell you this quick story. I was thinking. For some reason, my mind was a little scattered this day and something came over with me where I was like, “Wouldn’t it be wonderful if I didn’t just treat anxiety disorders, but I treated the person and the many problems that are associated with the anxiety disorder? Isn’t that a beautiful goal? Isn’t that so? Because it’s not just the anxiety, it’s the little tiny areas in our lives that it impacts.” That’s when I, out of me, as soon as I finished the meditation, I went on to my-- I have this organization board that I use online and it was arousal, let’s talk about pee and poop, which is one episode we recently did. Let’s talk about all the things because anxiety affects it all. We can make little changes in all these areas and little changes. Slowly, you get your life back. I hope this gives you a little bit of your sexual expression back, if I could put it into words. Maybe not expression, but just your relationship with your body and pleasure. I love you. Thank you for staying with me for this. This was brave work you’re doing. You probably had cringy moments. Hopefully not. Again, none of this is weird, wrong, bad. This is all human stuff. Finish up, again, do check out the book. Her name is Emily Nagoski. I’ll leave a link in the show notes. One day we’ll get her on. But in the meantime, I’ll hopefully just give you the science that she’s so beautifully given us. Have a wonderful day. I’ll talk to you soon. See you next week. Please do leave a review. It helps me so much. If you have a few moments, I would love a review, an honest review from you. Have a good day.

In this week’s podcast episode, we are reflecting on the question, “Does anxiety make you need to pee or poop? Yes, you read that right! Today, we are talking ALL about how anxiety can cause frequent urination and the fear of peeing your pants. Have you found yourself getting anxious you might need to pee or poop in public which, in turn, makes you need to pee or poop in public? Bathroom emergencies are way more common than you think. I even share a story of how I, myself, had to handle the urgency to 🏃🏼‍♀️🏃🏿‍♂️ to the restroom. In This Episode: Why do we need to pee and poop when we are anxious? What causes the psychological need to urinate or defecate when anxious? How to stop anxiety Urination How to manage a fear of peeing your pants or pooping your pants How to use mindfulness and self-compassion when experiencing nervous pee syndrome Links To Things I Talk About: Overcoming Anxiety and Panic https://www.cbtschool.com/overcominganxiety ERP School: https://www.cbtschool.com/erp-school-lp Episode Sponsor: This episode of Your Anxiety Toolkit is brought to you by CBTschool.com. CBTschool.com is a psychoeducation platform that provides courses and other online resources for people with anxiety, OCD, and Body-Focused Repetitive Behaviors. Go to cbtschool.com to learn more. Spread the love! Everyone needs tools for anxiety... If you like Your Anxiety Toolkit Podcast, visit YOUR ANXIETY TOOLKIT PODCAST to subscribe free and you'll never miss an episode. And if you really like Your Anxiety Toolkit, I'd appreciate you telling a friend (maybe even two). EPISODE TRANSCRIPTION This is Your Anxiety Toolkit - Episode 280. Welcome back, everybody. I am so thrilled to have you here with me again today. Today’s format is going to be a little different. I have fused the “I did the hard thing” with the question that we’re going to address today. Usually, I sit down to the microphone and I look at my screen and I think about what I want to talk about, and I just start talking about it. To be honest, that is how this show goes. It has always been how this show has gone. But a follower on Instagram reached out to me this week and posed a really great question. So, with her permission, I will anonymously invite you to listen to the question, and then we’re going to talk about some solutions. The reason I wanted to go word for word is I think you’re probably going to get what she’s saying, because I’ve been in this position. I know most of my clients have been in this position. It’s not the funniest thing to talk about. I mean, I love talking about it, but it’s not the funniest thing for you to talk about, or often people have a lot of shame and embarrassment around this topic. So, I wanted to just, let’s just talk about it. Now, the reason I say I love to talk about it is, you know probably from previous episodes, I commonly ask my clients pretty personal questions. And often questions are like, are you prioritizing time to pee and poop? Are you holding your pee and poop? My job is to ask the questions that people are often too afraid to bring up. I often ask some personal questions about sexual arousal and things like that, again, because I have been trained to understand there’s a lot of stigma and shame, and embarrassment around these topics. And so I try to de-stigmatize them and take the shame out of them by just addressing them because they’re normal human struggles that we have. As you may imagine, today, we’re talking about anxiety and pee and poop, and how anxiety can often make us feel like we urgently need to pee or/and poop. That’s the topic of today. I’m going to read you this. It’s a two-part question. I’m going to address them separately, but all from the same situation. It said: “Kim, I hope you are well. I was reading your post yesterday about the hardest part of facing your fear.” To give you some backstory, I did a post on what the hardest things about facing fears are. I posed this question to Instagram and everyone wrote in. And using the results of what everyone wrote in, I created a post. And number seven was physical symptoms, especially bowel issues, and it really resonated with me. Why do we need to pee and poop when we are anxious? “You have said before that when you get feelings of discomfort, to just sit with it and do nothing.” That’s a common theme I talk about, is if you have discomfort, do nothing at all. You just sit with it. “But when it comes to bowel issues or needing to urinate due to anxiety, I get confused at what to do. Should I be sitting with it or going to the loo because that’s what my body needs? There are sort of two parts to my anxiety. With this, I’ll give you an example.” She said, “This weekend, I’m going to a christening and I get anxious for these types of events, like christenings, weddings, theater, anywhere where there is lots of people and they sit together in a certain way. I feel anxious about needing to go to the bathroom. It’s almost like I’m anxious of the symptom of anxiety.” Yes. Now this is exactly what it is like for so many people, and it’s a really great question. Here is my response. Naturally, it’s a normal part of the human instinct to need to pee and poop when you’re anxious. Hundreds of thousands of years ago, when we were faced with danger or some kind of threat, in order to get away from that threat, usually you needed to be able to run many, many, many miles in a very short period of time. Now, we have cars and planes to get away from danger, or we have technology to help us to get away from danger. But back we needed to run that long-distance and exert a lot of energy. And so naturally, our bodies get rid of weight and waste so that you can be prepared to run a long distance away from the threat. Often the easiest way to get rid of that waste and weight is to defecate (to go poop) and to urinate, which is to go pee, or in some cases, throw up. Some people when they’re anxious, because their brain has detected danger, whether there’s danger or not, you may do one of those three things. That’s a very, very normal approach to the fight, flight, and freeze. So, in this case, let’s say your brain has set off a false alarm and is saying there’s going to be lots of people there, and what if you need to pee and poop? So now you’re afraid of the symptom of anxiety like they’ve asked. What do you do? So here is my answer to that. When we have any symptoms of anxiety – increase in heart rate, sweating, lots of racing, thoughts, it could be tummy ache, it could be the need to urinate – yeah, we do want to practice the art of sitting with it, meaning tolerating it without reacting to it in an aversive way, meaning trying to resist it, make it go away, how can we remove this discomfort from our life? When we do that, we get into a cycle where you’re constantly trying to get rid of discomfort and that keeps you stuck. In this situation, yeah. If you have a slight urge to urinate or to go to the bathroom, if you’re able to, do try to tolerate that discomfort. However, if there’s a strong urge to go to the bathroom, there is absolutely nothing wrong with going to the bathroom. What I would say to you is it depends. The answer is it depends, and it’s a very personal one. I will tell you a story personally. I know it was probably TMI, but I remember when I was becoming an American citizen, I was overwhelmingly anxious about this situation. I was afraid of everything. I was afraid of the test. I was really emotional about becoming an American. I felt like I was denouncing my country. I was so anxious about the security process. I was so afraid that I was going to mess up and get into some legal trouble, even though I’d done everything by the book. It was really, really overwhelming. The minute I got in line, which were these thousands of people in line, I needed to go to the bathroom, like right now, it had to happen. So, in that instance, yes, I’m going to ask somebody where the bathroom is and I’m going to go to the bathroom. So, I did okay. TMI, but we’re talking about it. Everybody pees and poops, so I’m not embarrassed. Now, as soon as I got back in line, I lost my spot. I was at the back of the line again. My husband was with me. “Uh-oh, I need to go to the bathroom again.” I already know, I’ve probably dropped a lot of that weight. My brain thinks that there’s a major danger when there’s not. So, my job then is I could have easily gotten out of line again to try and get rid of that discomfort and that fear and that uncomfortableness in my stomach. But because I knew I’d already gone, my job was, I really need to get into this security building as a government building. I can’t keep getting out of line. My work then was to practice seeing if I could just hold that feeling. Now I’m not here at all saying or suggesting that you should hold for long periods of time or even to be where you’re tolerating an experience of pain. Again, it depends. The answer is, it depends. If you’ve already gone, can you hold on? If let’s say you’re holding on and you’re like, “Oh no, it’s definitely coming, I need to go,” by all means, go. That’s not a compulsion. It’s just you listening to your body. It’s you giving yourself permission to just go with the flow and again, it’s a wonderful exposure of giving your body’s permission to run the show. How to stop Anxiety Urination? I think the answer is, listen to your body, see what you can do. Again, we always want to be experimenting with tolerating discomfort for long periods or as long as you can. Bit for no reason should you hold for long periods of time and put yourself in additional pain. Now that being said, if you’re going to the bathroom, just to remove your anxiety about going to the bathroom, or you’re going to the bathroom to remove your anxiety of whether or not you will pee or poop your pants, that’s a different story. If you’re going to the bathroom to relieve anxiety, not physical, like actual urgency to go to the bathroom, well then yes, you’re giving into fear. We don’t want to let fear win, particularly when your brain is telling us there’s danger when there’s not. A perfect example, I’m becoming a citizen. I have to take a test. There’s no real danger. The worst thing that could happen is I fail the test or I don’t bring a paper or something. In this case for the ceremony, the worst thing that could happen is you would need to go to the bathroom, right? Or even if you maybe-- again, the worst thing that could happen is you would have to go. But if fear is saying, “Oh no, no, there is really bad possible, maybe possible maybes,” because fear does that, it always gives you the possible maybes – then no, we would not go to the bathroom just to relieve anxiety. If a lot of people, specifically those with panic disorder, they are very, very afraid of the sensations of anxiety. So, your job is actually, if that’s the case, to practice leaning in and having those sensations, tolerating those sensations. Or if you’re going to do exposure and response prevention, even better, you would purposely try to create the scenario so that you could simulate the anxiety and practice tolerating it that way. So, my answer, I know, isn’t direct. It is, it depends. But when it does come to fear, it’s always going to be the same – do not let fear make your choices. Do no. The next part of the question, I think, is another part of this, which I think is really important. So, they said, the second part is, “If I do need it and I have to leave the room during the ceremony, I wonder what people will think of me. I feel like I’m being a disruption. Also, if I have to move past anyone, I sit down, I feel like a nuisance. And then too, so often at the end of the seat--” so they sit at the end of the seat, excuse me, just in case. “Some of my compulsions, safety behaviors around this are needing to know where the nearest toilet is, going multiple times beforehand. Or I may do a certain number of pelvic floor squeezes whilst in the toilet.” They said, “Sorry if this is a long message, I just wanted to explain fully. I think the main thing I’m asking you is, should I be sitting with the feeling or not? If you do not see this up, the rest is just saying about the message.” There we go. I think there’s so much great opportunity here for exposure and really willingness to be uncomfortable. The first thing is, everyone pees and poops. There is no shame in needing to go to the bathroom. I have a lot of clients who, when they’re anxious, they got to go. They got to go. It’s not anxiety. They’ve got to go to the bathroom or there’s going to be an accident. Not the fear. It’s like, “No, it’s actually coming.” If that’s the case, your job is to give yourself permission to be a human with anxiety and to be gentle and compassionate toward yourself that yes, sometimes people need to leave ceremonies. If someone behind you is judging you for needing to leave, that is a full reflection on them. It means nothing about you. Human beings are allowed to come and go as they please. If they need to pee and poop, that is their right. What I would encourage you to do is, this is like a social anxiety sort of talk, and we’ve got some podcasts on social anxiety, but your job is to give other people permission to judge us and do nothing about it. Do nothing. Do nothing about their judgment, because their judgment is a full reflection of them and their beliefs, not of us. The next part is they’ve gone over a ton of safety behaviors – checking the toilet, going multiple times. I would strongly-- if it were my client and you guys do what’s right for you always, take what you need, leave the rest. But if it were my client or if it were myself, I would strongly suggest other than otherwise not doing these behaviors. We don’t want to be doing behaviors. This goes for every topic. We don’t want to be doing behaviors just in case, that just in case behaviors keep us stuck in a cycle of anxiety, that just in case behaviors validate your fear as if your fear is true and important and a fact. We don’t want to do that. We can’t do that because when we do that, we keep the fear cycling. So, I would actually encourage you to not check for bathrooms, not go to the bathroom before, unless of course you genuinely need to, not just because of fear. If for some reason you have the need, practice saying “I can have it.” If the feeling is the pressure is down in that bowel and that pelvic area, that won’t kill you either. I always think of when I’m on an airplane to Australia, you know what happens? You get on the plane, you put your bags away. You’re getting ready. And then they say, preparing for takeoff, the seatbelt light comes on, and then immediately you need to go pee. And you can’t get up. They won’t you, so you hold it. People hold it all the time. Again, we don’t want you to push you through pain, but you can hold it. Be really honest with yourself. Nothing terrible is going to happen. If it’s really urgent, of course, I mean, even on a plane, if you’re really going to pee or poop your pants, they’re going to let you stand up. They’re not going to make you sit in the chair. Try not to be doing these behaviors. Practice tolerating the discomfort of other people possibly judging you. One thing to keep in mind here too is when-- let’s say you go back to my story, I had to leave the line. I could have done a lot of mind reading, which is a cognitive distortion, which is going, “Oh, they think this and he thinks that, and she thinks that about me.” That’s all mind reading. You don’t actually know what they’re thinking. They might be thinking, what a beautiful dress you’re wearing, or they might be thinking, man, I can’t wait for this ceremony to be over. You have no idea, they might be thinking about something so different. So, it’s important that we also practice not mind reading what people think about us. There you have it. These urgencies to go are normal. Everyone pees and poops. That’s just the facts. It doesn’t matter whether you do it once a day or 20 times a day, depending on if you’re anxious. Give yourself to not be perfect. A lot of times, we also talk about when people are doing exposures or they’re having a panic attack, they’re like, “Ah, it’s not just the panic attack. I don’t want people to see me having a panic attack,” or “It’s not just the anxiety. I don’t want to have to cry in public.” The work here is you’re a human being. If you’re a human being, you won’t be perfect. If you’re holding yourself to a standard where you, number one, aren’t allowed to cry, you’re not allowed to pee, you’re not allowed to poop, you’re not allowed to disrupt other people, Well, that’s a lot of expectations you’re putting on yourself. That’s a lot of pressure that you just created in your head. No one else is expecting perfection from you. So, maybe adjust the expectations there as well. Now the last thing I will address, which isn’t specifically to the pee and the poop, is some people get a lot of gas when they’re anxious. They have a strong urgency to pass gas. This is very common for people who have irritable bowel syndrome, same with getting diarrhea or needing to pee or poo. This is very common. If you have IBS, please do speak with a doctor. Let them know that you’re struggling with this. There’s nothing to be ashamed of. They can, of course, diagnose you, make sure they maybe get you some help in those areas. Again, if you need to pass gas, no different. Humans pass gas. It’s not something to be completely ashamed of. Is it embarrassing? Yes, it is. But you do what you have to do. You just have to get through. I’ve heard so many people tell me stories of their most anxious moment being made more difficult because they had no choice, but to pass gas during that. And if that’s the case for you as well, again, I think any human who ridicules someone for needing to pass gas, which is such a human thing, I think we pass gas 17 times on average a day. Everyone, not select people, everyone, anyone who passed judgment on you for that is probably may want to step up their ability to be compassionate and empathic. Again, it’s not about you, it’s about them. So, be super, super gentle with yourself. I think I hit my limit of how many times I said pee and poop, and now we’ve added in pass gas and we’ve even used the “diarrhea” word, which I think is epic. I think I’ve checked all the boxes for today’s episode. So, I hope that it was helpful for you. I genuinely hope that it just dropped some of the anxiety and judgment you have about yourself in regards to the urgency to need to go and pee and poop. If I were to summarize it, I would say it’s very common to need to urinate, go to the bathroom or even pass gas. Lots of people have even diarrhea, very, very strong diarrhea. If that is the case for you, do what you need to do as best as you can. It’s okay if you need to go to the restroom. No problem. If you’re only going to reduce your anxiety about needing to go, I encourage you to try and challenge that some. Again, we do not want to give all of our power to fear. We actually want to ignore fear and give it none of our attention. If you can do that, you’re doing amazing hard work. I love you all so much. Thank you for holding space for me as we talk about all things, bowel-related and urination-related. Even though it’s uncomfortable, it is so important for us to be having these conversations. I hope again, it was helpful for you, and thank you for holding space for me as we talk about these things together. All right. I love you all. I hope you’re having an amazing, amazing week. I hope you’re being kind to yourself and really opening your heart to your own suffering instead of shutting it down because you’re suffering matters. It deserves to be held tenderly. It is a beautiful day to do hard things. I cannot finish an episode without saying it. I encourage you, if you’ve gotten this far in the episode, to practice the hard things as much as you can every single day. Have a wonderful day, everyone.

In todays podcast episode, together we do a self-compassion check in.  First, we address what is self-compassion and then, we check in on our needs.  Mindful Self-Compassion involves first, being aware of what we need and what needs tending to.  In this episode, we also walk through a self-compassion meditation together. In This Episode: What is Self-Compassion? What do I need? How can I give myself self-compassion right now? Self-compassion meditation. Links To Things I Talk About: https://read.amazon.com/kp/embed?asin=B08WGW9XCZ&preview=newtab&linkCode=kpe&ref_=cm_sw_r_kb_dp_XSDYJ2MCRJBYEFCPS5NF&tag=cbtschool-20 ERP School: https://www.cbtschool.com/erp-school-lp Episode Sponsor: This episode of Your Anxiety Toolkit is brought to you by CBTschool.com. CBTschool.com is a psychoeducation platform that provides courses and other online resources for people with anxiety, OCD, and Body-Focused Repetitive Behaviors. Go to cbtschool.com to learn more. Spread the love! Everyone needs tools for anxiety... If you like Your Anxiety Toolkit Podcast, visit YOUR ANXIETY TOOLKIT PODCAST to subscribe free and you'll never miss an episode. And if you really like Your Anxiety Toolkit, I'd appreciate you telling a friend (maybe even two). EPISODE TRANSCRIPTION This is Your Anxiety Toolkit - Episode 279. Welcome back, everybody. Today on Your Anxiety Toolkit podcast, we are talking about self-compassion. We’re doing a self-compassion check-in. It’s been a little while since we’ve checked in on how are you doing with your self-compassion practice. Now, today, we have added a little meditation for you just to supercharge your self-compassion practice. That is my agenda for today. We haven’t done a ton of check-ins lately because life just seems to get away from us. For those of you who do not know, in 2020, I wrote a book called The Self-Compassion Workbook For OCD. It was the joy of life and the biggest challenge of my life business-wise. It was such a huge agenda to have on my plate just as 2020 and COVID breakthrough, but I’m so grateful it’s out. When it was released, I had a lot of stuff out about self-compassion. And then I haven’t checked in with you guys on how you’re doing. So that’s what today is about. Now, before we get into the episode, let’s do the “I did a hard thing” for the week. We always check-in and someone submits the thing that they’ve done that is hard, because what we like to say is “It’s a beautiful day to do hard things.” And today’s is from Anonymous. They said: “I’ve recently been diagnosed with OCD and struggled my whole life with anxiety. Unfortunately, until now I was never properly diagnosed until I was 45. I have started working with a new therapist and we are focusing on ERP. At first, I couldn’t even tell her about my fears and intrusive thoughts. I have harm OCD among other various categories. Now, we are doing imaginals around some of the things I never thought I could even address, and I’m so proud of myself.” I’m proud of you too. “It is changing my life. I cannot tell you how important it is to get a proper diagnosis and never give up. You will get better. You just have to get the right help and be willing to do the hard things.” Anonymous, you are giving me the chills. Now, for those of you who don’t have access – anonymous has access to a therapist – if you don’t have access to a therapist, we do have an online course called ERP School. An ERP School is an online course that will teach you how to practice ERP at home, in your pajamas, all the skills that you need to get you started. Now, it does require you to be self-motivated. But if you are self-motivated and you are ready to learn, head on over to CBTSchool.com and you can get all the information there. All right, let’s go over to the show. It’s self-compassion check-in time. WHAT IS SELF-COMPASSION? What is Self-Compassion? It means how have you been treating yourself? Remember, self-compassion is ultimately treating yourself with the same that you would treat somebody else. So, if somebody else came to you and said, “I’m struggling with A, B, and C,” what would you say to them? How would you treat them? How would you respond to them? How would your body language change? Would your voice lower? Would your voice soften? Would you give them a hug if that was appropriate? Would you soften your eyes and let them know that everything was going to be okay, and that you had their back unconditionally? That is how you would treat yourself. So my question is, how are you doing with this? I want you to check in regularly, way more regularly than we are here today. But I want you to check in with yourself preferably every day or multiple times a day and ask yourself, how am I doing? And then we’re going to move into, and I know a lot of you remember this from previous episodes, but I want you to ask yourself the golden self-compassion question, which is, what do I need right now? What do I need? Let’s do this together. I want you to find a comfortable place. If you’re driving, please do not close your eyes. You may listen along. If you’re not driving, you may close your eyes. You may rest your shoulders. You may bring a gentle smile to your face. And I want you just to slowly bring your attention to your breath. And when I say breath, I don’t mean the physical rise and fall of your chest. I want you to bring your attention to the air that is going in and out of your body. You breathe in... The air goes into your lungs, replenishes, restores you. And then you breathe out air. And I want you to become familiar with this air as it enters your body and exits your body, replenishing you, supporting you, feeding you. And as you bring your attention to this air, I want you to gently slowly drop down into where you are and ask yourself, what is it that I need right now? If you notice being bombarded by many, many thoughts, that’s okay. Just tend to one at a time. Each one of them, each one of those thoughts gets a moment. And you are going to use your wise mind to decide which ones you’re going to tend to. As you ask yourself “What do I need right now,” you may notice your mind sharing with you, “I need rest. I need a moment. I need to laugh. I need food. I need to pee. I need water. I need to be kind to myself.” And take one at a time and take stock in acknowledging nonjudgmentally that that’s what you need. Nonjudgmentally, which means we’re not going to judge that we need it. We’re not going to treat ourselves poorly because we need it. We’re just going to acknowledge that’s what we need. Now, if you notice that your mind is coming up with other things like criticisms, a list of things to do, it might be telling you, you should be doing something different and more productive, they’re the thoughts that we maybe don’t tend to because you’re tending to those all day. Now is the time to check in for what you need. Say, “I’ll be right with you later, thoughts. Right now, it’s time to nourish me, to fill my cup so I can go and do those things later.” We breathe in air... And we breathe out air. Now we bring our attention to those needs and ask ourselves, is there anything we can tend to right now? Maybe the softening of your shoulders. Maybe to let go of the to-do list. Maybe to celebrate the wins that you’ve had today or yesterday or whenever. What do I need? Sometimes it’s to cry. Sometimes it’s to feel our feelings. Sometimes it’s to validate our own feelings and that’s our job. That’s our job. What a wonderful opportunity and a wonderful job we have, which is to be our first line of support and care, that we deserve that. Maybe you’re surprised by what’s showing up in what you need. Maybe you’re surprised that you need something and it’s something that you don’t usually need. That’s okay, too. Just be curious and open to that voice inside you. Now, if you’re struggling to identify what you need, I want you to just gently remind yourself that the wish to be compassionate towards yourself is self-compassion enough. If it doesn’t land and you don’t have this powerful experience or gentle experience, and for you, it’s actually quite gritty and edgy, that’s okay. Just the intention of being here and asking is so wonderful. I often think of my husband. If I went to him and he was struggling, and I said, “Is there anything I can do to support you?” he may not be ready to ask for my help. But just me offering it, the intention of being there to support means so much. And we can be that for ourselves. So again, take a deep breath in... And breathe out. And just give it one last time. Is there anything you can offer me in how I could support me? Which is you. Or is there anything you need? You might even offer it to your body parts if there’s particular areas struggling. Mind, what do you need? Tummy, what do you need? Foot, what do you need? Neck, what do you need? Now, as you’ve done this, I hope that you have been kind and non-judgmental, and non-critical. But if you are, I still want you to see this as a win. The check-ins can be so rich even when they’re bumpy. We’re going to slowly open our eyes... We’re going to bring our awareness to what’s around us and come grounded into the present again. And I hope that it’s the check-in you needed. I hope that you got to explore your needs, which are important, and then nothing to be embarrassed or ashamed of. It’s okay to have needs. In fact, it’s normal and natural and healthy to have needs. We all have them. Have a wonderful day, everybody. I hope you are doing well. Before we finish up, we are going to do the review of the week. This one is from Jessrabon621, and it says: “Amazing podcast! I absolutely love everything about this podcast! I could listen to Kimberley talk all day and her advice is absolutely amazing. I highly recommend this podcast for anyone struggling with anxiety or any mental health professional that wants to learn more.” Thank you so much, Jessrabon621. I love, love, love, love your reviews. Please do leave a review. I am trying to get to a thousand reviews and I will be giving away a free pair of Beats headphones to one lucky winner who leaves a review. Have a wonderful day, everybody. And I will see you all next week.

In this week’s episode of Your Anxiety Toolkit Podcast, I share what I learned from my 3-day silent meditation retreat. This 3-day silent meditation retreat was rough, I won’t lie.  I had to ride many highs and lows, so I wanted to share them with you. Links To Things I Talk About: Tara Brach Silent Meditation Retreat home schedule https://www.tarabrach.com/create-home-retreat/ Mindfulness Book https://www.amazon.com/ ERP School: https://www.cbtschool.com/erp-school-lp Episode Sponsor: This episode of Your Anxiety Toolkit is brought to you by CBTschool.com. CBTschool.com is a psychoeducation platform that provides courses and other online resources for people with anxiety, OCD, and Body-Focused Repetitive Behaviors. Go to cbtschool.com to learn more. Spread the love! Everyone needs tools for anxiety... If you like Your Anxiety Toolkit Podcast, visit YOUR ANXIETY TOOLKIT PODCAST to subscribe free and you'll never miss an episode. And if you really like Your Anxiety Toolkit, I'd appreciate you telling a friend (maybe even two). EPISODE TRANSCRIPTION This is Your Anxiety Toolkit - Episode 178. Welcome back, everybody. I am so thrilled to be here with you today. I recently got back from a three-day silent retreat. I was by myself for the entire three days. It was a three-day silent retreat. I have done silent retreats in the past at Buddhist monasteries and Buddhist retreat centers. This is the first time I’ve done it on my own, and I followed the Tara Brach self-retreat website. I will leave the notes in the show notes so that you can check that out. It was amazing. I can’t lie. I had so many mind-blowing moments and I want to share with you each and every single one. I’m going to give you the cliff notes version. Otherwise, I would have you here for days on end. But I am so excited to share that with you. Before we do that, of course, you know we always do the “I did a hard thing.” This is a segment where someone can write in, submit the hard thing they’ve done. This one is by Mgwolfie1992, and they’ve said: “I have OCD and ASD. Certain shirts do not feel right. Before starting ERP, when I put on a shirt that’s uncomfortable, I immediately take it off, which was making me late for work. After starting ERP, I have slowly worked my way up to wearing and keeping that uncomfortable shirt on for 12 minutes.” Mgwolfie1992, this is just you doing the work. I’m so, so impressed. This is exactly what it’s like for everybody listening or watching today, is it is about just small baby increments and getting yourself higher and higher and a little more difficult, a little more difficult. I’m so impressed with the work that you’re doing. This is just so incredibly powerful and rewarding, and I hope that you keep going. Let’s talk about what I learned from my three-day silent retreat. Just to give you a setup, I rented through Airbnb a small little cabin in the depths of Topanga, which is very close to where I live in Los Angeles. I was following the Tara Brach home retreat that she created at the beginning of COVID. Now, when COVID hit, I so desperately wanted to do this, but I was in the middle of writing The Self-Compassion Workbook For OCD, and so I did not have time or the bandwidth to really go and really be with myself. I just had so much going on. As you probably remember, the world just felt so scary and no one knew what was happening. So I definitely wasn’t ready to do something at that time. After several years or even months at this point where I feel like I’ve really, really prioritized my mental health and my medical health, I was finally in a place where I just felt like I needed some time to really go and let go of some things. I could be doing this at home. I could do this every day and I have since I returned, but I really felt that I needed these three days to do a deep dive into really some things that I had been working through having a medical illness, a chronic illness. I have postural orthostatic tachycardia syndrome, really coming down out of the pandemic and so forth. So, I really felt like I just needed this time to really not have the kids around and just drop down in and do that really hard work. I took with me a journal. I took with me a book called Mindfulness by Joseph Goldstein. I strongly recommend that you try it. It is very heavy on Buddhist philosophy, but it is such an important book about mindfulness. And so to start off, the thing that I learned the most was I needed so desperately to go back to basics. Everything felt so complex – everything I was teaching, everything I was doing in therapy, the practices of my own. It just felt like there were so many spinning parts. When I got there, I just dropped down to like, “Kimberley, let’s go back to the basics.” So I wanted to share with you what those basics were. Number one, I went right back to the core of mindfulness, which was mostly me. The main agenda was to observe what showed up instead of being in reaction to it. Here, when life is so busy and chaotic and so many things happening at once, it’s really hard to be an observer. I think I have lost my ability to do that. And so once I got there, I promised myself and my friends that I would not be contacting them, that I would have just one part of the day where I would text people back. I would check my phone, make sure everybody was okay and my clients were okay and my staff were okay. I would respond back, but very limited. And that throughout the day, if I felt the need to pick up my phone, or I felt the need to call, or I felt the need that I needed to talk to someone, that I had to stay in that feeling. And that’s why I really chose the silent retreat. I wanted to create an environment where I couldn’t rely on anybody except myself, and that no matter what I felt I had to hang on and I had to ride it out and I wanted to really drop down a little deeper and really explore what was going on for me. Now, the thing that was most profound is the first day was excruciating. I mean, painful. I had every emotion under the sun. At one point at the evening, when I told my husband I would call after me waiting through these emotions all day, I did text and he asked how I was doing, and I said, “This is so hard. I don’t even want to be here.” I didn’t ask for his advice, but he did say via text, “Just keep going.” So, I did. Of course, I did. But what was so fascinating to me, and one thing I really learned about myself, and I’m wondering if you do the same thing, is I had gone into this silent retreat not exhausted. Usually, by the time I take a break, I am so wiped out that I’m completely like starfish on the bed, completely out of it. This was really interesting because, for the first time, I wasn’t exhausted, and on the first day, I kept having the thought, “You don’t deserve this.” I kept thinking, this is ridiculous. People are at war. There is floods in my home country. So many people have it worse than me. “You don’t deserve this, Kimberley. This is unnecessary. This is actually very silly of you to have asked to do this three-day silent retreat.” I was so shocked at those thoughts. Now, here is where the observing skill was so helpful for me. Instead of having that thought and then going, “Yeah, you’re right,” and then beating myself up or maybe even going home or feeling guilty or punishing myself, I just observed it and went, “Huh, that’s interesting. I’m having thoughts that this is selfish,” or “I’m having thoughts that this was silly.” Instead of fusing with those thoughts, I just observed them. And I also observed the feeling and going, “Uh-huh, I feel guilty,” or “I feel selfish.” But instead of saying, “I am guilty and I am selfish,” I didn’t over-identify with those emotions, which is another mindfulness skill that I wanted to go back to the basics, is how much we over-identify with the thoughts we have. If something is uncomfortable, we go, “Oh, that means it must have to go away, and this is wrong. I’m wrong and I shouldn’t be feeling this way.” Instead, I just sat in it and I had this-- I want you to just imagine me. If you’re listening to the podcast, you won’t be able to see me. But if you’re watching me on video right now, I just had my head and kept nodding and smiling, like I was almost dancing with my head and just going, “Uh-hmm, yes, brain, I hear you. Yes, mind, I can hear what you’re saying, but I’m not going to connect with that. I’m going to allow it. I’m not going to push it away, but I’m just going to observe it.” Oh my gosh, I had so many breakthroughs, one after or the other, of just catching these rules and beliefs I have and how invasive they are and how reactive I am to them. Even though I’ve practiced this for years, I just knew I needed this time to let go of all of this. Now the second thing I learned besides really dropping down into the basics and observing everything and not identifying was, in the Mindfulness book that I was reading, and I had it as my agenda to read it, is I had to practice going back to accepting impermanence. Now impermanence is a Buddhist concept that they talk about a lot. Basically, what it means is that this is temporary. As I sat and I meditated so much on this three-day retreat, not so much the second day, but the first and the third day were really good meditation days. I sat on my meditation seat and all I would do is just try to stay in the moment and notice the impermanence. So, as a satisfying feeling showed up, I would just notice that this is temporary, that it will go, and I’m not going to cling to it. As an uncomfortable thought showed up, I said to myself, “This is temporary. I’m not going to cling to it. I’m not going to push it away.” Everything that showed up, I just kept going, “This is temporary. This is temporary.” Some people would probably argue that that’s a problem. Like, why would you push away good thoughts? But I had to keep reminding myself that my attachment to good is what creates a lot of my suffering. A lot about impermanence is also looking at the fact that everything is temporary. In this beautiful rental that I had was these beautiful windows. I would sit right at the edge of the window and I would overlook this beautiful creek, all these trees, and leaves. A part of the meditation that I had practiced and I have practiced for many years is to meditate on impermanence, which is to sit and look. This time my eyes were open, and everything I see, I contemplated how temporary it is. If it was a leaf that is just newly budded, I would imagine it fully coming into bloom, falling off the tree, and then completely breaking down into the ground where it was mud muddy and sludgy and yucky. And then looking at, let’s say the wood and going, “Yes, that too will break down over time.” Looking at my hand and my face and my body and imagining me too once was very youthful and now looking slightly older and acknowledging that that too is impermanence and that I too will die. From that meditation, I cried. I sobbed actually, and I let go of a lot of beliefs and values I was hanging onto that really aren’t my values in terms of me having to stay young, that me having to stay liked by people, that I had to hold onto this idea. Instead, I was actually moving towards saying, “It’s okay. You can like me or hate me, because you liking me may actually be temporary. You may only need me for a period in your life. And then you may not need me.” And then again, observing what showed up for me and letting go of that too. It was just this massive cycle and it kept going and going. I would keep hitting these same things that I needed to let go of and learn and practice like observing and recognizing that things are temporary and that it doesn’t mean anything about me. I know this may actually be a lot, but I can’t tell you how powerful it was. It was such a beautiful experience of letting go, of catching where I’m attached to things, and then letting go of that as well. I’m not saying that because I let them go they don’t bother me anymore. I am now in a cycle and it got me going and now allowing that letting go to be more automatic. Whereas before, I used to joke with my husband and my best friend. When they’d make a suggestion to me, like maybe they would offer me some advice, I would respond a little defensively. And that’s one of the reasons I really wanted this three-day retreat, is I could feel the tension in me on how inflexible I was and how I was being stubborn and holding tight on things. I knew that’s not what my core nature is. I’m going to keep this short and I’ll give you one more thing that I learned. And this thing has probably been the most beautiful lesson I’ve ever learned. It’s been so synchronistic because so many things have really reinforced things since I’ve returned. This is the idea of independence versus interdependence. I think since I recovered from my eating disorder, I have made it my goal to be independent. I don’t want to rely on people. I don’t want to ask them for help. I want to be a strong woman. I want to be a powerful human. I want to be peaceful in myself. I want to be self-sustaining, if that makes sense. This has been such amazing growth for me. I have learned so much and really learned my own strength because I made a deal with myself that I would always be my first person. Through that, I have learned to trust myself, to rely on myself, that I’m stronger than I thought. It’s a big reason why I say it’s a beautiful day to do hard things, is because I’ve practiced that my whole life. But I was reading something from one of these, in the Tara Brach retreat, she has a lot of retreat talks and I was listening to some of these Dharma talks. One of them was that we’re interdependent. Even though we’re independent, we also need other people. And that actually through being interdependent is where we build community. It made me realize that I think I’ve swung too far in the independence. If there was a pendulum swinging, I’d swung too far in the independence and I needed to recognize how much I need other people. I need my friends, I need my husband more, I need my children more in different areas, that I need to ask for help more. It doesn’t mean I have to pay people. It doesn’t mean they owe me. It doesn’t mean I now fully swung the other direction into always being dependent. It’s that I’ve acknowledged that change happens more on the local level. Since I created this podcast and I have an Instagram profile, I think my mind had very much gone to a large scale. Like, I have to make a huge difference, that I could make a huge difference. Something came through me, a sense of knowing in terms of, yes, I can make a large difference, but I can’t forget the local difference that I can make, the connection with my neighbors, the connection with my school. Particularly since COVID, we’ve become so technological. How can I actually connect with people more on a one-to-one basis instead of a one-to-thousand? For some reason, that really spoke to me and I’ve never been more empowered and excited to serve you all because I think I needed to come out of the big crowd, thousands of people and really just start to go back to thinking one-to-one and thinking about the person instead of the crowd. I think that that will help me a lot in terms of being more connected, feeling more connected, feeling not lonely in things. They have that whole thing about you can be surrounded by people, but still feel lonely. I think that’s probably why I felt lonely in the past. They’re the main things I learn. There are so many more, but really, I just want to emphasize, if you can create a one day or even a half-day silent retreat where you sit and really be with your emotions and commit to seeing what comes up, you will be shocked at the explosion of experiences that you have inside you. It doesn’t have to be three days. You don’t have to rent someplace. You could do it in your own home, even in one room if you need it, and really drop down. When those really painful emotions come up, really sit with them and be with them and practice letting them wax and wane as much as you can. That’s what I learned. I hope that that has been inspiring to you in some way or another. For me, I’m more committed to my meditation practice than I’ve ever been. I’m more committed to my mindfulness than I’ve ever been, and I’m more connected to my business than I’ve ever been, which is really, really beautiful. All right, thank you so much. I am so grateful for you being here with me today. I just love this work I’m doing with you and I hope that it is beneficial to you. Before we finish up, let’s do the review of the week. This is from kdeemo and they said: “This podcast is a gift. I just found this podcast and I’m binging on the episodes. I learn something through each episode, and I love her practical advice and tools. I feel like part of a community-what a gift!” Thank you, kdeemo. Please, please do go and leave a review. I know you are very busy. I very much respect your time, but the best gift you can give me is just a view and honest review. It helps me to reach more people and that makes me feel so fulfilled and happy. Have a wonderful day, everybody.

Common treatment of derealization and depersonalization Kimberley Quinlan SUMMARY: Derealization & depersonalization are common experiences of anxiety. In this episode, we take a look at the definition of derealization and depersonalization. We also explore the common symptoms of derealization and depersonalization and the treatment of derealization and depersonalization. I also explore mindfulness and CBT skills to help you manage your discomfort and anxiety. In This Episode: The definition of derealization The definition of depersonalization Explore the symptoms of derealization Explore the symptoms of depersonalization Comparing derealization vs depersonalization Common treatment of derealization and depersonalization Links To Things I Talk About: ERP School: https://www.cbtschool.com/erp-school-lp Episode Sponsor: This episode of Your Anxiety Toolkit is brought to you by CBTschool.com. CBTschool.com is a psychoeducation platform that provides courses and other online resources for people with anxiety, OCD, and Body-Focused Repetitive Behaviors. Go to cbtschool.com to learn more. Spread the love! Everyone needs tools for anxiety... If you like Your Anxiety Toolkit Podcast, visit YOUR ANXIETY TOOLKIT PODCAST to subscribe free and you'll never miss an episode. And if you really like Your Anxiety Toolkit, I'd appreciate you telling a friend (maybe even two). EPISODE TRANSCRIPTION This is Your Anxiety Toolkit - Episode 227. Welcome back, everybody. I am so grateful to have this time with you. As you know, I promised this year would be the year I doubled down and get really into the nitty-gritty of some of the topics that people don’t talk enough about regarding anxiety. Today is so in line with that value Today, we are talking about what is derealization and depersonalization. These are two what I would consider symptoms of anxiety. I see it all the time in my practice. I see it reported and commented all the time on Instagram. If you follow me on Instagram, we put out tons of free information there as well. This is such an important topic. And for some reason, we aren’t talking about these two topics enough. My goal today is actually to give you a 101 on derealization and a 101 on depersonalization. We can touch upon derealization disorder and depersonalization disorder as well, but at the end, I want to give you as many tools as I can to point you in the right direction. Before we do that, let’s do the “I did a hard thing,” because we love that, right? The “I did a hard thing” is a segment where people submit the hard things they’re doing. The main reason I do this is because, number one, you’re my family. We’re all in this together. But number two, often people, many years ago when I started the podcast, people were like, when I started saying it’s a beautiful day to do hard things, which I say all the time, a lot of people were saying, “But how hard does it have to be? And how do I handle the hard things? Can you give me an example?” And so, these have been just such a wonderful way to share how other people are doing hard things. This one was submitted anonymously, and they said: “I’ve struggled with suicidal ideation for a very long time. And after years of therapy, self-discovery, and lots of hard work, I’m finally accepting that I am better off in the world than out of it.” Now I just have to take a deep breath and nearly cry because this is seriously the hard work. Sometimes when we’re talking about “I did a hard thing,” we’re talking about facing one small thing or one large thing, but I really want to honor Anonymous here and all of you who are doing this really long-term work and deep, deep work around really acknowledging how important you are and how much the world needs you in it and on it. So anonymous, I love you. You are amazing. I have such respect for the work that you’ve done and are doing, and thank you. Again. I think we don’t talk about suicidal ideation enough either. In fact, I should really do an episode on that as well. I respect you and I’m so grateful you submitted this week. Okay, here we go. I have some notes, which I rarely use notes for episodes, but I didn’t want to miss anything. I’ve got so much I want to share. I will do my best to break this down into, like I said, a 101, small bite-size helpful tools. You will hear me, as I talk, taking little deep breaths and that’s because I have to practice slowing down. Just a little off-topic, when I’m doing podcasts, I get so geeked out that my brain races, and I’m all over the place and I’m talking fast and I have to slow down, “Kimberley, pump the breaks, lady.” Let’s together take a breath... and let’s just be together. First let’s talk about derealization. The definition of derealization is that derealization is a mental state or a psychological experience, it could also be a physiological experience, where things feel unreal. Not like, “Oh, that’s totally unreal, man. Amazing.” I’m talking where they don’t feel real. When you have derealization, you might feel detached from your surroundings. You don’t feel connected to what’s going on around you, and people and objects may also seem unreal. Often people, when they have derealization or derealization disorder, feel like they’re going crazy. Actually, they feel like they’re going crazy. Not just the term that people use on the street. They actually feel like they’re losing touch with reality. When we talk about derealization disorder, we’ll talk about that here in a little bit, but we could use them interchangeably. Lots of people have derealization without having the disorder, but to have derealization disorder, you have to experience derealization. So I’m including them both there. Now the prevalence of derealization, I wanted to just give you this information because I felt it was very validating. I myself struggle with derealization and depersonalization. It was really validating for me to hear that more than half, more than 50% of people may have this disconnection from reality at least once in their lifetime. 2% of people experience it enough for it to become some kind of disorder, just like derealization disorder or even a dissociative disorder like amnesia. If you’re concerned, you can go speak with your doctor or your therapist, or a licensed therapist for an assessment if you’re concerned about it. A lot of people who I have seen have already been to the doctor, gotten cleared. Schizophrenic is often a very big concern. People often feel that they’ve been misdiagnosed. Now derealization is similar, but distinctly different from depersonalization, which we would talk about here soon. Some symptoms of derealization include feelings of being unfamiliar with your surroundings. You feel like you’ve never been there before, or you may feel like you’re living in a movie or a dream. You may feel emotionally disconnected from your loved ones or colleagues or friends. You just feel very numb. Like I said, you’re just very out of order. Things feel very strange. Your surroundings and the environment also may appear distorted, blurry, colorless, two-dimensional, or artificial. I remember the first time I ever had derealization. I was sitting across from a client and I was an intern. I was very anxious. I’ve talked about this on the podcast before. I was sitting across from them and all of a sudden, their body looked like a caricature of themselves. The caricature is where their body is really small and their head is huge. I was looking at my client, trying to be a therapist, and I’m thinking what happened. All of a sudden, their neck was very, very small and short and their head looked gigantic. It looked like a drawing, not three-dimensional, but two-dimensional. And that was so concerning to me. I freaked out. I got through the session. Thankfully, again, I had tools to use. But it was really scary. It actually brought on some panic later in that evening because it didn’t go away for a little bit of time. Now, depersonalization, the definition of depersonalization involves feeling a detachment, not from your environment like in derealization, but from your own body and your thoughts and your feelings. Think of it like it’s like you’re watching yourself from an outsider. I always say it’s like you’re flying on the wall, looking at yourself, or it’s like looking at a movie of yourself. Now, symptoms of depersonalization include feelings that you’re an outsider observer, like I just said. You’re disconnected to your body again. Others report that it feels like they’re a robot and that they don’t have control of their movements. Again, you feel like you’re watching yourself and you don’t have control of what’s going to happen next. Another symptom of depersonalization may include the sense that your body and legs and arm appear distorted. They may feel enlarged or shrunken. Some people report that their head is wrapped in cotton. That’s a different symptom. Another example I always use with my patients is often when I have depersonalization, which isn’t very often anymore, is I’d look at my hand and I couldn’t tell if it was my hand or not. I didn’t feel like it was my hand. Again, really scary, can feel really concerning in the moment. Now you may also experience some numbness, whether that’s emotional or physical. Some people say all of these symptoms are similar for derealization as well. You may feel like your memories lack emotion. Again, you’re disconnected from your own experience. So, that can be an additional symptom of depersonalization. Now for both, I’m going to talk about them together now. For both, the duration of these symptoms may last just a few minutes, they can last a few hours. Some people, particularly if you have derealization disorder or depersonalization disorder, it can be days, weeks, and months. In that severity, I would encourage you to go and speak with a mental health provider who is trained and can assess you properly. Now, to be diagnosed with derealization or to be diagnosed with depersonalization, there is no lab test. There’s no scan you can have. It requires a trained professional to review your symptoms and give you the diagnosis. You could probably, by listening to this, define for yourself whether you have the criteria to meet this classification. But if you’re wanting to be sure, I strongly encourage you to seek professional help to get that diagnosis. Now, the prevalence of the struggles almost always start in late childhood or early adulthood. The statistics, this is why I have my notes today, the average age starts around 16. 95% of cases are diagnosed before the age of 25. Not always, but that has been the common statistics that they’re showing. I think that’s really helpful to know. Now, that being said, what do you do from here? The treatment of depersonalization and derealization is often CBT (Cognitive Behavioral Therapy). Basically, what we do, and this is a lot of the work that you probably already have skills if you’ve listened to a lot of the podcast episodes – a lot of it is around practicing your mindfulness tool. The first thing I want to let you know is it doesn’t mean you’re going crazy. I totally get that. It feels like you are, but it doesn’t. The good news is, when you can’t stop appraising it as “I am going crazy,” you’ll actually start to notice it’s just a really strange feeling, but it doesn’t mean anything is wrong. I once had a teen client who told me, he said he was laughing and we were giggling together. He said, “The crazy thing is some of my friends pay a lot of money to feel this way by using drugs,” and he says, “I have it for free. I have this strange feeling, this out-of-body experience. And I don’t even have to be under the control of a drug or a substance.” He said, “When I looked at it from that perspective, I stopped appraising it as if it’s dangerous.” And that was a game-changer for him to stop appraising it as if it is a dangerous problem. For me now, when I have derealization, it usually occurs when I’m driving. I used to panic that that meant I was going to crash. But then when I just said, “Okay, I’m just having a feeling and I’m going to let it be there.” I’m not going to do anything about it. I’m not going to judge it negatively. I’m going to allow it to rise and fall on its own. And I’m going to put all of my attention on just staying present. Now your brain is going to say, “Yeah, but present is bad. Present is terrible. Bad things are going to happen. What if you’re going crazy?” And your job is actually to practice just letting those be thoughts, because that’s what they are. They’re thoughts. Just because you have them doesn’t mean they’re facts. Lots of people have derealization. The clients I’ve had who’ve had severe derealization and derealization and depersonalization disorder, they now say, “Yeah, it happens. No big deal. They just go about my day.” Now in the early stages of treatment, you’re going to hate this idea, but it works, is we actually used to purposely induce this sensation so that they could practice tolerating the discomfort without responding in unhealthy ways or in compulsive ways. We would sit them down and spin them around in a chair. We would have them stare at the wall. We would have them look at really psychedelic YouTube videos where the colors and the patterns are all wavy like seventies, like psychedelic. And we would practice inducing the feeling. From there, they would practice willingly allowing the discomfort and going about their day, being gentle with themselves, engaging in the things they value. Of course, they might feel great, and that’s okay. You can slow down a little and do what you need to do. But ultimately, when you have depersonalization and derealization, the goal is simply to do nothing at all. Crazy. When I tell my patients that, they’re like, “Oh my goodness, you’re either crazy or you’re brilliant.” By the end, usually, they say that this treatment, not me, but the treatment is brilliant, because it teaches them not to be afraid of it and not to try and live their life avoiding it. I’ve had patients report that they’ve avoided things at great length just to avoid the experience of depersonalization and derealization. And when they avoid it, it just keeps them stuck and keeps them scared and keeps it happening more. The other thing I will add is, do not check to see if you’re derealized or depersonalized, because just the act of checking for it, like a mental check, can actually bring on the symptoms. Now, that’s easier said than done. Am I right? Yes, it’s very hard. I know it’s easy to say, “Just stop doing that.” But if you’re engaging in a lot of checking behavior, sometimes it’s helpful to catch when you are and bring yourself back to the present, do whatever disengagement skills you can use to get you back into the present moment. Again, we don’t want to push the discomfort away, but we also don’t want to give too much hyper attention to these sensations and symptoms. If you’re struggling with these symptoms, go and see a mental health professional. You can quiz them, ask them if they have skills in this. Look on their website, see if they’ve got any information about it that will help you to get the help that you need. This is great. Like I said, this is what I call derealization and depersonalization 101. But there are many, many other tools that you can use to help manage this. One day I will do my best to create an online course about this that goes into detail so you have that, but for right now, I hope that this is helpful. Now, before we finish up, I’m going to do the review of the week. We have an amazing review here from Jessrabon621 and they said: “Amazing podcast. I absolutely love everything about this podcast. I could listen to Kimberley talk all day and her advice is absolutely amazing. I highly recommend this podcast to anyone struggling with anxiety or any other mental health professional that wants to learn more.” Thank you, Jessrabon621. I am so grateful that I’ve helped and I’m so happy that you’ve left a review. Thank you. I love your reviews. They help me so much. 2022 is the year that I want to get a thousand reviews. If you can help, I would be so grateful. Go in wherever you’re listening, click on the reviews, leave a review. You don’t have to write something. You can just rate it. Leave an honest review. I am so, so grateful. We will be giving a pair of Beats headphones to one lucky winner by the time we hit 1,000 reviews. So I am so grateful. Have a wonderful day, and I’ll see you next week.