As part of this year's OCD Awareness Week, Shala Nicely, LPC, a cognitive behavioral therapist and author of Is Fred in the Refrigerator? Taming OCD and Reclaiming My Life, will be hosting an AMA right here on HealthUnlocked on October 14th at 3pm ET.
What's something you want to know about OCD but were always too afraid to ask? Shala will be here live to answer all your questions! Learn more about her at ShalaNicely.com, and start posting your questions HERE for her to answer on Monday!
That is a very exciting announcement.
How is this AMA going to work? It doesn't seem like this forum software is intended for real-time conversations.
Hi Selesnya! You can do AMAs on pretty much any forum, including HealthUnlocked! Here's an example of one from the Multiple Sclerosis Association of America: healthunlocked.com/mymsaa/p...
What is an AMA?
AMA stands for Ask Me Anything and originated on Reddit. It's really just a time to chat and ask whatever questions you might have. It goes on in real time so that you can post your questions and get answers right away, as in an in-person discussion. The conversation ends up being archived so that you can go back to it later and go through the transcript of what happened, even if you can't actually participate at that moment and ask questions.
Hi everyone! Thanks for joining us for our #OCDWeek AMA with Shala Nicely! What's something you'd like to know about OCD? Start asking questions and Shala will answer them in order.
Hi Jess, I'm glad to be here!
Could you talk about the Greater Good concept?
Sure! Jeff Bell is the originator of that particular concept. Your “Greater Good” is composed of two sides of the empowerment coin. One side is your purpose in life; the other is how you can be of service to others. You can use that to motivate yourself to do ERP by saying "what's my greater good here? Is it to relieve anxiety by doing a compulsion (which will just make my OCD stronger)? Or, is it to do my exposure and be uncomfortable on purpose so that I can get stronger and beat my OCD?" (which are both examples of what your purpose might be in the moment). If you'd like to learn more about this concept, you can refer to Jeff's book When in Doubt, Make Belief.
Sorry for this being a non-straightforward question:
How much attention should be put on ERP and non-avoidant behaviors, and how much do you look at the other areas of mental health and having a mentally resilient and flexible approach to life?
Looking at the OCD community, there is rightly a strong emphasis on ERP and not avoiding your fears. This seems absolutely necessary, but it is not enough to live a meaningful life. If you embrace a whole philosophy such as ACT, you have a framework of which being open to the experiences of life is but one component, and there are other crucial skills to work on. To what extent should a therapist/patient relationship be focused on addressing the whole needs of a person to live a mentally healthy and engaged life, and to what extent should it be focused on the specifics of problem-solving and overcoming obstacles that are directly related to OCD?
How do you make people aware of this need to change their mindset and approach to life? The therapist can only gently guide a person and can't make the changes themselves.
That's a great question! Unfortunately there isn't a straightforward answer, as it depends on each individual's situation. Because OCD is so overwhelming, I've found the need to clear away a lot of the OCD by doing ERP before you can focus more generally on living a mentally healthy and engaged life. If you try to just work on being engaged with life without directly focusing on ERP, OCD will probably try to sabotage what you are doing. If I look at how I do therapy with my clients, I start by focusing on ERP, and as the person gets better we start spending more time looking at how to rebuild a meaningful life, but ERP is almost always still a component of that.
I also think that the mindset shift is something that happens through the process of therapy. Those of us with untreated OCD have a mindset that's influenced by the disorder, often quite rigid, controlling, and black and white. The purpose of exposure is to learn to be more flexible and go with the flow; I let clients know that's the mindset we're heading for as we work on exposure, and then as they becoming more and more successful defying OCD, they see that mindset in action for themselves.
And so do you end up continuing therapy with clients as they make those changes in mindset and their problems evolve? When do you consider your work to be "done". If we treat OCD as a process/lifestyle, then there is never really an end-point.
I work with clients on a weekly basis until their YBOCS score is as close to the subclinical range as we're able to achieve, and then I tend to move people to monthly sessions, and during those sessions we work on any residual OCD symptoms and helping them build the kind of life they'd like to live. When the person feels they have the knack of doing maintenance ERP and their OCD is staying at the same low level and they are working well on learning how to identify and address issues on their own, they "graduate" from therapy. But they are always welcome to back for booster sessions. Our work is never actually "done" as we're all works in progress :), and I see clients for as long as both the client and I feel there's benefit from continuing the process, and it will be different for every person.
Have you heard of inner child work? Have you seen that bpd is linked with OCD?
I have not heard of inner child work. And to clarify your second question, are you referring to Borderline Personality Disorder? If so, I don't know what the research says about whether there's a link b/w OCD and BPD, but they can certainly be co-occurring.
What has your experience been like as an OCD therapist? How is different from what you expected? Is it as rewarding as it would seem to be? And how does it compare to being in sales?
(Thanks, BTW, for Fred. I love your two books.)
My experience as an OCD therapist has been good, as we're very fortunate to have a treatment, ERP, that works well for most people. I'm not sure I had many expectations about what it would be like, but it is quite rewarding to help people take back their lives from a devastating disorder. And sometimes my sales background comes in handy, as all ERP therapists end up having to "sell" ERP to clients by providing the rationale of why it works, why taking the new "I want this" attitude will be helpful, and by helping clients approach exposures while OCD screams in the background that "this is very bad idea!" And I'm so glad you like my two books...thank you for the kind words!
I’m just beginning my OCD journey, but better late than never at 56. My question is about compulsions. With contamination it is easy for me to see how I avoid. But with health anxiety, it’s not so obvious.
Do I need to spend time on this to see what the compulsions are?
Hope this makes sense.
It's never to late to begin! And yes, absolutely find out what the compulsions are. The key to beating OCD is to stop doing compulsions, so identifying them is crucial. Often compulsions for health anxiety can be both physical (checking things, avoiding doctor appointments or going too often, for example) and mental (ruminating over whether you really could have a disease, planning what you'd do if you did, replaying how you might have gotten sick, etc..). Compulsions can also include becoming depressed because you've convinced yourself you really are sick (see psychologytoday.com/us/blog... to learn more about this subtle compulsion). So spending time figuring out how you are doing compulsions is a great use of time!
Thank you! I live in Atlanta and I know you’re not taking on new clients but is there someone who you’d recommend?
Try Anxiety Specialists of Atlanta in Dunwoody as I think they have a few new therapists coming on board and may have some openings. Emory has also recently opened up an intensive program for OCD and you can contact Jordan Cattie, PhD about that. You can also check the treatment provider database the IOCDF has. Unfortunately, many of the ERP therapists in Atlanta have a wait list or are full. 
Do you really end up taking the confrontation of a client's fear to the extreme? Can you just stop once you've basically gotten to be minimally functional again? This is mostly me feeling that my biggest fears are too scary to fully face.
When I'm working with a client on exposure, I'm trying to help them become maximally functional again. Minimally functional probably means that OCD is still making a lot of the decisions, and OCD is not a good decision-maker when it comes to creating a meaningful life! I don't do "extreme" exposures, per se, I just help clients face the fears that are interfering in their lives. By the way, OCD will always tell you that your "biggest" fears are too scary to face because it wants to stay in charge. It gets desperate as you start getting better and it raises the stakes by telling you "oh, you definitely can't do that!" because if you did do it, you'd see that it's just one of OCD's lies and it would lose more power. Always good to remember that OCD is a liar through and through.
I wanted to know about OCD and PTSD. I did so well with OCD treatment and was training as a mindfulness teacher when PTSD just floored me. The OCD had more or less kept it at bay since I had experienced the index trauma at 19 (I am now 41, had OCD tx 7 years ago). My OCD symptoms are now very much under control but I get confused about how best to manage or address PTSD which I find much harder. I was refused EMDR as being inappropriate for OCD so did Art Therapy instead but people tell me that also exacerbates OCD. Urgh!
Both prolonged exposure (PE) and cognitive processing therapy (CPT) are two evidence-based treatments for PTSD that you might consider. And yes, EMDR is inappropriate for OCD although it is another evidence-based treatment for PTSD. If your OCD symptoms are under control, I would encourage you to find a therapist trained in one of these evidence-based treatments to work on the trauma symptoms. Trauma symptoms can be maintained through avoidance, so finding someone to help you work through the symptoms could be very beneficial in helping you find some true relief and freedom. You can go to ADAA.org or ABCT.org to find a therapist trained in treating trauma.
Thanks Shala. I live in Ireland where there is no access to the therapies you mention. I was unaware EMDR was inappropriate even when OCD not active. Thanks for clarifying. I am aware that avoidance is considered a maintaining factor in behavioural theories.
What advice do you have for couples dealing with OCD? Do you have strategies for partners trying not to accommodate? I guess that goes for other family members as well...
I would advise couples to have an open conversation about how best the partner without OCD can support the one with OCD. It's important that it be a joint decision, because if the partner without OCD decides to stop accommodating across the board, it can make things worse for the person with OCD because now they are overwhelmed with a bunch of exposures they might not be ready for, especially if they all happen at once. It's better to have a conversation about what symptoms the person with OCD would like help with and come up with a plan for how the partner can best stop accommodating in that area(s) so that there's agreement up front. A great book on this subject is "When a Family Member Has OCD" by Jon Hershfield.
What's your view on the role of medications in treating OCD? Is it a case by case basis, or have you generally found it be helpful?
To me it seems like the biggest gains are to be made in therapy and not medication, but that is all based on my own experience.
That's it from Shala! THANK YOU to Shala for joining us, and thank you to our participants for your excellent questions! Check out all of our OCD Week activities (including other AMAs) over at iocdf.org/ocdweek.
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