Q&A with Dr. Stephanie Lonsway on OCD and ERP (Full version)

Q&A with Dr. Stephanie Lonsway on OCD and ERP (Full version)


– All right, hi everybody, visiting us
from the nOCD landing page. I’m Stephanie Lonsway, I am a clinical psychologist in Michigan and the NOCD Clinical Director. I’ve been with NOCD for, coming up almost on a year here, and was really excited
to be working with them. I’ve been in a private
practice for almost five years where the majority of
the clients that I see have OCD as their primary diagnosis. And as I’m sure many
people have experienced, it’s hard to find a provider and get in, and so I was excited that NOCD was willing and excited to tackle the idea of getting more people
trained in how to treat OCD and to improve access to care. So those are some of the
thing that brought me to that. And to just give you a little bit more background about myself, I think it’s been 10 years now that I have been treating
individuals with OCD. I started at Northern Illinois University in my graduate program. I was part of their training program and we just had people in the community who would come into our
clinic with symptoms of OCD. And luckily, I worked in the
Anxiety Research Lab there, so we got a lot of training
and intensive supervision in working with those individuals and doing observations about exposure and response prevention. And from there, I got the opportunity to go work with AMITA Health. If anybody from Illinois
has heard of them, or from the Midwest, hopefully beyond, has also heard of them. They have IOP, PHP, and
residential programs for individuals specific to OCD. So I worked with them, and their Director, Dr. Patrick McGrath, mentored me for about four
or five years, on and off, where I would go out and
do practicum experience, which meant I would do actual
therapy with their clients. And I also worked with doing research. So part of my dissertation research actually came out of individuals who were in their program there. So from there, I went on to
the University of Michigan, where I had a really great time, again getting more intensive supervision, working with individuals doing exposure and response prevention for OCD and then other anxiety disorders as well, helping run groups for
people with social anxiety, mindfulness-based
cognitive therapy groups, and had a lot of different types
of theoretical orientations that I was introduced to. But exposure and response
prevention is my primary approach that I use with OCD and kinda excited to be talking to everybody today and hear more about what you’re
looking to learn about OCD. I’ll do my best to answer questions. Sometimes I’ll have to give generalities, certainly because the information that would be most helpful to you, is gonna be really
specific to your situation. But I will certainly do my
best to help respond to those. Let’s see here. So, hi, see a couple people coming on. If you wanna give out a shout and let me know where you’re from. This is my first time doing Facebook Live, so thanks for joining
us and bearing with us. It’ll be fun where everybody
is giving us a shout-in from. A couple of questions from people that we got earlier on was, what does therapy look like for OCD? I should probably start with what is OCD? Probably most people coming
to this Facebook Live event are aware but obsessions
are intrusive or unwanted thoughts, feelings, or
urges that people experience as distasteful, disgusting,
anxiety-provoking. So it’s really just kind
of unwanted experience. And sometimes people think that
obsession’s just a thought. It can certainly be… Hi in Chicago. It can certainly be an image also that could come into your mind. For example, sometimes
people might imagine that they’ve run somebody over and kind of have this flash
of an image in their head. Or they might also have the
thought, I ran someone over. So obsession cans look a
couple of different ways. And then certainly there’s
the compulsion part, which is the effort to mitigate, get rid of, reduce that anxiety, because it’s so distressful to have that anxiety experience that’s triggered by the obsessions. So coming back to kind of
what therapy looks like, most of us who have
been trained extensively and working with obsessive
compulsive disorder will… Oh hi, hi in Australia, that’s great. So most of us who have been trained are gonna be approaching it from exposure and response prevention. Let me know if you guys have heard that. shout out, too. Exposure and response
prevention is basically we’re gonna expose you to
the triggers for anxiety. We’re gonna trigger those obsessions because we kinda need to
activate that fear response, that anxiety or disgust
response you’re experiencing in order to help your body
learn that anxiety is normal and this will eventually kind of fade, and then we have the
response prevention part. Now this is really key
because if you think about it, you’re going through your life naturally triggered all the time, right? There’s not a day that you
probably aren’t going through already getting triggered. So you’re like, I’ve got this
exposure part down already, but why am I not learning from it? It’s really about response prevention. So response prevention is where we come in and we say we’re not
gonna do the compulsions. So then compulsions are
the things that you do in response to the
anxiety and the distress that they’re there for a reason. In the short term it makes you feel good. In the short term it
helps reduce your anxiety. But long term it prevents
you from learning that the trigger wasn’t actually dangerous in the first place. So, with the exposure
and response prevention we’re gonna help you set up
exposures to trigger the anxiety and then make sure that
we prevent the compulsions or sometimes you will hear them described as rituals from occurring. So, maybe going back to
that example I gave earlier, a lot of people tend to
connect with this one is that idea that I have
an obsession that comes up that I have hit somebody and maybe killed them with my car
as I was driving by. And so what we might do
for an imaginal exposure, for example, is to have them imagine that every time they’re in the car that they have hit somebody and then to not do the
response prevention of, say, and we’ll ask what are your compulsions? What are the things
that you’re urged to do to make yourself feel better? Or to like reassure yourself
that things are okay. So you might say, I wanna go
back and drive my car back over the same path and just
double check and make sure or I wanna look in my rear view mirrors. So I might have them
practicing imaginal exposures that they’re driving and
they hear an odd noise and maybe we’ll play some
background kind of noise in my office or at home
when they’re practicing, and they have to imagine that
they keep driving past that. Or if we’re in the office,
maybe somebody will go out and they’ll take a drive
and we have to do the loop and they can’t go back and check. So we’re trying to do
response prevention there. Let’s see, yep, this is the live session that began at 1:30 CST, kinda answering some
of the questions here. And that’s an interesting question. I’ve heard that ERP alone isn’t enough, even if all compulsions are cut out. So, I have found that, yeah, ERP is the most effective for most of the people most of the time. So as a provider that’s gonna
be the way that I train. I’m gonna use the science
to tell me where to start. But everybody is an individual. So there are different therapies out there and different approaches
that can augment the therapy or help enhance it. Usually I find that most of my
clients really want to start with exposure and response prevention, but again, there are other therapies or other versions that can be incorporated like acceptance and commitment therapy, mindfulness based therapies, so there are different ones out there. But again usually after kind of educating my clients will want to start with exposure and response prevention. But I think it’s also key
to do response prevention. Mental compulsions are something that people are really good at and don’t even realize they’re doing. So I’ve had a lot of
clients who have come to me and said, I’ve done ERP. I got better, it improved, but it never really got
me where I wanted to be, so I’m seeking additional treatment, and then when our first couple of sessions I’ll run through with
them doing an exposure, and I’ll quickly realize maybe they’re doing a mental compulsion. So then I will teach them subtle way to try to block that mental
compulsion from happening, and all the sudden they’re like, oh, something different
happened this time. I really, I didn’t do the compulsion. I felt the uncertainty, I felt the anxiety come down over time. So, for example, one way that I do that is I’ll tell them to say
the obsession out loud. It can be a really subtle way of kind of interrupting the brain process, ’cause you can’t, it’s
hard to say out loud and think something different. There’s too much cognitive load, too much happening in our brain. So if we, when we kind of add that burden of saying it out loud at the same time it’ll be harder to do some
sort of internal compulsion, something like perhaps
praying to yourself, reassuring yourself, telling yourself that I’m okay, I’m okay. If you’re actually saying it out loud it’d be a little harder to do that. So that might be a way
to really try to enhance the exposure and response
prevention exercises to get the most out of them. Okay, great. It looks like we have
some people from Ohio. Looks like there are
some more comments there. ERP for real. Okay, heard acceptance
can be the missing key when ERP isn’t enough. Yeah, definitely, I think
a lot of my clients have, we’ve moved into kind of
once we really understand exposure and response
prevention principles that the idea of acceptance
can be really helpful. And I think for me personally,
the way I describe it, is it goes back to even
the DSM five definition of an obsession, which is our, this is a small version of it, but there’s a thick version that describes criteria that need to be met in order to diagnose OCD, depression,
many other concerns. And it’s really about the description to me from an obsession. An obsession is a, something that is unwanted
by the individual. So, when we’re kind of resisting our emotions, our thoughts, we’re labeling them as bad, then we’re gonna interpret it as bad, and we’re gonna feel
worse in reaction to that, versus somebody who might not have OCD has the same thought, oh,
did I just kill somebody? They might not smile after it, but they might have that
same thought but go, just a thought I had today and kinda move through their day. So they’re accepting it, they’re not judging the
thought for being there and saying that it’s a bad thought, I shouldn’t have had that thought or said something bad about me. Instead there’s a little bit
more of an acceptance level. But again, that exposure
and response prevention can be really helpful initially, too, for just reducing the level of distress, and it makes it sometimes
easier to think about that with it later. So I think earlier I was talking about what does therapy look like. So let’s back up to the first session ’cause I think a lot of people get, or even further, the first phone call. I think a lot of people
get nervous at that point. They know that something’s
going on in their lives that they could use some help
with and want some help with. Just call. It’s fairly easy. Just call or text depending on the agency that you’re working with or the group that you’re interested or the individual you’re interested in working with. I have people that when
I’m at my private practice they just call me direct and
I call them back and say, tell me what you’re interested in. Tell me what you’re calling me about. And we’ll just talk for a couple minutes and I’ll get them scheduled
for their first session. The first session is usually
a 60 to 90 minute session, is pretty typical, where we’ll send you some paperwork ahead of
time, just consent forms, release of information, maybe
a couple questionnaires, stuff like that. And that allows us more
time then when we meet to actually be really getting to know you. When you come in for your appointment we’ll come greet you very
happily and bring you back. This is my office here,
to give you guys an idea about what an office might look like. Hopefully a warm comfortable setting, that otherwise you can
also do telehealth, too, where you meet virtually like this, and then you get to be in my
virtual office, I suppose. But that first appointment,
we’re excited to meet you, we wanna learn what’s
bringing you in to see us. And we’ll do assessment from what we call like biopsychosocial approach where we’re asking you questions
about your biology, your physical symptoms,
your medical history, that sort of thing. The psycho, biopsycho
part is gonna ask you about psychological symptoms. So what are your obsessions like? What are your compulsions like? And we’ll help you figure those out or ask you questions about
it as well, your experience. I’m gonna be helping to ask questions like when you need reassurance
how do you get that? When you’re experiencing doubt how do you make yourself feel better? And then usually we’ll
have you do questionnaires, like the Y-BOCS is a really
commonly used OCD questionnaire, that hopefully you’ll get
some sort of questionnaire when you go that’s another
way of tracking symptoms, in addition just asking
you also how you feel, it’s nice to have kind of
like a standardized way to be tracking your progress. And then from that first biopsychosocial, sorry the social part is
learning about your support, learning about where you might be having any issues in relationships or have strengths in those relationships to help you through
progress in your treatment. So we’re gonna take
our symptom assessment, our biopsychosocial assessment, and again, this is most providers, but probably not all
will add in other pieces. And then we are going to give you our diagnostic impressions. Do we think this is OCD? Do we think this is maybe
generalized anxiety, panic, is it something else? And then discuss with you your
individual treatment plan, which may include exposure
and response prevention if we are looking at OCD. So, and then kind of from there usually we finish up our assessment in case we had lingering questions over the next two to three sessions where from then on you’ll
either come in twice a week or once a week, depending usually
in the beginning at least, to establish the relationship, and just let’s get things rolling. Why wait, right? You’ve already waited long
enough to get your appointment. So from there we set
up your treatment plan, which might have… Oh yeah, louder, yeah please. I will definitely be louder. Which will have a hierarchy
probably of things that make you feel anxious
and trigger anxiety, and then you’ll break those down as you go through treatment and
start doing the exposures. So trying to look at some
of the questions here. ‘Cause I could go on about
treatment for a while. How do I book a virtual session? That’s a great question. It’s pretty easy, you
kinda call and you just ask if they offer telehealth. That’s usually the most
common phrase that you’ll see. Actually nOCD does offer
telehealth in select states. Right now we are working our best to become available to everybody. But you could try going through NOCD. We offer assessments and therapy using exposure and response prevention. Otherwise, if you’re looking
for private practice, too, you just call your insurance company, make sure that they cover
telehealth or ask if they do. Otherwise, out of pocket
might be an option, too, but certainly understand
that that can be a challenge. And for my sessions, usually I have a platform that is HIPAA secure, and NOCD has it as well. So that’s gonna protect
your confidentiality. So you wanna make sure they do
have a HIPAA secure platform. But you’re just able, then, to meet over telehealth
like this for your sessions. I actually find that it works even better than I would have thought for OCD, because, the triggers aren’t always
present in my office the way that they’re present in your home or at your work, at your
school, wherever you may be, and so what’s nice about telehealth is you can kinda take me with
you as your therapist, and we can actually do stronger exposures ’cause you’re actually in the settings. Looking at some of the… Oh I am louder now, thank you. Thank you, I don’t want
to be yelling at you guys. Let’s see, can OCD feel extremely real? Looking at expanding that question. For example, I’m not having
thoughts as frequent as before and they haven’t been producing much anxiety or no anxiety in some cases. Still feel like things might not be right. Yeah, and self diagnosed, so. It worries me a lot that I’m just lying. Oh, yeah, so it can be, I really do recommend meeting with a mental health
professional if you’re able, to talk through your symptoms. And get their professional opinion about, their educated professional opinion, make sure that they are educated on OCD by asking them questions about what has their experience been, have they been supervised,
what approaches do they use? But I do recommend getting an assessment because that is a really
common obsession, actually, is my OCD is not real, I’m making this up, I don’t really have a problem. Do I have a problem? And you can actually do
exposure and response prevention with those doubts as well about even is OCD really a disease? So I do recommend going
and getting an assessment, even if you aren’t sure about therapy yet, even committing to that one time, going for an assessment,
get a diagnostic impression. But, from there I think that you could do ERP even around
doubting if you have OCD. So you might say to
yourself over and over again I may or may not have OCD. And then kinda sitting with that anxiety, that discomfort that it produces, and then again, response prevention, preventing yourself from Googling to tech or from asking anybody
that you have shared with that you might have OCD to prevent yourself from
asking them if you have OCD. So, also, be some ways coming to mind, but I even have therapists
who call me to consult and they’re like, I don’t know what to do because they now don’t
know if they have OCD. I’m like, that’s still OCD (laughing). You can still look at that
as an obsession and treat it. Let’s see. I haven’t done anything
as far as my OCD goes with doctor other than meds. Been dealing with it on my own. Trying to tell myself nothing will happen. Feel like it’s getting
a little bit better. Well, that’s good. Yeah, so, you know, OCD
waxes and kind of wanes if it goes untreated. Unfortunately for most it
doesn’t like spontaneously just kind of really improve. So I do recommend treatment. If you’re not sure where to start, too, again, give us a shout and let us know if you’ve downloaded the NOCD app. Part of what I love about our NOCD app or our website is there
are tons of resources to help you feel educated, help you feel like you better understand what OCD is, and then also feel more
connected to people who, and can identify with people who might have it through our community. It’s such a great resource. A lot of my clients after they go check it out for the first time they come back and go this is awesome. The shame has been
lifted and I feel better. Just even from that perspective
from feeling connected. So I would recommend, even if you’re trying to
start with some self help, there are some great resources out there as far as books. The NOCD app has great information on it along with the website and
we also have free ERP tools that are in the app that you could start practicing exposure and
response prevention, but certainly if you find
that it’s not improving or it’s getting worse then go check out getting an assessment,
whether that’s through NOCD or a local provider, we’re here for you. We want to meet you. We are excited to have your phone calls and meet you when you’re coming in. Let’s see, let’s see. Couple of questions about. Oh yeah, going back to medication. Usually that, that’s certainly
an individual approach and I would recommend
speaking with your physician, if you haven’t already. You know, opening up to them about, I’ve been having these intrusive thoughts, or I’ve been having these compulsions, these things I feel like
I really have to do, and they’ll wanna be helping
you with that as well. Selective serotonin, well, let’s see, serotonin
reuptake inhibitors, or SRIs, are the class of drugs
that are usually prescribed to help with symptoms of OCD. I think this is a very individual thing to go talk to your physician, I’m not a prescriber so I
can’t really speak to that in much detail other
than there’s several SRIs that can be helpful, so
if one isn’t working, not getting you the result
that you’re looking for, talk to your doctor. See if there’s another SRI
you can try or something else. It’s important to be
assertive and share with them. A lot of providers love to know that you’re in therapy as well. We certainly want to help you get better with all the resources
that we can give you. So I don’t have a ton more
to say about medication or that I can say without
knowing a person specifically, but do wanna mention that don’t be afraid to talk to your providers about it, including your therapist, ’cause sometimes people
are nervous to say, oh I know you don’t do medication or you might not believe in it, we want what’s good for you so
let’s talk about your options including even if it’s just a consultation to find out what your
medication options are. Let’s see, here’s a question. If somebody has obsessional thoughts that cause avoidance behaviors does the person have OCD. Thoughts are intrusive and distressing but the person deals with his anxiety by avoiding doing his work rather than performing a typical compulsion. Avoidance is a typical compulsion. Yeah, so I would be wondering
if that person has OCD. I would be assessing further with them. If they are having an obsessional thought, image, or impulse that
is then causing them to react including avoidance. That might be a compulsion. So I would certainly be
asking more about that. Let’s see. Well thanks, Ben, for
saying I’m doing great. (laughing) I appreciate that feedback. I like a little reassurance
once in a while. Why isn’t OCD talked about and referred to as a silent illness? Yeah, that’s a good question. I think there’s a lot of shame and OCD is misunderstood. I also feel like as a
system kinda going back in our educational system as providers, we don’t get the training
that maybe we should have. I was really fortunate to have been in an anxiety disorders lab with people who did research on OCD
and related disorders, had the chance to go train at AMITA and get that really intense experience. Unfortunately a lot of
us aren’t even really given the opportunity to do
that early on in training. So hopefully we’ll help advocate for that and change and get more
providers exposed and understood. But I think, too, that
from our perspective we have more to do, and I also feel like there’s wonderful organizations out there like the International OCD Foundation
that is helping with this and NOCD, we are really
trying to get out there and improve. I think that it helps to know that there’s thousands and thousands of
people in the community. So that hopefully, the
community isn’t silent. So hopefully this wouldn’t
be known as that much longer. Let’s see here. I’m kinda looking at the questions. How do I do exposure
and response prevention OCD if the symptoms are not there all the time? Good question. And let’s see, so I think I certainly
would want to do more of a functional assessment
with anybody’s obsession to understand what are the triggers, when is it happening? We’ll do self monitoring a lot
for the first couple of days or the first week to help you track and better understand what’s happening. But even if something isn’t
happening all the time, you can do kind of like
intentional exposures where, and again,
there’s not details here, but say it feels like
the throat is closing and you get somatic symptoms. Maybe what you might do,
if the throat is closing due to like say dry mouth, you could do a live Facebook event and talk for a half an
hour and try to evoke some of that dry mouth feeling. For people who might be
having something like their heart racing a lot
during their obsessions, and that’s something that
they feel uncomfortable with and then want to do a compulsion, make their, kind of make their somatic or physical symptoms go away. We might actually do like jumping
jacks in my office before. Then we trigger the thought
of I ran somebody over. So there are ways to kind of
activate the physical symptoms, and if you can combine kind
of your physical symptoms with your thoughts, with
an image, with a sound, with a smell, like the more
kind of sensory and real you make something probably more effective the exposure will be. So it’s not that something has to, you have to wait for an
exposure to naturally happen. You could certainly also
do imaginal exposures as well as trying to evoke
some of the physical symptoms. I mean, I’ve had people
laying on that couch who had chest tightness and
I’ll hand them all my books from over here and we’ll just kinda keep laying the books on top. Not ’til it’s too discomforting, but ’till they get that pressure feeling, and then maybe we’ll start
another part of the exposure to get them triggering the thought like I’m not gonna be able to
breathe and deal with this. So there are lots of ways, and that’s, again, where it’s
kinda nice to have a provider who has some experience, at least, to get you going with ideas and think really creatively about
how to do exposures. Relationship OCD. That one comes up a lot. Yeah, jumping, and relationship exposures, jumping from moment to moment. Yeah, exposures with relationship OCD are a common occurrence in this office. So certainly a common type of OCD. We could get into a
discussion about types, but it does help, I think,
some people to feel like they identify with
others when we talk about different subtypes of OCD. So for relationship OCD, usually that’s when you
doubt your relationship, doubt your love, doubt
somebody’s love for you. And it can go in a bunch
of other themes, too. I’ve done, usually what I’ll do, if somebody’s willing, is we’ll bring in their
significant other with them and educate them first about OCD and about exposure and
response prevention. And sometimes we’ll then
start doing exposures where whenever the person
thinks I’m not sure if they, if they’re worried that
the other person doesn’t love them anymore and they’ve
been seeking reassurance, that’s a compulsion, say. And they might text
them throughout the day or call them several times. Maybe what we’ll do for
an exposure that week is have them, whenever
they think that thought, do response prevention where they’re not then allowed to text or message or call and ask that. So we’ll do that kinda naturalistically whenever it does pop up
and they feel triggered. Then their response would
be no response, right? That they’re supposed
to sit with that anxiety and not seek reassurance. And we might even do some in
vivo or real life exposures where we’ll tell the significant other that we’re gonna do exposure for the week where they tell their significant other I may or may not love you this week. Difficult, but again, it helps them, usually people come back and they’re laughing saying I can’t believe that. But they can’t laugh about it until they stop doing the response prevention and kind of distance themselves, kind of diffuse from the
obsession a little bit. So, that would be kind of
examples of different ways that you can do exposure
and response prevention with relationship OCD. But again, there’s lots
of ways to be creative and hopefully get the support
of the significant others or family members involved there. Let’s see. A lot of questions, I love this. For stuff we don’t get to today, ’cause I think we’re almost, oh we are up on time, we’ll
hopefully take some notes and come back next time, which actually, yeah please feel free to send
us at [email protected] to questions you have for
future events like this because I know we can
only do so much today. And let’s see, one of the
questions that came up is do you give therapy over the internet or is it somebody else? In my private practice
I do offer telehealth, and in my role with NOCD I, I’m the clinical director
so I’m helping train the individuals who would
be giving you telehealth, and then I’m always available, love to consult with them directly on the care that they’re
giving you along with our Chief Medical Officer,
Dr. Jamie Feusner. We’re both just, we tell
our pros, we call them, our licensed mental health professional to don’t hesitate call us,
ask us questions, consult, because we wanna give
you all the resources that we can from our team. So we do that quite often. And let’s see, maybe one more. Somebody’s writing here, ERP
work is a lifelong process. Yeah, my hangups have been the
fear that if I do something or don’t do something that
something bad will happen to someone I care about. Not sure how common is this. Yeah, it’s common Randall. Yeah, it’s responsibility
kind of themed OCD is really, really common. People also feeling responsibility that they have to even get
better for other people, too. So it can get very complicated. And I agree with you, thanks for sharing. It is a lifelong process. Hopefully it becomes more second nature the more that you do it. It is like a muscle that
you have to strengthen that maybe you haven’t used before or if you haven’t used it in a while you need to restrengthen it again. So, yeah, it’s, I have people who will even see me in treatment. They’ll feel great,
they decide that they’re ready to wrap up, and I’ll
see them maybe for our booster sessions every
once in a while, too, every couple of years even. So don’t be afraid to do that as well because life happens, and therapy isn’t going to
prevent life from happening, but it is hopefully going to
help you feel more capable of recognizing what’s happening
when you’re experiencing it and feeling more confident being able to handle it when it does. And also confident that you
know what works for you, which I think is important, too. I love when people are
good consumers of therapy. They know it works for them. They know ERP works for them. Do it. So yeah, wonderful. It was really nice
meeting everybody today. I think we ran over time. Today went by much faster than I expected. Thank you so much for
all the participation, all the questions, and I will hopefully
see you all again soon. Thanks, have a great day.


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