Ep 4: The Hidden Struggles of OCD: A Deep Dive

00:00 Introduction to OCD and Its Impact
02:12 Understanding Obsessions and Compulsions
04:57 The Challenge of Diagnosis and Treatment
07:36 Exploring Taboo Themes in OCD
10:03 The Cycle of Compulsions and Anxiety
12:36 The Role of Uncertainty in OCD Treatment
15:16 Long-term Effects of Untreated OCD
25:00 Understanding Relationship OCD
30:21 Navigating Therapy for OCD
35:35 Assessing OCD: Key Indicators
38:18 Finding the Right Therapist for OCD
41:32 Common Tricks and Traps of OCD
48:22 Reframing OCD: From Monster to Overactive Alarm System
51:32 Introduction to Healing Anxiety and Trauma
51:33 Understanding the Role of Therapy

Lisa Weiss (00:02)

Hello everyone and welcome to Brave Minds, Healing Anxiety and Trauma, the podcast brought to you by Brave Minds Psychological Services in New Jersey. On this podcast, we'll explore the journey of healing, resilience and mental well-being. Whether you're navigating anxiety, processing trauma, or supporting somebody who is, you are in the right place. I'm Lisa Weiss, I'm a licensed mental health therapist here Brave Minds and each episode we'll dive into real conversation, expert insights and practical tools to help you better understand your mind, support the healing process, and in today's episode, we're chatting with Linda Farag. She is our therapist here at the practice that specializes in working with individuals with OCD. So before we begin, please remember that this podcast is for informational and educational purposes only. It's not intended to diagnose, treat, or replace professional mental health care. If you're in crisis or need support, please reach out to a qualified provider. You are not alone in this and your healing matters. Let's jump in.

Lisa Weiss(00:56)

So thank you so much for chatting with us today. I'm super excited to dive into your niche and learn more about the work that you do. So yeah, can you tell us a little bit about yourself and the work that you do here at Brave Minds?

Linda Farag  (01:09)

Yeah, so my name is Linda and I'm a licensed social worker here. I am developing a niche in OCD and particularly how it shows up in ways that can be a little bit sneakier as well as I work with a lot of neurodivergent clients, particularly autistic and ADHD or clients. And you definitely see a lot of overlap there with OCD, as well as things like chronic illness and chronic pain, which also tend to have a lot of overlap with both neurodivergence and OCD. So yeah.

Lisa Weiss(01:45)

So interesting. I know today we were really going to be chatting about OCD. So can you give us like a general understanding or like an overview of OCD or like how you would define that?

Linda Farag  (01:56)

Yeah, so OCD stands for Obsessive Compulsive Disorder, that's essentially what it is, obsessions and compulsion. So obsessions are thoughts that are intrusive, repetitive, that don't align with the way that you actually think, the things that you believe, the way that you want to be, and they are things that the OCD brain gets fixated on and continues to return to.

The compulsions are repetitive behaviors that somebody with OCD does to help relieve the anxiety that's brought up from the obsession. So it becomes a constant cycle of experiencing the obsessions, performing the compulsions, and unfortunately, all performing the compulsions does is perpetuate and continue the obsessions. And so it leads to this cycle of anxiety and using coping strategies that just end up continuing the anxiety and sometimes even worsening it.

Lisa Weiss(02:55)

Can you have one without the other? Like obsessions without the compulsions?

Linda Farag  (03:00)

Theoretically, you can for the majority of cases. If there don't seem to be any compulsions, there typically are. But a lot of times it can be a little bit harder to identify. The compulsions can be completely invisible. They can be hard for even the person who is struggling with them to identify that they are compulsions. So they will not present the therapy and say, I have compulsions. I have these things that I feel like I need to do because it becomes almost like a second nature, like the way that their brains process information, the way that their brains respond to fears and anxieties.

Lisa Weiss(03:36)

And I remember you saying, because Linda has been wonderful and has done a presentation here at the practice, but sometimes these could be like mental compulsions. And I'm not sure if that's something we were planning on chatting about later on ⁓ in this episode, but can you share with our listeners like what that might look like for someone?

Linda Farag  (03:52)

Absolutely. So mental compulsions are similar to the way that physical compulsions a lot of times people are most familiar with things that are shown a lot on TV that are easier to depict to an audience like washing your hands repeatedly or checking something repeatedly. But a lot of what OCD actually looks like is entirely within oneself is entirely mental and from the outside observer, it does not look like that person is completing any compulsions. And so that's something that unfortunately a lot of times gets missed by not only the person struggling with it, but a lot of times the people that they go to for help.

Lisa Weiss(04:32)

Yeah, and that sounds very challenging, especially because it's not on the surface. And something that you shared a stat. So you had mentioned that the statistics around OCD diagnosis can be discouraging. And it takes an average of 14 to 17 years from onset of symptoms for someone to get diagnosed with OCD. And it's even longer than that to get proper treatment. So why do you think that is, or what do you feel like contributes to that?

Linda Farag  (04:56)

Yeah, so there are, I think, a few different things that contribute to that. One of the biggest ones is a lack of knowledge, unfortunately, on what OCD looks like and the flexibility that we have outside of just viewing it as something related to perfectionism or always needing to be orderly or organized. And so there can be a lot of symptoms that get missed by providers, by therapists. Another big contributor to that is shame around OCD. And a lot of people will experience different forms of OCD that can be incredibly difficult and not only just difficult, but can actually be risky for the person in some ways to share with a provider, to share with a friend or family member, and that there's a very real chance that they'll be misunderstood, as well as a lot of times people with OCD can sing the obsessions out loud or saying the things that they do in their heads or things that they do in private spaces to help themselves stay calm. A lot of times it can feel, it can make them feel like crazy when they're saying it out loud to somebody. and can make them feel like they are going to be judged or perceived as a somebody, ⁓ again, like a very reductionist term, but somebody who's like crazy, somebody who is dangerous, somebody who is unhinged or not grounded in reality. And so there can be a big concern around being misunderstood. And so even when people with OCD do present the therapy and are able to share some of the things that they obsess over. There are a lot of times the things that are causing them the greatest distress, a lot of times are the things that they can't actually talk about in therapy. And that's what a lot of times will lead to a significant delay in diagnosis as well.

Lisa Weiss(06:49)

incredibly isolating, like to feel like that's not something that they can seek help for because there is so much shame around that.

Linda Farag  (06:57)

Absolutely, that there's something that you are suffering with day in, out. It's causing you so much internal conflict and pain. And the people that are closest to you in your life, the people that are supposed to be there to help you, your therapist, your psychiatrist, your doctors, when none of those people feel safe or when it feels like what you are dealing with is so dark and so... like disturbing to other people, it is incredibly isolating and does lead to a lot of feelings of, again, that shame and as well as like a lot of hopelessness of being completely alone in this struggle. And with OCD, it's always your fault. So feeling alone in this struggle and then it's also your fault. And because it's your fault, you can't ask for help.

Lisa Weiss(07:41)

Yeah, that feels very heavy and I'm curious too because so even after people like seek help and they're seeing a therapist, what do you feel like contributes to them not getting the proper treatment? Do you feel like that's just like a general misunderstanding of OCD or what do feel like is going on there for people?

Linda Farag  (07:59)

think there's a few different things. One of the unfortunate pieces is that a lot of times they will even present with an OCD diagnosis, but not receive exposure and response prevention therapy, which is the gold standard therapy and what empirically has been shown to provide them the greatest amount of relief as quick as possible. And so what is really discouraging is when somebody actually does present the therapy with an OCD diagnosis that they've had for a while, but have more so received CBT talk therapy without that response prevention piece that is crucial for OCD. And so unfortunately, sometimes they are taught things like cognitive restructuring and like reframing, and those become rationalizing compulsions. And so the things that they are taught in therapy, unfortunately, just end up being sabotaged. by the OCD and if that's not caught by the clinician, then that person is not going to experience again more than that like temporary reduction in the anxiety from using the coping skills that their therapist is teaching them rather than experiencing that decrease in symptoms over time that we actually want to see. Another piece is again, clients not feeling safe. with their therapist telling them. And this is a good time to jump into what ⁓ I'm referring to in terms of some of the really dark and disturbing presentations of OCD.

Lisa Weiss(09:24)

Yeah, absolutely. That was my next question for you. What are some examples of taboo or unacceptable, air quotes, OCD themes that people can experience?

Linda Farag  (09:34)

Absolutely. So OCD clings onto basically any disturbing thing that you can think of. So there is something called harm OCD. And so that is very focused or that is focused around a fear of harming others or harming yourself. And so that can be like emotionally harming others. And it can be like a worry of like, maybe I accidentally hurt this person's feelings or maybe this person's mad at me, but it can become very extreme as well. And it can feel like I am worried that I am going to stab my partner. I am worried that I'm going to neglect my child. I'm worried that I'm going to do something to hurt myself or end my own life. And those can be super disturbing. And a lot of them are words that we don't particularly want to say out loud as well. So there are a lot of very dark sexual obsessions that people will experience. And I also want to clarify when I say sexual obsessions, that it is incongruent with what the person actually desires. And it is not a obsession in a focus of like, are sexually obsessed with somebody and like you are thrilled by the idea of being sexually involved with them and that kind of dynamic. And so when we do talk about sexual obsessions, I always make it very, very clear to my clients that I am well aware that when they're sharing obsessions with me that I know that these are not things that they actually want, but are things that they fear. And that is why a lot of times, most of the time when people experience harm OCD, it'll be around harming the people that they love the most. It won't necessarily be around harming somebody that they don't quite know or have a good relationship with. Like that could definitely be somebody's obsession is like, I'm going to hurt my second cousin that I've met three times. But generally, it's either going to be I'm going to hurt a stranger and it's very general. And if it is specific, it's I'm going to hurt someone I really love and I really care about and is really close to me. And so it is a complete opposite from what they actually want. And that's why it causes so much distress when it comes to things around sexuality. That's where you see something called pedophilia OCD, a worry that somebody is sexually attracted to children or wants to hurt a child. There are also obsessions around incest and bestiality and, again, really horrible things that nobody wants to talk about. And so those are very often obsessions that people will deal with for years or even decades before being able to verbalize them out loud if they are ever able to verbalize them out loud. And so that can be one of the things that is most painful is that shame of feeling like you are dangerous, of feeling like you are a bad person. And how do you go to your therapist and tell them you're scared that you're going to molest a child? Like, how do you go to your primary care physician and tell them that? Or how do you tell your partner? How do you tell your spouse that you're scared that you're going to hurt the children? And what reaction are you anticipating from them and it is very likely that you will be misunderstood. So it is a very, very difficult place to be in to be able to ask for help.

Lisa Weiss(12:47)

Absolutely, which further leads to that isolation and I'm sure there's a lot of avoidance of I'm gonna make sure I'm not the one giving the kids a bath or I'm gonna make sure I'm not in the kitchen with the sharp knives with my child. Which I feel like is probably one of those mental compulsions.

Linda Farag  (13:02)

Absolutely, is there are a lot of mental compulsions that cause a lot of pain for particularly people with harm OCD ⁓ with ⁓ sexuality related OCD as well as OCD related to Just in general like loss violence grief things that are Very damaging to our psyches or things that are very hard on our psyches And so one of the very difficult ones, well, for example, be something called flooding. And so flooding is again, kind of similar to what we talked about a few minutes ago. Flooding is actually like a therapeutic strategy that we use in CBT, but it can also become a compulsion. And for somebody with OCD, they are not using it in a therapeutic way. It is very often a way of checking as well as a form of self-punishment. And so if you are worried that you are going to, let's say, stab your partner, you may flood yourself with images of you doing that, with images of your partner being hurt, with images of you at their funeral or you in jail. you are doing a couple of things here. One of them is punishing yourself for having this thought by showing yourself these terrible images and therefore not sitting with the discomfort of the possibility of allowing yourself to get away with it, to get away with having a thought like that. The other thing that you are often doing is checking to see how you feel. And when you picture yourself doing something that feels so horrible to think about, or when you picture something, you being in a really horrible situation or something horrible happening to the people that you love, you are able to tell yourself, I don't want to do that because it feels horrible to think about that. Unfortunately, that doesn't work. It works in that moment and you feel good in that moment. But then the next time that thought comes up of I'm cutting vegetables and I just got a little bit irritated at my partner because they keep poking their head into the kitchen and bugging me, and this is my quiet time. And which is a totally normal human experience that anybody might have. But somebody with OCD may have that thought of, what if I just lost control and stabbed them? I mean, anybody could actually have that thought, a random thought of, what if I just stabbed my partner right now? Because I'm so sick of them interrupting me while I'm making dinner. And somebody without OCD would really be able to just brush that off and be like, that was a weird random thought. That's silly. Somebody with OCD would really dive into that, really dig deeper. Why would I think something like that? Do I actually want to do that? And that's where the testing a lot of times can come in. And so it is the compulsions are painful, but still provide a relief from a more painful shame or anxiety.

Lisa Weiss(15:49)

And I imagine that's like very temporary, like short term and then probably, well, I guess in your opinion and you know, your experience like makes that anxiety bigger, like by giving into those compulsions, like validating that anxiety or that worry.

Linda Farag  (16:05)

Yes, absolutely. Because that is reinforcing to your brain that this is a necessary process you have to go through to keep the people around you safe to avoid being a bad person. There can be a feeling of, need to reflect on my actions. I need to reflect on my desires or my impulses, all these different things. And that's where it can be really tricky because we should be engaging in self-reflection. But with OCD, it's not. Or in a compulsive situation, it is not genuine like self-expiration and growth. It is again, analyzing the, I'm actually gonna bring in the term reverse reasoning. So the forward process of reasoning is you collect evidence and you use that evidence to come to a conclusion. Reverse reasoning is you start with the conclusion. and then you work your way backwards. And so that's what OCD looks like a lot of times is I know I'm a bad person. Let me work my way backwards from there. I know something bad is gonna happen to me. Let me work my way backwards from there. And that's when we bring in all of the different pieces around, ⁓ this is why I think something bad is gonna happen. This is why I think I'm a bad person or I'm a danger. And then we have to respond to that with the compulsion of this is why I'm not a bad person rather than allowing ourselves to sit with that discomfort of that uncertainty.

Lisa Weiss(17:26)

Is that part of the work that you typically do with people, like sitting in that discomfort?

Linda Farag  (17:31)

Absolutely. So being able to sit in ⁓ uncertainty is a really big part of OCD treatment, particularly for, you know, there's a lot of things with around OCD where there is like a more clear answer. So if we're talking about, for example, like locking a door, the door is either locked or it's not. When we talk about, are you a bad person? Like that is not a very like black and white. It is or it isn't situation that we can like hear the facts, know, here's the evidence you're a good person now, you're a bad person now. And then there's also like existential OCD around like the meaning of life and the afterlife and higher concepts of like morality and like all these different things where there is only uncertainty or we can only ever find uncertainty. There is no very clear answer for any of these things. Unlike something like the door is locked or it's not. And so when it comes to things that we don't have certainty in, that is really where also we employ a lot of mindfulness and simply allowing the uncertainty to be there and being able to coexist with it rather than that search for certainty. Because the problem is OCD is going to constantly raise the bar. For what you need to feel okay. So it's never just going to be the same compulsion at that same intensity forever. As we engage in the compulsion, generally it will become more specific or become more intense over time.

Lisa Weiss(19:06)

Totally makes sense. And I used to say this to clients and I think I might've gotten this from Fawn, but it is kind of like a game of whack-a-mole where it's like you get it in one space and it can pop up somewhere else. Like, we're no longer doing this particular thing, but like now it might look different over here, if that makes sense.

Linda Farag  (19:22)

Absolutely. And that is like a lot of times what I will see in my clients when they present after having already done a lot of work on their OCD is again, things have evolved, but the symptoms, the overall level of like distress and dysfunction has not gone down that much. And what a lot of times you'll see is a lot of times OCD fears will get more realistic as somebody ages. A lot of times OCD will first show up in adolescence and can definitely show up earlier. And a lot of times tends to be something that is consistent through somebody's life, even though the symptoms will definitely go up and down or even go into remission depending on different psychosocial factors and as well as hormones and biological factors as well following somebody through their life. And what a lot of times will happen is when somebody experiences like OCD in childhood, a lot of times it will be around things that are very like fantastical. And when you get older, it becomes around things that are very, very realistic and things that happen every day to people like death, sexual abuse, accidents, choking. We do a lot of work with food allergies and like anaphylaxis.

Lisa Weiss(20:36)

it evolves over the lifespan. And I think that's so interesting too, of like, even hormonally, like what kind of changes are happening in the body and like those ebbs and flows as far as like, okay, maybe we're in remission now, but like those kinds of things can resurface later on.

Linda Farag  (20:50)

Yes, thank you. Yeah, so a lot of times what will happen is when we address just the content of the particular obsession, rather than like managing, having OCD as a whole, that's a lot of times what will happen as well, is the symptoms won't go down in intensity, it'll just change. So we'll address like one obsession, but then it'll just evolve. Like, okay, we addressed this obsession around hitting somebody with your car. But now I'm having an obsession around leaving my doors unlocked. Now I'm having an obsession around, again, making another mistake where something bad happens. So a lot of times it follows the same theme, but the focus will change. And so that is a lot of times another way to track how effective therapy is. Are the symptoms actually going down over time? Is the person experiencing relief? Is the OCD just one step ahead? And do we need to then focus more on equipping them with strategies to prevent those cycles from starting rather than just putting out the fires?

Lisa Weiss(21:53)

Absolutely. Yeah, because then it's just going to continue to pop up over life, which is also exhausting for people. OK, so I know we were talking about just like different compulsions people do with the more taboo types of OCD. Was there anything that you feel like maybe we missed in that conversation?

Linda Farag  (22:10)

Yeah, so there are, we talked a little bit about flooding, ⁓ also very similar to like analyzing hypothetical scenarios of putting yourself in hypothetical scenarios and testing how you would feel or how you would react. Something else that people will often engage in is, identifying, it's basically feels like just planning for the future. But the compulsion is actually that you are finding a way for you to be certain that a bad outcome will not happen. And so in the case of like food allergies, for example, a lot of times we talk about with our clients that there is no way to be 100 % sure that you're not going to have a food allergy reaction. And so that is where people get stuck with the OCDs. The OCD is again going to continue raising that bar of, okay, if I have an allergic reaction, I'll use my EpiPen. What if your EpiPen doesn't work? What if your EpiPen's expired? What if you leave your EpiPen at home? Okay, you're going to address all of these things. These are the contingency plans. What if there's traffic on the way to the hospital? What if, so the OCD is just going to constantly raise the bar for the plan that you need to have. And so somebody will find themselves you like up to hours of their day, trying to create contingency plans for everything. And the OCD is going to continue raising the bar for how much planning they need to do to feel safe because there isn't ever really going to be a limit because there isn't ever going to be certainty that you're going to be okay, that that bad outcome isn't going to happen.

Lisa Weiss(23:44)

Absolutely, yeah, and it makes me think of like in CBT where we do like want people to question worst-case scenario and like and then you know then what if those kinds of things which can can be helpful in some cases but not in with individuals with OCD because it sounds like it will just continue to build.

Linda Farag  (24:02)

Absolutely, and it can be really tricky. ⁓ One of the other very common compulsions that comes up in the therapy room is reassurance seeking. And so if a therapist is not careful, they may just continue providing their client reassurance in a way that doesn't actually help address that obsession that they're experiencing. And so there's a lot of situations as therapists that we want to continue to provide reassurance, and there's a lot of situations where So for example, we work with lot of trauma clients and adult children of narcissists and people who've like dealt with lifelong gaslighting that will need and that do benefit from a lot more reassurance at the same time. And that is why it can be a little bit tricky sometimes also to parse out. Like you have a trauma client who's constantly asking for reassurance. Is the reassurance helping them? Are they getting better? Are they getting more sure of themselves? Or are they continuing to rely on you in that, for that reassurance and the therapist is just engaging in that compulsion with the client without realizing it, without anybody realizing it? Yeah.

Lisa Weiss(25:05)

totally makes sense, which is why, and I know we're gonna talk about this in a little bit to like make sure you're working with a therapist that's like equipped to, and like knows ERP, those kinds of things. So we'll get into that in a little bit, but I am curious to hear from you, like are there long-term effects to suffering from these symptoms without treatment?

Linda Farag  (25:25)

Absolutely. So it has a really significant impact on your mental health. It also has a really significant impact on your physical health. Being under that amount of stress and then also expending that much mental energy, it can really impact your relationships. Again, talking about not being able to share the pieces that you were struggling the most with can make it difficult for you to feel connected to people. There can be a sense of If my loved ones really knew what I was thinking or if my loved ones really knew what I was struggling with, they wouldn't love me anymore. They would think that I was dangerous or they would not really think for an OCD or it would be, they would know that I am dangerous. They would realize that I am the dangerous person that I feel that I am or that I know that I am. As well as there are, there's something called relationship OCD that can really get in the way of being able to have a healthy long-term relationship with somebody without the interference of the symptoms. And it is something that can be difficult to manage even when you know that that's what you're dealing with, let alone when you don't realize that that's what you're dealing with. A lot of times it's just this internal struggle that you can't really work through with your partner. And so it can really ⁓ interrupt somebody's ability to feel safe and loved and also make you feeling like that they are a safe person for their partner in relationships.

Lisa Weiss(26:48)

That's so interesting and that's honestly something that I have not heard of before. So I'm curious, like how does one identify that? I know you were saying just about like how they are feeling within the relationship, but what are some like signs or what would you be seeing?

Linda Farag  (27:01)

Yeah, so relationship OCD. So one of the common obsessions with relationship OCD, particularly when we're talking about romantic relationships is what if this person isn't like the one for me? What if I'm with the wrong person? What if I'm a bad partner? What if I don't love my partner as much as I should or as much as I think I do?

What if my partner doesn't love me as much as they should or as much as I think they should? And so there are a lot of doubts. And again, when we are talking about OCD, there's there's certainty and there's like the feeling of like just right or the quality of like just right. And so you see that with relationship OCD as well is like the one, the right relationship, the best partner, like a good partner. So trying to put these very like black and white labels on things that are not black and white at all. and so one of the ways that you might see that, for example, is if you have anxiety around, what if I don't love my partner? imagining yourself breaking up with your partner and analyzing how you feel. I feel sad when I think about breaking up with my partner. So I don't want to break up with them. So I do love them, but what that'll turn into is. Did I feel sad enough that I broke up with my partner? Maybe I would get over it. Does that mean that I don't love them? And so a lot of times what that can contribute to is like constant doubts in the relationship and constant reassurance seeking, constant testing, avoidance of different interactions with your partner or avoidance of disagreements or conversations with your partner.

And so when the person with OCD does not realize that that's what's going on, they treat all of these thoughts as very important and crucial and that they all need to be dug into. And not staying connected to the fact that those are thoughts that really any happy person in a relationship will experience as well. Those are totally normal human thoughts. But for somebody with OCD, we assign so much importance to random thoughts and to automatic thoughts.

And so there is a feeling of I need to keep digging into this thought so I can find the certainty that this is the person. And again, love and romance and relationships don't quite work that way either, where we have this litmus check, ⁓ litmus test that we could do, where we could do like a blood test and find out how much oxytocin we have in our blood when we're with this person. Like we can't identify that it's a very nuanced abstract concept. And so that's a lot of times where it can be really hard to like identify the OCD. Cause again, it's not going to be a lot of it's going to be mental. It's going to look just like general, like insecurity in a relationship. might be misinterpreted by the therapist as like this person's not happy in their relationship. Let's like explore that and not necessarily identifying it as that's not necessarily what this is a reflection of. This is a fear, not a genuine expression of how this person is perceiving or feeling in the relationship.

Lisa Weiss(29:56)

Yeah, I think that's such an important thing to think about, especially because that's not uncommon for people to come and talk about those kinds of things. Or even for our listeners, chatting with loved ones and friends about relationships and things like that. But lot of what I'm hearing from you today, the gray area, it feels very uncomfortable.

Linda Farag  (30:17)

Yes, absolutely. With OCD, we want certainty, we want control. We want to be able to predetermine things for ourselves and to be in control of things that we have no control over. And a lot of it is the difficulty accepting the risk that we all take every day going outside.

Being in a relationship, having a child, having a job, having friends, all of these things that enrich our lives, that make our lives worth living, all come with risks. If you have somebody that you love, you are risking losing them. If you are going out to do something you enjoy, you are risking getting hurt or worse. If you are trying something that you want to do that's new, you are risking failure.

And so a lot of times that is what prevents people from OCD with people, sorry, people with OCD from being able to engage in the things they want to engage in and from being able to put themselves out there and engage in those wonderful things about life because of the difficulty accepting that risk that we all have to accept when we engage in life, when we engage in living.

Lisa Weiss(31:34)

Absolutely, which I know this is like the third time saying that, but it's like it can be very isolating. So that leads me to my next question of like, how do you help your OCD clients feel safe sharing some of these disturbing thoughts with you? Like, what are you doing in the therapy room?

Linda Farag  (31:50)

A great question. One of the top things that is also one of the simplest things that I do in the therapy room is just name these things for clients, letting them know, not everybody with OCD struggles with these things. You may hear some of these symptoms be like, whoa, I didn't know people with OCD have those kinds of thoughts. My OCD is really focused around getting sick, and I had no idea that people have like obsessions around sexual orientation and things like that. And one of the caveats I kind of want to throw in there is to also be mindful that OCD can, in the terminology I use though, it's a little bit weird, can be kind of like contagious almost, like somebody with OCD will hear about somebody else's obsession and be like, should I be worried about that? Wait a minute, this person has a point. Like that is concerning. And so that is just something I'll like throw out there as a caveat. But I do like to just go in and say, I know that this is what OCD looks like for people. For some people, it can be a little bit easier to talk about their OCD or some aspects of their OCD. For some people, it can be incredibly difficult letting them know that they do not have to these things out loud to me. And that's one of the things I really like about the YBox and other assessments, because they can write it down. They can check it off. Or they can just say like, Yeah, there are things on here that I experience. I always let them know that the door is always open for them to come back. Like the assessment process for OCD is not just the first couple of sessions where we're digging into what they're currently experiencing with the obsessions. Because not only can they always turn, like come back and say, these are also things I'm dealing with, OCD also changes. Obsessions also change. The content naturally is going to shift, at least slightly over time.And so that's really one of the biggest things. it's so wonderful to see the relief that somebody experiences when I say like, yeah, like people with OCD do have horrible intrusive thoughts and images about hurting other people, about hurting children, about doing all these things and seeing the relief that they are not going to get treated as a, or be interpreted as a danger, as a sexual deviant, as one of like the most horrible things that you could be or doing one of the most horrible acts that you can do that they will be perceived as somebody who is suffering and that they will have their pain witnessed for once and Not have to explain that they don't or not have to like convince themselves or me That they don't actually think that way or that they don't actually want to do those things

And so just naming it can be one of the most impactful things. And at the same time, just like a very simple thing that I do as well is naming it. And, you know, when it comes to, for example, like pedophilia OCD, one of the things that people will experience and not realize is like a normal reaction is groinal sensations. And so it's really also important to me for me to name things like that if somebody does disclose to me that they do deal with obsessions with asexual content, I think it's really important that they may, even if they have that piece of knowledge, they may not necessarily realize that the groinal sensations or having some kind of response in your groin is also a very normal response with that form of OCD and is again, not indicative of any sexual desire related to the obsession and is simply like a normal physiological response to having an obsession with a sexual content.

Lisa Weiss(35:22)

Yeah, I mean, it sounds very important for people to know and like to have you bear witness to those kinds of things and to be able to hold space in this non-judgmental way. Because I am sure like that's what makes people apprehensive to share with other people to be scared about what other people are going to say.

Linda Farag  (35:39)

Absolutely, is. I mean, can imagine how terrifying it would be, especially like imagine a new therapist, you know, going into your intake and like, hey, I have horrible, scary thoughts, you know, that I'm going to hurt my children. Like, that's really scary. And, you know, the therapists may get scared too.  You know, lot of times people will also have, people, like professionals, clinicians will also have a really strong reaction to somebody's having like harm OCD, particularly around like suicide. And we'll immediately like go into safety planning and things like that, which is of course super important. But a lot of times the safety plan will include compulsions. And so if there is a fear of like hurting somebody else, the safety plan may include stay away from knives. That's a compulsion. That's like the last thing we want this person to be doing. We want them to be holding knives because we know that they're not, they don't want to hurt anybody. They're the last person that's going to be hurting anybody. but a lot of times they will get prescribed things like stay away from knives, stay away from children. You know, like you need, you need a different kind of help. All that does is reinforce the obsession. And if you have an experience like that, it is very, very unlikely that you will go back to a therapist for

Lisa Weiss(36:48)

because why would you? That was like a traumatic experience ⁓ when you're trying to get help and being made to feel that way. You had mentioned something earlier about like the assessment phase. I am super curious and I'm sure other people are too about like what does that look like for you when you are assessing OCD?

Linda Farag  (37:04)

So there are definitely some flags that I look out for that tell me that like I really need to have OCD on my radar. One of those is like lifelong or very long term anxiety that has not responded to therapy. Anxiety tends to respond really well to CBT and to therapy. And so that tends to be a really big red flag to me that this might not be generalized anxiety disorder. This might be OCD that we're dealing with. And that might be why therapy has not been effective for them, despite a lot of times doing, again, like years or even decades of therapy for their anxiety. Another piece is the aspect of, you know, keeping an ear out for the things of like just right, doing it a specific way, doing it a certain way. When they are using different strategies that they are very like repetitive, that you are noticing some of those patterns and some of those trends that you tend to see with things like mental compulsions. And then of course, if somebody comes in like suspecting that they are experiencing OCD, I do jump into the assessment process for that as well. So the assessment process will involve when you do use a tool like the Y-Box, the Yale Brown Obsessive Compulsive Scale, is one of the, or I think probably the, I think is the most used scale assessment tool. It kind of just goes right into like, do you experience these obsessions or do you experience these compulsions? And so I find it really important to like spend some time with the client beforehand explaining what obsessions are and what compulsions are. And then going through that can be a really great assessment tool as well. But one of the big things can be parsing out like, this a coping, effective coping strategy? Is this a compulsion? And so that is..That is a really crucial part of the process because if the person has OCD and we put off the assessment process and they have, and we are treating it as an anxiety disorder or as trauma or something else, and we are missing that OCD piece, we are not likely to give them the relief that they are looking for.

Lisa Weiss(39:04)

Yeah, and think it's helpful for people to know like what that process would look like, especially with there being, you know, maybe there wasn't a good experience with a therapist in the past and like what does a therapist do for clients who is very knowledgeable in this area. So I thank you so much for walking through that. That leads me to my next question. So what are some signs that a therapist really gets OCD and especially the more taboo or lesser known types of OCD?

Linda Farag  (39:30)

So I definitely want to encourage anybody who is looking for an OCD therapist to very directly ask a new therapist what their experience is working with OCD and what they use to treat OCD. ERP, Exposure and Response Prevention, should be on that list. There are a lot of other wonderful modalities that are great to integrate with ERP. Like for example, ⁓ inference based cognitive behavioral therapy or ICBT, acceptance commitment therapy, ACT, both of those are also fantastic things, as well as mindfulness can be wonderful to integrate with OCD treatment. But I do definitely recommend working with a therapist who also has a understanding and can also provide exposure and response prevention therapy as well. You should feel comfortable, you should be able to share with them something that makes you feel crazy to say and not have them look at you like you have several hits. That I think that that is one of the things that can be most healing for clients as well. Very often, my OCD clients will say, you know, here's my obsession. I know that sounds crazy. I know that sounds ridiculous. And it can be a big relief just like here in response, like maybe but also like that is a very common concern like that's a very common obsession and like you this is More or less normal in the context of experiencing OCD and that you are not like again completely alone isolated a freak and experiencing this particular obsession or performing this compulsion that In the context of having OCD, it makes sense that you'd be thinking that makes sense that you'd be feeling that way. It makes sense that you are doing those things. And being able to identify that even when, even though one is acting irrationally, having the therapist understand that when you have OCD, it is the rational thing. Like when you do genuinely feel like something horrible is about to happen to somebody in your family, And like, you really believe that with your bone and like in your bones, it's rational to freak out and to like do everything you can to prevent that thing. But obviously that is like when we actually lose, lose the connection to reality and rationality. But it, it's very validating for somebody to like hear that. I think it's also really important to validate to clients, like how hard ERP is. and how hard therapy for OCD is and how...Sorry, I'm trying to find the words. But it just goes like how you have to go against every fiber of your being sometimes when you're resisting a compulsion or how you have to put yourself in the zone where you like genuinely believe something terrible is about to happen because you didn't perform your compulsion and like having to sit with that. I think that it's very important that your therapist has an appreciation for how difficult that is. Does not shame you for needing to take things slow or needing to not being able to meet an exposure goal and to really be able to like honor your successes rather than taking them for granted or taking them as their own successes.

Lisa Weiss(42:35)

Absolutely. And I'm curious too about just like… What are some common tricks that come up with OCD? And especially to, it kind of leads me to this because it's like the therapist really has to have an understanding and how does the client feel as safe as they possibly can in this space. But I think it could be good for people to hear too about what are some OCD tricks.

Linda Farag  (42:55)

Absolutely, yeah. Thank you so much for asking that, that it can definitely be another really helpful part of therapy is being able to call out the different ways that OCD will try to trick or cheat the situation. And then that a lot of times can again feel very validating and as well as enlightening and can take a lot of the power out of those tricks. One of the very common ones is it's just not worth the risk. The risk is that something horrible is going to happen to somebody I love and the cost of that is I just have to flip the light switch on a few times. I might as well. So there can be the like, it's not worth the risk. I would rather do this than deal with that risk than deal with the anxiety. Another is like escaping guilt around making the wrong decision of like if I don't perform the compulsion, if I allow myself the uncertainty, this is going to be the time that something bad is going to happen. And then I'm going to have to live with that shame and that guilt for the rest of my life. And there can be a big fear of regret and guilt as well, like making the wrong choice. And so There could be a great sense of like, it's just not worth it. You might as well do this and you might as well like just help yourself feel safe and protect your loved ones. Another is living the fear is a really big one for people with OCD, kind of similar to when you're like engaging in that flooding. You're like living in that moment that you're afraid of. Or when we talk about food allergies and you're having an anxiety of an anaphylactic reaction or an obsession of an anaphylactic reaction. you'll start to feel your shortness of breath. You'll start to feel like a sensation in your throat or your face will feel hot. And so you'll start to experience some of the symptoms of an anaphylactic reaction. And then that puts you in living in that fear, kind of similar to like a fear of choking. Like you're gonna experience shortness of breath, you're living out that fear. And so that can be a way that when you become like submerged in that, it's so hard to talk to yourself. and not talk yourself out of it, but it's so hard to stay grounded in the reality of what's actually happening around you because internally you are living in that feared situation and not your current reality. I'd mentioned before reverse reasoning of like we start with the conclusion and then we collect evidence to prove the conclusion. Double jeopardy is another one. And so that is, for example, you are you have an anxiety that you didn't turn off one of your burners. So you go check all your burners and then you try to go on with the rest of your day, go to bed, whatever it is. The double jeopardy sometimes comes in where the OCD goes, well, maybe when you were checking, you knocked it over. Or when you are driving, for example, and you're having an obsession around, you accidentally hit somebody with your car.

You're obsessing so much that your brain then says you were zoned out for the whole last five minutes obsessing about hitting somebody with your car. What if while you were obsessing about hitting somebody with your car, you actually did and you were so lost in your obsessions about hitting somebody with your car that you missed actually hitting somebody with your car. And so it is that like the double jeopardy of engaging in the compulsion reinforces the obsession of like, what if engaging in the compulsion actually made the obsession more likely? And then you have to do it again. And then again, it's like that. cycle where it really only ends when it feels like your anxiety has sufficiently gone down or a lot of times it's just you are exhausted. Another one is also similar to analyzing hypothetical scenarios of testing it out. That one, it can be a lot more physical rather than just mental. And so one of them, for example, if you have sexual orientation, OCD, or a concern that you are attracted to a member of the same sex, you might look at like gay porn. You might look at something that you might look at other men and see whether or not you're aroused and like test it out and use that as validation that your obsession is true or not true. And then again, it is generally not going to resolve the obsession and what it's usually going to lead to is ambiguity. And then OCD takes that ambiguity and says, well, that ambiguity is confirmation of your obsession. And then it restarts the cycle again. And kind of similar to like, it's not worth the risk is, but maybe this time is the, you know, it hasn't happened before, but maybe this time. And I really don't want it to happen this time. So there can be a lot of things that people with OCD will kind of like tell themselves or things that like the their brain will tell them that will prevent them a lot of times from resisting the compulsion. And you know, that's why definitely personify OCD a lot of times like very sneaky sabotaging and a lot of OCD comes down to like safety behaviors. A lot of OCD comes down to like in over one of one of the theories that I really like refers to something called like monotropic processing and it is basically like not being as ably ⁓ as easily able to transition off of a certain thought process or a certain train of thought and so I think that's one of the things that contributes to the like neurobiology of OCT is getting stuck. and not being able to shift focus as much or like not being able to resolve a certain like thought process and move on to a different one. Another is like a dramatized reaction to risk. I think that the people with OCD in our like, um, tribal societies and our like hunter gatherer societies were probably played like a purpose in the evolution of like OCD years, we're able to see every possible worst case scenario that could happen. Very creative in that way, like creativity for, I don't know for evil, but creativity for suffering. Um, and I just imagine like that could be that, that potentially like played a role in these like smaller societies of So and so is able to think of every bad thing that could happen and has come up with every contingency plan possible. And so the OCD brain really is just working really hard to protect itself, like protect us from danger. But unfortunately, it just ends up causing a lot more suffering and pain than actually preventing it. And so that's one of the things that I wanted to highlight too is sometimes it can feel very discouraging for somebody with OCD to hear or be taught the analogy of OCD as the monster, OCD as a demon, OCD as the brain. A bully, yes, a bully. Because you're also telling them at the same time that a lot of people deal with OCD for many years or throughout their lives. And so a lot of times the messaging that can be received is just like, just have this bully that I have to live with in my brain. I just have this monster in my brain. And a lot of times shifting it a little bit into this being an overactive alarm system and a system that gets stuck and identifying the different things that the ways that we have to interact with information differently in our world and the way that we have to interact with our thoughts a little bit differently to prevent ourselves from getting stuck on these tracks for preventing ourselves to getting stuck into these spinning vortexes or like these obsessions and compulsions can feel a lot better than that feeling of like, have to fight with this monster in my head for the rest of my life to have any peace. And rather, how do I shift the way that I interact with the world and I interact with my brain so that I can manage this, so that I can identify that thought of what if I stabbed my partner? So I can catch it there rather than allowing it to spiral into days, months, years, decades of avoidance and compulsions and fear and shame.

Lisa Weiss(50:57)

Absolutely. Yeah, and people deserve to feel better and that there's like proper help out there and I love that you gave the direction before too about like how do I find a therapist that specializes in this? So I just want to thank you so much for your time and all of this wonderful information. I think it's really going to help a lot of people.

Linda Farag  (51:17)

Wonderful. Thank you so, so much for having me.

Lisa Weiss(51:20)

All right, thanks. And I'd love to continue the conversation too. I know there's so much more that we can dive into about this. So I'm hoping for an episode two on this.

Linda Farag  (51:27)

All right, that sounds good. I'll get working on it.

Lisa Weiss(51:29)

All right, thanks Linda, take care.

Linda Farag  (51:31)

Take care. Bye.

Lisa Weiss (51:33)

Thank you so much for joining us on Brave Minds, Healing Anxiety and Trauma. If you're ready to take the next steps in your healing journey, the therapists at Brave Minds are here to support you. Please reach out to BraveMindsNJ.com to learn more about our services or schedule a consultation. Please remember, this podcast is for informational purposes only and is not intended to diagnose or treat any mental health condition. Take good care and we'll see you next time.