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Finding Your Perfect Rest-to-Productivity Ratio The Burnout Dilemma Ever felt like you’re constantly running on empty, juggling a never-ending to-do list, and battling that nagging voice that tells you you’re not doing enough?  You’re not alone.  In a world that glorifies hustle and productivity, finding the right balance between rest and work can feel impossible.  But what if I told you that striking this balance is not only achievable but essential for your well-being? Today, let's dive into the concept of the rest-to-productivity ratio—a game-changing approach to ensure you’re resting enough to fuel your productivity and thrive without burning out.

In today’s discussion, we’re delving into the seven mistakes some OCD therapists are making in 2024. While the title might seem provocative, the goal is to highlight concerning trends in OCD treatment and provide insights that could enhance therapeutic approaches. Remember, this is my opinion based on what I've observed in various forums. I don't claim to have all the answers, but I hope to spark a constructive conversation. Mistake #1: Insufficient Initial Education Importance of Education at the Start of Treatment Many clients report feeling thrown into exposure and response prevention (ERP) without adequate preparation. Therapists must take the time to educate clients about OCD, their obsessions, and compulsions, and what to expect from treatment. This foundational knowledge empowers clients, giving them a sense of control and a clearer understanding of their journey. Mistake #2: Failing to Instill Hope and Confidence The Power of Hope in Treatment Therapists must remind clients that they have the potential to succeed. Treatment for OCD can be highly effective, and it's crucial to communicate this. While maintaining a realistic perspective, therapists should focus on the positive aspects of available treatments and instill a sense of hope and confidence in clients. Mistake #3: Neglecting Evidence-Based Modalities Therapists should prioritize evidence-based treatments, particularly ERP. While it's important to integrate supplementary approaches like ACT, mindfulness, and self-compassion, the core of OCD treatment should be grounded in proven methodologies. Clinicians need to stay informed and ensure their clients understand the rationale behind chosen treatments. Mistake #4: Misconceptions About ERP Being Traumatic ERP: Not Abusive When Properly Delivered Concerns about ERP being traumatic often stem from poor delivery rather than the method itself. Proper education and a strong therapist-client rapport can mitigate these fears. It’s vital to ensure clients understand why they’re facing their fears and to provide a supportive environment throughout the process. Mistake #5: Rigid ERP Plans Flexibility in Treatment While structured plans are important, rigid adherence can be detrimental. Treatment should be flexible and tailored to the client's evolving needs. Engaging clients in the planning process and adapting as necessary ensures that the therapy remains client-centered and effective. Mistake #6: Overlooking Barriers to Progress Exploring Underlying Issues When clients struggle with certain exposures, therapists should explore the underlying barriers. Understanding the client's fears, trust issues, or other relational dynamics can provide insights that help adjust the treatment plan accordingly. This approach prevents avoidance behaviors from taking hold. Mistake #7: Not Assigning Homework The Role of Homework in OCD Treatment Homework is a critical component of OCD treatment. Without it, progress can be significantly hindered. Therapists should find creative ways to ensure clients complete their assignments, offering support and accountability measures. This empowers clients to practice skills outside sessions, enhancing overall treatment efficacy. Conclusion These seven mistakes highlight areas where OCD treatment can improve. It's essential for therapists to remain flexible, informed, and supportive, tailoring their approaches to each client's unique needs. Open communication and a collaborative mindset can help address these common pitfalls, ultimately leading to more effective and compassionate care. Remember, this discussion aims to foster growth and improvement. If you're a client, don't hesitate to discuss these points with your therapist. Together, we can create a more effective and empathetic therapeutic environment. Transcript Today we’re talking about the seven mistakes some OCD therapists are making in 2024. Now, I know the title sounds spicy, but in no way am I trying to be spicy. What my goal is today is to talk to you about some of the things I’ve heard, whether that be on social media, on podcasts, on blogs, or at conferences, when people are talking about the treatment of OCD that deeply concern me.  Now, let me first say, in no way do I consider myself the moral police on OCD treatment. In no way do I believe that I am the knower of all things. In no way do I think that I know more than other people, my way or the highway. That is absolutely not what I’m saying here today.  However, I am going to give you my opinion on some of the things that I hear that deeply concern me. I’m just here to share what I think is helpful. I hope, if anything, it’s here to really reassure clinicians that they’re on the right track because there are some amazing, amazing OCD specialists out there. If not, if this is something that you may find is calling you out a little, please, I’m here to hopefully bring some goodness into the world. Let’s talk about the seven mistakes some OCD therapists are making in 2024. As I said, this is all about my opinion. Again, in no way am I the moral police, but let’s talk about it. My guess is you’re probably going to agree with everything I say. If not, I’m totally okay with being disagreed with.  Mistake #1: Not spending enough time at the beginning of treatment educating their client about the research and the science-backed treatment approaches that are here ready for us to use for OCD So often, I hear clients saying in my office that they had this experience of ERP exposure and response prevention where they were just thrown into it, and they were like, “Let’s just go.” I get that. I love an eager therapist. I love a therapist that’s not going to waste people’s time, but we have to spend a lot of time in the beginning educating them about the condition of OCD, helping them to understand their obsessions and their compulsions and how we get stuck in them and how they can be so seductive and how they can trick us, and also talking about what’s coming, what treatment’s going to look like, and what you can expect.  We have to spend a lot of time talking about that as well so that the person who’s engaging in this treatment feels a sense of mastery over what’s about to happen. They feel like they can make decisions as they go because they’ve got a plan. They can see them crossing the finish line. They can keep that. They know what that’s going to look like, and they can use that to inform their decisions and how they connect and communicate with the clinician. Mistake #2: Not instilling hope and confidence in the client We have to remind our clients that they have everything that they need, that the treatment can be very, very successful, and that it’s an experiment. We don’t have to get it perfect the first time. This is a collaborative experience. There’s a lot of hope here that by us collaborating and by us talking through what’s working and what’s not working and having them understand that this is actually a really good thing to have in terms of there are many conditions that the treatment sucks, the treatment isn’t that effective. The treatment doesn’t help as much as it does with OCD.  I never want to do the toxic positive thing with clients, but I also want them to acknowledge the conditions. This is one that we actually have some good research on. We have some good treatment options. We have these great supplement modalities that can help us along the way. We want to infuse them with hope. We want to infuse them with confidence in this process. I do often see particularly younger therapists not spending enough time really bringing a sense of hope to treatment because it’s so scary. They’re already in so much pain. They’ve probably been through treatment that sucked in the past. What we want to do is really focus on that hope, because hope is often what motivates us to take those first baby steps.  Mistake #3: Not engaging in evidence-based modalities This is a huge one. I could spend a whole podcast episode or a week on this topic. There is so much misinformation about treatment and what is considered evidence-based.  Now again, I’m not here to tell anybody what their treatment should look like. That’s a personal decision, and every client gets to make that decision. Who am I to judge? People need to come and know that they have agency over their lives and the decisions they make. But clinicians should be educated, and they should educate their clients on the options for evidence-based treatment modalities.  Now, I am a huge supporter of exposure and response prevention. I have been trained in it. I have been doing it for 14 years. I have seen it succeed over and over and over and over again. As I’ve been public in saying, I see no reason to abandon that.  Now, that’s not to say that I haven’t introduced modalities that supplement ERP. I love the use of ACT. I love the use of mindfulness-based cognitive therapies. I love the application of self-compassion. In many cases, I have applied dialectical behavioral health therapy to clients who are struggling with emotional regulation. Maybe they’re having self-harm or suicidal ideation. Absolutely. As time continues, we’re seeing newer approaches and modalities come up. But I see it in my job as a clinician to educate my clients on the treatment, what has worked, and what I’m skilled at doing too.  The other thing is there is some research on other treatment modalities besides ERP. I think that’s wonderful. I mean, my hope is that one day we have something that is a sure thing, 100%, and we can absolutely promise that we’ve got guaranteed results. This is going to be something that I continue to learn and educate myself on, but my opinion is that I’m sticking with ERP. I love it. I find it so helpful and empowering. It lines up with everything and my treatment that has helped me. For those who are wondering, I am a committed ERP therapist. Mistake #4: Saying that ERP is traumatic or abusive Now, in fact, this concerns me so much that I did an entire episode with Amy Mariaskin. It’s Episode 365. We talk specifically about this very sensitive and important topic, “Is ERP abusive?” What came from that episode, which is very similar to this one, is I don’t actually feel like ERP is an abusive treatment modality. I think that sometimes how it’s delivered can be concerning, but that’s the truth for any treatment modality. You could say the same about cognitive behavioral therapy. We could say the same about any medical treatment in terms of how the delivery can determine whether it harms people who are vulnerable. One thing that I will be very clear, and I believe this in my heart, is the narrative that exposures, that facing your fears is mean, is a traumatic experience. I agree that if you’re having someone face their fear without giving them the education that they need and not explaining to them why they’re doing it -- believe me, guys, let me also disclose here. I’ve made a lot of these mistakes myself as a clinician. Let’s just be open. I have been in this particular situation. Actually, if I’m going to be really honest with you, number one, that mistake of not educating your clients, I learned that by a client telling me, “Kimberly, I do not understand why you’re having me do what you’re doing. I’m someone who needs to know what I’m doing, or I’m not going to trust you. Slow down and tell me what this looks like.” Again, no judgment over here. I’ve made a lot of these mistakes myself. But I think that throwing people too fast and too hard can feel very overwhelming, very activating.  Again, these are things we learn as we get better. Every clinician makes mistakes. That’s what makes them good clinicians. In no way do I want clinicians to feel blamed or judged here. We’re human beings. We’re doing the best we can, and every client is different. Sometimes we also need to build a rapport with clients so that they can share with us. We talked about that in the episode with Amy.  The most important piece here is having a rapport and a connection of trust and respect so that the client knows that they can tell us that this doesn’t feel right, that this crosses my values, my limits, and my boundaries. This doesn’t feel like it’s something that lines up with my values. We can have a conversation about that and be respectful about, “This is what works for me in this relationship, and this is what’s not,” or “Here are my concerns about ERP. Could you help me to work through this, or could we consider having a conversation before we move forward?” I think that’s what also helps this from being experienced as a trauma as well.  But if this is something that is a hot topic for you, go and listen to that because it’s such an important, compassionate, respectful episode. Amy did a beautiful job of going deeper into this specific topic.  Mistake #5: Following an ERP plan that has zero flexibility I get it. When I first started as an OCD therapist, I was trained to use a very structured exposure and response prevention plan. There were modules and systems, and you had to follow the manual. I loved my training. My training literally set me up. It was some of the best OCD training I think anyone could ask for. But there were times when I stuck to the plan so diligently that I missed the client. I missed their needs. I missed hearing from the client on what they think the next step is.  Now, what I have found to be so beneficial is to talk to the client. What would you like to do next? This is our plan that we originally made together because we talked about it at the beginning of treatment. Do you feel like you’re ready to take this next step? What’s getting in the way of you taking this next step? Let’s discuss. Is this the right step based on what we thought we knew, or are we going to shift it up now?  I think that the flexibility in treatment helps teach clients how to be flexible in their daily lives as well. We don’t want to follow a rigid plan unless there’s some clinical reason to do so. I think we also have to understand here that some intensive treatment programs require really rigid plans because of the severity of the disorder. Absolutely, I completely get that. But I think where we’re really going with that is it has to be individualized. We have to understand the client’s needs in order to make a plan. And then from there, we can decide what’s best. But we have to stay away from rigidity.  I also don’t love any treatment modality that has modules that make the clients go through modules because, again, I think it misses the client, where they’re at, what their needs are, and what else is going on in their life. Again, every clinician delivers it differently. I respect every clinician to know what’s best for their clients, but it’s something that we can look out for. Mistake #6: Moving on without exploring what was getting in the way Let’s say you had a treatment plan and the client said, “Ah, that doesn’t work for me.” And then you just say, “Okay, fine,” and you move on without slowing down and getting curious. Tell me about that. What’s getting in the way of you being able to do this exposure? Is there an obsession I’m not aware of? Is there something else happening that’s happening relationally, or is there a trust issue or rapport issue between you and I that might be getting in the way of us not completing that part of the treatment plan that we had originally agreed would be helpful for you?  It’s really important, and I’ve seen this with my own staff, with my own consultation with other clinicians. Moving on too quickly can allow OCD to get sneaky and help them engage in avoidant compulsions. We have to be really careful about not engaging in compulsions with our clients. Sometimes our client’s OCD can be very convincing in getting us to not address certain issues because of an avoidant compulsion.  Again, complete transparency. I’ve been there a million times, so absolutely no judgment here. These are all things we just have to keep an eye out for and do the best that we can. Consult as much as we can. Do a little check-in with ourselves. I try to do a check-in every week. How is each client going? How are they doing? Where am I stuck? Where are they stuck? Am I having any blind spots here for this client? And this could be one where there’s a real big blind spot. Mistake #7: Not assigning homework to clients This one is so hard. Again, I’ve been there. Often, when clients are in a lot of distress and they have a busy life, a family, or a job, we might assign homework, and they might show up on Tuesday at nine o’clock and say, “I’m so sorry, I didn’t do my homework.” You say, “Not a problem. Let’s try and get it done this week.” Send them home with the homework. Next Tuesday at nine o'clock, they show up and still haven’t done their homework. Sometimes, I see this a lot, therapists go, “Okay, they’re not someone who does their homework. I’ll pivot, and I’ll make sure we’re doing extra exposures in session.”  That’s a really great pivot. But I would usually stop there and have a conversation with the client and really help them understand, not from a place of judgment or shame, but that their success in treatment goes way down when they stop engaging in their homework assignments. We have to really stress to clients that one hour a week is not enough and that we have to find creative ways and motivation tools to help them make sure they’re engaging in their assigned homework.  I have allowed clients to send me the thumbs-up emoji in an email to show me that they’ve done it, or maybe they’ve called into my voicemail to confirm that they’ve completed their homework. Again, I don’t make them do this, but I always offer them, what can I do? What service can I offer you that will help you stay accountable for your homework? Because for every minute of homework you do, you have massively pushed the needle in the success of your treatment. I often see a lot of clinicians just disregard homework and say, “It’d be great if they did it, but they won’t.” I would stop and pause there and really explore with the client and make sure they understood that treatment won’t be that super successful if they’re not engaging in homework.  Again, we want to get creative. We want to collaborate with them as much as we can.  What can we do to help get that homework done?  Can we set more realistic goals?  Can we stack it onto another routine that you do?  Can we help with accountability?  Can we bring in a loved one or someone who can support you?  What can we do to help increase the chances of you getting better?  Because I always say to my patients, my hope for this treatment is to teach you everything I know so that you can be your own therapist. Not to say that I don’t want to treat you, and I think you shouldn’t need a therapist. I just want you to be trained to think about it so that when you’re at home and you’re struggling or maybe you’re in recovery, but you have a little lapse, you can recall, “Oh, I remember the steps. I remember what I need to do. I feel empowered. I know this works. I’m going to get to it and trial that first.” There are the seven mistakes some OCD therapists are making in 2024. Please know, there is zero judgment here. Please also know, this is just my opinion. I fully respect that every clinician is going to come from a different perspective. I fully believe that every clinician comes and sees their client and has the ability to really meet them where they are. I just wanted to bring this up because these are topics I’m discussing with my staff, and I think that it’s something that maybe would help you today.  I’m going to send you off with a big, loving hug and remind you that today is a beautiful day to do hard things.  If you’re a client and your therapist is engaging in some of these behaviors, don’t be afraid to bring it up. We’re a collaborative team here. I always tell my patients, I want to hear your honest feedback. I want to hear if something’s not working for you because that helps you, and I’m in the business of helping.  Have a wonderful day. I’ll see you next week.

9 Ways to Stop Picking Your Skin This Summer As summer approaches and the weather gets hotter, many of us are eager to wear shorter sleeves and enjoy the sun. However, this often leads to increased skin exposure and, unfortunately, a greater temptation to pick at our skin. In today's article, we'll explore nine strategies to help you stop picking your skin this summer. These tips have been helpful to many of my clients, and I hope they will be just as beneficial for you. Understanding Skin Picking Before we dive into the strategies, it's important to understand what skin picking is. Clinically known as dermatillomania, skin picking is a type of body-focused repetitive behavior (BFRB). People with this condition may pick at their skin, arms, lips, scalp, nails, and even more sensitive areas like the pubic region. It's similar to trichotillomania, which involves hair pulling. It's crucial to note that skin picking and hair pulling are not forms of self-harm. People who pick their skin are not trying to hurt themselves or seek attention. They often do it because they are either understimulated (bored) or overstimulated (anxious or overwhelmed). Understanding this can provide insight into the strategies we'll discuss. Strategy #1: Awareness Logs Awareness logs are a powerful tool in any stage of recovery. By logging every time you have the urge to pick, noting how much you picked, where, and for how long, you gain a better understanding of how this condition impacts your life. Many people find that having to document their behavior reduces the frequency of picking. Awareness logs are a key component of habit reversal training, a cognitive-behavioral therapy technique specifically designed for BFRBs. For more information about BFRB School, our online course for skin picking and hair pulling, CLICK HERE Strategy #2: Keep Your Hands Busy Engaging in a competing response can help divert your urge to pick. Competing responses might include using fidget toys, holding a stone, or playing with soothing textures. You can find many affordable fidgets online or at dollar stores. Create a basket of tactile items that you can use to keep your hands busy. Place these items around your house, in your car, and at work to ensure they are easily accessible when you need them. Strategy #3: Create a Skincare Routine A good skincare routine can help prevent irritation and dryness that might tempt you to pick. However, it's important not to overdo it, as too much attention to your skin can also trigger picking. Consult with your doctor to develop a routine that keeps your skin healthy without exacerbating your condition. Strategy #4: Use Physical Barriers Using physical barriers (called habit blockers) like gloves, band-aids, or long sleeves can prevent you from touching and picking at your skin. Some people find that keeping their nails short or wearing fake nails can reduce the tactile satisfaction of picking. Identify what works best for you and use these barriers consistently. Strategy #5: Self-Compassion Practicing self-compassion is vital. Beating yourself up for picking only increases negative emotions like shame and guilt, which can lead to more picking. Instead, practice radical acceptance and reduce self-criticism. This approach can help you feel more motivated and improve your overall well-being. Strategy #6: Manage Stress and Anxiety Managing stress and anxiety is crucial, as many people pick their skin to cope with these feelings. Cognitive-behavioral skills can help address faulty cognitions and behaviors that exacerbate stress. Consider taking an online course, like Overcoming Anxiety and Panic, to learn effective stress management techniques. Strategy #7: Establish a Support System Having a support system can make a significant difference. Whether it's family, friends, or online support groups like those at BFRB.org, having people to check in with can help you feel less alone and more accountable. Some people find it helpful to text or call a support person when they feel the urge to pick. Strategy #8: Stay Hydrated and Healthy Good nutrition and hydration can impact your skin's health. Speak with your doctor about how to maintain healthy skin through diet and hydration. Additionally, consider looking into over-the-counter medications like N-acetylcysteine, which has been shown to help with skin picking. Always consult with your doctor before starting any new supplement. Strategy #9: Set Realistic Goals and Track Progress Set achievable goals and track your progress. Instead of aiming to completely stop picking, focus on gradually reducing the behavior by a small percentage each week. Tracking your progress helps you see improvement and identify what strategies are working. Remember, small steps lead to significant changes. Conclusion These nine strategies can help you stop picking your skin this summer. Whether you use awareness logs, keep your hands busy with fidgets, or establish a support system, each step you take brings you closer to managing this behavior. Remember to practice self-compassion and set realistic goals. If you need additional support, consider enrolling in courses like BFRB School or Overcoming Anxiety and Panic. Transcript Today we’re going to cover nine strategies to stop picking your skin this summer. It’s getting hotter. You want to start wearing shorter sleeves or have your skin exposed to the sun more often, which means you’re more likely to start picking at your skin. Let’s talk about nine strategies that you can use right away. Hopefully, you find them as helpful as my clients have. Welcome back. I am so excited to talk with you about nine strategies and skills that you can use to stop picking your skin this summer. But before we do that, let’s just first do a little deep dive into what skin picking is. Clinically, we call it “dermatillomania,” and it’s a kind of body-focused repetitive behavior. Often, people with skin picking will pick out their skin, their arms, their lips, their scalp, and their nails. There’s really no limit to where someone can pick their skin. Some people even pick pubic areas under their arms or around their genitals. There is, as I said, no off-topic area that people will pick. It’s completely normal for people to pick in one or all of these areas. It’s similar to a condition called trichotillomania, which is hair pulling. Again, hair pulling is another type of body-focused repetitive behavior, and people may pick at any area where there is skin on their body. It is important for us to first highlight that skin picking and hair pulling are not self-harm. People who pick their skin aren’t trying to hurt themselves. They’re also not trying to just get attention. They do not want to be damaging their skin or giving their skin abrasions and such. It’s just a part of a condition, and we have a little bit of insight as to why they’re doing it. Often, people with skin picking, or dermatillomania, are skin picking either because they’re understimulated, they’re bored, or we know they may be overstimulated. Maybe they’re very anxious, they’re feeling hyper-reactive to feeling overwhelmed with either emotions, stimulation, or thoughts. We do know that people who engage in this skin-picking behavior are more likely to pick either when they’re overstimulated or understimulated. That’s something to think about, and there is a clue there into some of the strategies that we’re going to use today. Let’s get to it. Let’s start talking about some of the strategies that you can use to stop picking your skin this summer. Strategy #1: Awareness Logs Awareness logs can be so helpful at any stage of recovery. An awareness log is either a piece of paper or a document on your computer or on your phone, where you log every time you have the urge to pick your skin, how much you picked your skin, where you picked your skin, and how long you engaged in skin picking. What this does is, number one, it helps us really understand to what degree this condition is impacting your life. Secondly, people often report that when they have to document it, they’re less likely to engage in the behavior because nobody wants to have to spend all their time logging it as something they don’t want to deal with. Awareness logs can be a very helpful skill for us in understanding our own condition and our own symptoms, and in addition, they can help us with motivation to slowly reduce this behavior. Awareness logs are something we use in a very well-known and researched way of using cognitive behavioral therapy, and the type of therapy is called habit reversal training. It’s the specific modality that we use for skin picking and hair pulling, and it is a key component of that cognitive and awareness work. Strategy #2: Keep Your Hands Busy Now again, when we’re using habit reversal training, we engage in something called a competing response. A competing response is a behavior that competes with the feeling of picking our skin. Now, a competing response might be fiddles or fidget toys. It could be holding a stone or maybe stroking a feather. It could be playing with other fidgets that we have. The cool news is that you can get so many fidgets online these days for a really low price, or you could easily go to your dollar store and look around for textures that feel beautiful to you, feel soothing to you, or help you with either the understimulation or overstimulation. What we want to look for here is, what are the specific tactile experiences that you can use to keep your hands busy? We actually have an online course called BFRB School, which is a specific course for people with hair pulling and skin picking, using skills like habit reversal training and cognitive behavioral therapy. We talk all about the core importance of using competing responses. I often tell my patients and my students to always have a bucket or a basket in the house of different tactile experiences, different tactile things that you can play with objects, so that at that moment, if you’ve identified in your awareness log that you’re feeling bored, you can engage in something that stimulates your creativity, stimulates your awareness. However, if you’re the opposite and you’re feeling overstimulated, you might dig into the basket and find something that’s quite soothing. Maybe it’s more like a silly putty, a gel, or something else that’s more soothing for you. These competing responses are going to be so important for you in getting very clear on what you need at that moment and having it readily available. I often say to my patients and my students, don’t just have it in one area of the house because, in that moment, you’re still going to want to just pick your skin. What we prefer to do is to have little pieces over the house, in your car, or in your office so that they’re easily accessible. Some people have it on their key rings, some people have it in their purses—whatever works for you. Again, that awareness log will help us identify specifically where you are when you’re having these urges to pick your skin. And then we can put in competing responses to compete with the skin-picking behavior. Strategy #3: Create a Skincare Routine That Helps You This is a little bit of a fine line, though, because we don’t want to engage in a skin routine that has you putting too much attention on your skin because, again, too much attention on your skin is going to mean that you’re more likely to pick your skin. However, we also want to make sure that we are not ignoring your skin, letting it get really dry, especially in the summer. Maybe you’ve had a sunburn or such, and you’ve got some wind chafing or something. Again, if you have any irritation on your skin that isn’t taken care of with a skin routine, you are more likely to pick at that skin, especially if there’s already an open wound or a scab. If you already have an open wound that you’ve scratched or maybe you bumped into something and you’ve got a little scab there, we want to make sure that we’re engaging in a really healthy skin routine to help that heal and repair so that you’re less likely to go and pick that. I would encourage you to speak with your medical professional about skincare and what would be best for you. Maybe you have a skin condition. Very commonly, people with skin picking do. Speak with your doctor about a skincare routine that will help your skin picking but not be so extensive that it actually makes it worse. I would trust that your doctor will be able to help you in that area. Strategy #4: Use Physical Barriers Again, going back to the gold standard treatment for skin picking, which is habit reversal training, we use what we call a habit blocker. This is something that blocks you from the habit of picking, and this can involve anything that stops you from being able to touch your skin. A lot of patients and students I have had have used things like gloves or band-aids to cover an area that they’re likely to pick. Maybe in the summer, they may wear longer sleeves even though it’s very hot because that actually stops them from getting to the area that they feel an urge to pick. You may also want to keep your nails really thin or cover your nails. Some people keep nails on, like actual fake nails, as a barrier to being able to touch the skin. Maybe it doesn’t give them that same tactile feeling of picking when their nails are medium-length. What we want to do here is identify for yourself the specific barriers that are helpful. The thing to remember here about skin picking is that everyone is different. Not one strategy that I’ve used for one client is going to be the strategy we use for another client. It’s going to be very much dependent on those awareness logs that you logged out of in that first strategy. Getting clear on specifically what are the triggers that cause you to pick your skin and what specific behaviors and habit blockers are helpful to reduce the skin picking that you feel the urge to engage in. Strategy #5: Self-Compassion We have to engage in not beating yourself up, not judging yourself, not punishing yourself if, in fact, you have picked or recently picked despite all of these strategies. Beating yourself up actually does not motivate you to stop picking. In fact, it usually brings up more emotions such as shame, guilt, sadness, anger, and humiliation. Those emotions can send us into overstimulation, making us want to pick again. Again, we want to engage in a practice of self-compassion. We want to engage in a sense of radical acceptance of ourselves, whether we pick or not. This is so important because we want to reduce our suffering, not make our suffering higher. We do find that people who practice self-compassion tend to have higher levels of motivation, decreased levels of procrastination. They tend to feel better about themselves and have higher self-esteem. They’re more likely to get out there and do the things that they love. Every moment that you’re engaging in in your life is a moment you’re less likely to be picking. It’s very, very important that you practice a self-compassion routine, even if it’s once a day. Anything is better than nothing to reduce that self-criticism where you can. Strategy #6: Manage Stress and Anxiety  I cannot stress this enough. It is so important when it comes to skin picking that we manage our stress. Again, a lot of people pick their skin because it is a way in which they can manage their stress. A lot of people with skin picking say once they start picking, they can exit out of reality and go into a trance-like mode where everything disappears and they feel relaxed and in the zone, and it takes away all of the stress. We can now understand why there is actually an urge and a pull towards picking and pulling, because who really wants to stay in stress and anxiety? Of course, it makes total sense. The more we can manage our stress using strategies, skills, and other tools like cognitive behavioral therapy, the less likely we are to use skin picking as a coping strategy. When it comes to managing stress, again, the most important thing we’re going to do here is what we call cognitive behavioral skills. It’s going to be taking a lot of our cognitions that might be faulty, leading us to have more anxiety, and also looking at our behaviors and the things that we do that may be actually exacerbating the stress and anxiety that we experience. If you’re someone who struggles with anxiety and stress, I strongly encourage you to check out our online course called Overcoming Anxiety and Panic. We go through all of these steps. You can do it from home, and it may help you to get an idea of what might be some of the things that are triggering your stress response, triggering your anxiety response so that you can manage that, so that then you can move on to manage your skin picking as well. Strategy #7: Establish a Support System We want to have a community of people who can support us as we go through these steps. It’s not an easy thing to overcome skin picking, so I really want to encourage you to find a support system, whether that be family or friends, or you can go to BFRB.org. They have a whole array of online support groups that you might be interested in looking at to get support, so you feel like you’re not alone and that you have the support that you need. Another option here is to also look for accountability bodies. Somebody who mightn’t even have skin picking. They might be a loved one, a friend, a parent, or a sibling—someone who you can check in with when your urge is really high. A lot of my students have said that it’s been very helpful when they have the urge to text somebody and say, “I have a strong urge. I’m texting you to let you know.” They may have already set up a plan on what to do. Maybe they jump on a phone call together, they might text each other throughout it to help the person ride that wave of the urge. Or maybe that person might encourage them to say, “Hey, you told me to remind you of this one thing if you have this urge.” Really, the importance of a support group can help you, or a support person can help you not only with feeling less alone, not only with beating yourself up, but also with putting these strategies into action, especially if you let them know about the strategies. Strategy #8: Stay Hydrated and Healthy Now again, I’m going to encourage you to speak with your medical doctor about this, but I just wanted to mention because I try to look at you as a holistic, full person, someone who’s not just your skin picking, but also, we want to have a look at things like your health. Take a look at your nutrition. Take a look at your hydration levels. Again, these things can impact our skin. If, let’s say, you’re having a lot of nutrition that’s causing a lot of breakouts and you’re someone who’s prone to skin picking, those two things together could become a disaster. You want to speak with your doctor or a professional in that area about specific nutrition, things you may want to avoid eating, and how hydrated you need to stay to keep your skin healthy, to reduce the chances of you wanting to pick and pull. A lot of patients I see, and a lot of students that have come through BFRB School, our online course for skin picking, have reported having skin conditions, acne, or certain things that have impacted how much their skin is irritated, how many pimples they’re having. Now, I’m not assuming that nutrition and hydration are the solution to all of that, but I would encourage you to speak with a doctor and just inquire about what you could do to make sure we’re addressing those skin conditions. Another thing to know here, and this is like an inside scoop, is that there are specific over-the-counter medications you can get that have been proven to help with skin picking. I’ll leave a link in the show notes for you to take a look, but there is a vitamin that’s called N-acetylcysteine. It is an over-the-counter medication that has very few side effects and has been shown to help people with skin picking. Now again, I’m not a doctor. I would strongly encourage you to speak with your doctor about that, but again, I’m trying to give you as many resources today as we can to help you get to the goal that you want. These are all things that you can take a look at and speak to your doctor about. Strategy #9: Set Realistic Goals and Make Sure You Track Your Progress  We want to set realistic goals. I always tell my patients at the beginning of treatment that the goal isn’t to completely stop skin picking, even though most people are coming for that goal. Because what I have found is, when you set that huge goal, it sets you up to fail. It makes you feel so bad if you slip. It makes you feel so much pressure. It’s such a scarier experience than if you say, “Hey, I’m just going to reduce this by 3 to 5 percent each week,” or month or day, whatever is right for you. We want to set realistic goals—goals that can help keep you motivated and goals that make you feel like they're achievable. We also want to track progress. One of the most important parts of treatment, once we’ve done that first awareness log—and we do this in BFRB School, I do it with my patients as well—is that once we’re off and running, we then track how well we’re doing. How well did you use your tools? What tools didn’t work? How long did you pick for? Where were you? What went wrong? We are not doing this to beat you up or to scrutinize you; we are doing it from a place of experimenting, gathering information to know specifically what’s getting in the way of your recovery and what your progress looks like. Some people may say, “I’m not making any progress,” but when we actually look at their logs, we’re starting to see progress in these small ways. Remember, small steps lead to medium-sized steps. Medium-sized steps lead to huge changes. The last strategy is probably the most important. I could have spent a whole podcast episode talking about that. It’s about setting realistic goals and tracking your progress. Again, if you are struggling with this and you want to take BFRBSchool.com, head on over to CBTSchool.com. You’ll get access to it there. It will take you through all of these steps. We also have modules on self-compassion, mindfulness, and healthy lifestyles that can really help you with this recovery as well. I’d strongly encourage you to consider that as a hopeful strategy as well. All right, guys, thank you so much. These have been the nine strategies to help you stop skin-picking this summer. I hope you found it helpful, and I’ll see you next week.

Today, we’re diving into a topic on how to become more self-confident, especially if you struggle with anxiety. Self-confidence is a quality we all desire, but for those of us with anxiety, it can seem particularly elusive. Let's explore how to cultivate self-confidence, even when anxiety is a persistent part of your life. Understanding Self-Confidence First, let’s clarify what self-confidence actually is. Many people mistake it for arrogance or an inflated sense of self. True self-confidence, however, is a deep trust in your own abilities, strengths, and judgment, even when faced with adversity. Anxiety can often undermine this trust, making us feel uncertain and vulnerable. But self-confidence is not something you’re born with—it’s something you develop over time. Debunking Myths About Self-Confidence Myth 1: Self-confidence is Innate One common misconception is that self-confidence is an inherent trait. This couldn’t be further from the truth. Self-confidence is a skill that can be nurtured and grown with practice and perseverance. Myth 2: Success Equals Confidence Another myth is that self-confidence only comes after achieving certain milestones or successes. While accomplishments can boost confidence, they are not the sole source. True confidence is built through the process, not just the outcomes. Myth 3: Confident People Don’t Have Anxiety It’s a widespread belief that confident people are free from anxiety. In reality, confident individuals often face anxiety just like anyone else. The difference lies in their willingness to face their fears and grow through the experience. Building Self-Confidence: Practical Steps Embrace Challenges Self-confidence grows from facing and overcoming difficult situations. Initially, the thought of tackling a tough challenge can be overwhelming, but each experience strengthens your trust in your ability to handle adversity. Practice Feeling Your Emotions Confidence isn’t about the absence of fear but rather the ability to feel and manage your emotions effectively. By practicing feeling emotions like fear, inadequacy, or shame, you become more comfortable and resilient in facing them. Identify Specific Scenarios Pinpoint the situations where you feel least confident. Reflect on what emotions these scenarios evoke and work on becoming more comfortable with those feelings. For example, if public speaking makes you anxious, practice feeling that anxiety in smaller, controlled settings until it becomes more manageable. Cognitive and Behavioral Strategies Cognitive Restructuring Changing your thoughts can significantly impact your confidence. Instead of telling yourself, “I’m going to fail,” try affirmations like, “I’m prepared and capable.” This shift in mindset can reduce anxiety and boost your self-assurance. Behavioral Exposure Facing your fears head-on through repeated exposure can be incredibly effective. For example, if public speaking terrifies you, join a group like Toastmasters, or practice in front of friends and family. Repetition helps desensitize you to the fear and builds confidence in your abilities. Reflect and Learn After facing a fear, take time to reflect on the experience. Ask yourself, “What did I learn?” This reflection helps you identify areas for improvement and reinforces your ability to handle challenging situations. Embrace Failure as a Learning Tool Failure is an inevitable part of growth. Instead of viewing failure as a negative outcome, see it as an opportunity to learn and improve. The more you fail and learn from those failures, the more confident you become in your abilities. Conclusion Self-confidence is a journey, not a destination. It involves embracing challenges, feeling your emotions, and learning from both successes and failures. Remember, today is a beautiful day to do the hard thing. Face your fears, practice self-compassion, and celebrate your progress along the way. Have a great day, everyone, and keep building that self-confidence! TRANSCRIPTION:  Hello and welcome back. I’m so happy you’re here. Today we are talking about how to become more self-confident, especially if you’re someone who has anxiety.  Self-confidence is something that a lot of people talk about. It’s something we all want more of. But if you are someone who has anxiety, you might actually find that being self-confident is really, really hard. So I’m here today to talk with you about how you can become more self-confident even if anxiety is here. Let’s do it.  First of all, what is this thing called self-confidence? Some people think that it’s like thinking really highly of yourself and that you think you’re the coolest—sort of arrogance—but that is not the definition of self-confidence. Self-confidence is a deep trust in your own abilities, your own strengths, your own capabilities, and your own judgment in the face of adversity. I get it. When we have anxiety, it’s very hard to feel that sense of trust. In fact, I think anxiety can sometimes make us feel like we can’t trust anything. We’re in a heightened state of fight, flight, freeze, and fawn.  What we want to do today is take a look at how we can improve self-confidence in the face of anxiety. Now, in order to do that, we first have to look at some of the myths about self-confidence. A lot of people think that self-confidence is just something that you’re born with, and that could not be further from the truth. Self-confidence is something we grow over time. Other people believe that self-confidence is something you get once you’ve achieved something, like you’ve achieved some success, or you’ve lost enough weight. That was me when I had an eating disorder. When I’ve finished a course, then I can feel confident. Or, when I’ve done enough practice, then I can feel confident. I understand that. However, that if-then statement creates a lot of opportunities for us to feel out of control and like it’s something that we can’t create on our own. I actually want to really take that idea away and lean towards another strategy.  Another common myth about self-confidence is that some people have it and some people don’t, and that it’s like an inherent piece of who we are—also not true. Anyone can work toward being confident. We have a lot of evidence. You probably know someone who’s really, really confident, and you don’t even think that they are warranted to have that much confidence—again, proof that we can grow self-confidence. It’s something that you can have that doesn’t require a certain accolade or level of success. It’s something that we can take on. Again, we are not using it in a way to hurt other people or to make other people feel bad. That’s actually not self-confidence. That’s usually coming from a place of insecurity.  Another myth is that confident people don’t have anxiety—also not true. Confident people are as afraid, if not maybe even more afraid, than the average person on the street. I don’t want us to believe that confident people don’t bring anxiety to the table, and we are going to take a look at how we can work with that.  Let’s now talk about how you can become more confident. Here’s the thing. As I have gone through some very difficult things, at the beginning of going through those difficult things, I too was overwhelmed with thoughts like, ‘I can’t handle it.’ ‘I don’t have what it takes.’ ‘This is going to destroy me.’ ‘This is going to ruin me.’ It’s like I’m just going to implode with this degree of suffering.  But what I found was that once I had been through that difficult season, I felt more confident. It wasn’t that I succeeded in it, though. It’s not that I conquered all during that difficult turbulence season. There was a different shift towards, again, trusting that I could handle hard things. Often we go into hard, scary things, saying, “If I only had been through this before, well, then I would feel confident.” But that’s actually not true.  A lot of self-confidence is your ability to feel the feelings you will have to feel when you do that hard thing, not the actual doing of the hard thing. The more we practice feelings of fear, threat, inadequacy, shame, or whatever it might be, the more we’re comfortable, open, and caring in feeling those feelings. That’s how we begin to feel self-confident in any situation, whether we’ve been through it before or not.  I had a friend who once told me that a very, very dear loved one, actually a child, had been through cancer. I had said to her, “How are you doing?” She said, “Oh, I’ve been through cancer. Nothing can take me down.” But what she meant by that is that it’s not that everything was in comparison to cancer; it’s that she had mastered feeling her feelings as she navigated something really, really difficult. She could go through something completely different. But because she’s already committed and gone through the willingness to have some really uncomfortable feelings, she had a sense of self-confidence, like, ‘I could handle anything at all.’ What I want you to think about here is, what are the things that you don’t feel confident about? What specifically are the situations, the scenarios, and the times in your life where you don’t feel confident? And then I want to ask you, what would you have to be willing to feel, and what would you have to build comfortability feeling in order to feel confident doing that thing? It’s just a question. Sometimes it’s like, “Oh, to be confident doing my exposure, I’d have to be confident feeling uncertainty.” “Oh, to go through seeing my child struggle, I’d have to be confident feeling maybe guilt or maybe sadness.” “Maybe to handle my parents’ aging, I’d have to be able to confidently and willingly feel grief.” Ask yourself these questions because they can help us identify the emotion that we need to practice feeling on purpose.  Now, when it comes to creating self-confidence, there are two ways we can target it. I talk to my clients about this all the time. We can create self-confidence by changing our thoughts, or we can create self-confidence by changing our behaviors. Let’s talk about creating or changing our thoughts. Let’s say you have something you need to do that’s creating a lot of anxiety. Maybe you have to do a public speaking event. You have a lot of anxiety. You could do some cognitive restructuring by changing your thoughts. Instead of saying, “You’re going to fail and this is going to be terrible,” you could practice saying, “It’s going to go great,” or “I feel like I know my stuff, I’ll be able to do it.” These are great strategies. We could use that.  Another strategy would be, if you have a fear of public speaking, go and do lots of public speaking, Maybe you would join Toastmasters. Maybe you would rehearse it in front of your family, your neighbors, or your colleagues. You would practice doing this behavior over and over and over again with repetition.  These are two very good ways to help with confidence building. However, let’s compare and contrast them. Let’s say that before this public speaking event, you spent a lot of time doing cognitive restructuring. “I’m going to do great. I’m going to do great. Nothing’s going to go wrong,” which we don’t actually know is true. But the thing is, when you walk up onto that stage, you don’t have a lot of proof that it is going to go well. You don’t have a lot of proof. If it doesn’t go well, you mightn’t leave there with a ton of confidence. However, if you’re somebody who instead practices facing that fear over and over and over and over again, as you go to walk onto that stage because you’ve changed your behavior repeatedly and you’ve practiced, you actually have trust in your ability. You have trust in your capability to feel fear. You know what fear feels like, you’ve practiced feeling it, and therefore you’re a little bit desensitized, or you’re a little bit feeling a sense of mastery over that feeling, and you are able to walk up onto that stage. My advice is that the better way, the more superior way to build self-confidence, is to practice facing that emotion as much as you can. In exposure and response prevention, which we use as the gold standard treatment for OCD and many other anxiety disorders, we’ve practiced facing fears over and over. What clients often tell me is, “I actually start to feel confident doing that thing. I start to feel confident taking flights. I’m starting to feel confident going to the post office. I’m starting to feel confident driving my car by actually doing the thing.”  The real moral of the story here is that confidence comes from repeatedly facing the thing that is hard for you. Identifying the specific emotion that makes it more difficult and practicing being willing to have that feeling. Now, here is where, going back to that cognitive changing of your thoughts, it might be very, very beneficial, particularly at the end of when you faced your fear. Meaning, after you faced your fear, you can actually stop and go, “What did I learn? What did I learn about facing my fear?” Let’s say the public speaking example. You go up in front of your partner, your mom, or your dog, and you present your presentation. You might say, “I learned that I don’t know the script well enough,” or “I learned that I’m still anxious, but I can handle the anxiety.” “I learned that when I have anxiety, I beat myself up.” Oh, interesting. So we have an opportunity to make another tweak in behaviors because if beating yourself up doesn’t work—PS, it never does—then we might want to change our behavior in that area. The next time we’re going to go and do that presentation, we’re going to work at not beating ourselves up this time. What else did we learn? “I learned that my body didn’t explode when I gave the presentation to my dog and then to my mom and then to my neighbor.” We’re starting to learn things, and we’re starting to change the way we think because we changed our behavior.  This is a really great strategy for anyone. There’s, again, an important cognitive era that we have that gets in our way of building self-confidence, and it’s this: “I’m a failure if it doesn’t go well.” This belief and this thought could create so much suffering. If I can leave you with one core thing to keep in your back pocket as you practice this, it’s that we need to fail a lot of times to get confident. We need to fail a lot of times to be good at something. That doesn’t mean there’s something wrong with us.  I create these podcasts and these YouTube videos all the time. I sucked at them when I first started, but I didn’t stop, and I didn’t say, “That’s because I’m terrible at it.” It basically meant I had some learning to do. I had some practice to do, and it’s okay to suck at things until you get better. The only way I got better was by doing it over and over and over again. I got a little more comfortable and a little more confident in myself as I strategized how I could tweak it a little bit to be better and not be like, “When I’m better, I’ll feel good about this.” Again, that’s a myth. Self-confident people still have anxiety. They just bring it with them, and they know in their hearts that there’s no emotion I’m not willing to feel. Again, as we get better at this, we can start to have a sense of mastery over the emotions that we have to feel.  Another thing I want you to think about here is if, as you do these scary things, you feel guilt, self-criticism, and shame. What we want to do is soften around that emotion, not add to it and be like, “Oh yeah, you’re right. I am the worst. I’m terrible. This is the worst thing ever. I’m bad and I shouldn’t be doing this and all the things.” Instead, we want to soften into it and change our belief around failure and learning and say, “It’s okay. I’m not bad at this. It’s okay that I’m not perfect at this.”  Everyone starts at zero. The people with a million followers on Instagram originally started with zero followers. The people who win Olympic awards in races were once not the fastest runner. They were once in their school and maybe getting beaten by people in their elementary school, high school, or college. We all start somewhere at the beginning, so give yourself permission to start at the beginning. Don’t let yourself give up trying a couple of times, and expect yourself to feel confident. Confidence comes from the repetition of doing the thing and practicing having the emotion that is uncomfortable in relation to that task or activity.  That is where I want you to change the way you think of self-confidence. It’s how I want you to change the way you lean into a task and an emotion as you do that task. I also want to remind you that today is a beautiful day to do the hard thing. This is why I say it on almost every episode. Today is a beautiful day for you to do the hard thing. I want you to go on after that thing that you want to do and practice this. Let the anxiety come, let whatever emotion come. I’m so impressed and proud of you for trying.  Have a great day, everyone.

Health anxiety is a common yet often misunderstood condition that can significantly impact one's quality of life. Whether it's worrying excessively about potential illnesses or constantly seeking reassurance about your health, the effects can be overwhelming. Understanding the nature of health anxiety and learning effective strategies to manage it can make a world of difference. In this article, we explore five essential things you need to know about health anxiety and offer practical tips for recovery, with expert insights from Michael Steer. 1. UNDERSTANDING HEALTH ANXIETY: WHAT IT IS AND WHAT IT ISN'T Health anxiety is a term often misunderstood by many. It's not just about being overly concerned with your health or frequently looking up symptoms on Google. Health anxiety can be categorized into two main disorders: Illness Anxiety Disorder and Somatic Symptom Disorder. Illness Anxiety Disorder involves a preoccupation with health despite not having significant physical symptoms. On the other hand, Somatic Symptom Disorder includes severe and persistent physical symptoms that cause substantial distress. It's essential to understand these distinctions to recognize that health anxiety isn't simply a matter of being overly cautious or paranoid about one's health. Moreover, health anxiety can often intertwine with Obsessive-Compulsive Disorder (OCD), involving obsessive thoughts and compulsive behaviors centered around health concerns.  2. NAVIGATING THE MEDICAL SYSTEM WITH HEALTH ANXIETY Dealing with health anxiety within the medical system can be particularly challenging. One of the critical aspects to remember is the importance of finding a healthcare provider who listens and validates your concerns. If you feel dismissed or unheard, it is perfectly acceptable to seek a second opinion or switch providers. Additionally, distinguishing between different types of symptoms can help manage health anxiety more effectively. Medical symptoms require immediate attention, such as severe chest pain or sudden numbness. Physical symptoms, like a sore back from yard work, are often benign and manageable with self-care. Psychological symptoms stem from anxiety and can include manifestations like tightness in the chest or dizziness. Understanding these differences can help reduce unnecessary panic and improve communication with healthcare providers. 3. TRUSTING THE RELIABILITY OF YOUR THOUGHTS A common challenge with health anxiety is differentiating between real medical issues and anxiety-driven thoughts. Think of your anxious thoughts as spam emails—they're real, but their content isn't always reliable. Health anxiety often triggers false alarms that feel urgent and terrifying. Learning to question these thoughts and not take them at face value is crucial. Techniques like cognitive diffusion can help change your relationship with these thoughts. For instance, if you've convinced yourself numerous times that you're having a stroke and it hasn't happened, the likelihood that your current fear is another false alarm is high. Questioning the reliability of these thoughts can help manage the overwhelming fear they generate. 4. THE ROLE OF COMPULSIONS AND SAFETY BEHAVIORS Health Anxiety Compulsions and safety behaviors, such as constantly checking symptoms or seeking reassurance, often exacerbate health anxiety. One significant trap is becoming inwardly focused, constantly monitoring your body for signs of illness. This behavior leads to a vicious cycle where anxiety increases symptoms, which in turn heightens anxiety. Shifting your focus outward and engaging in meaningful activities can help break this cycle. It’s essential to become more outwardly focused, enjoying life and participating in activities that bring you joy and fulfillment. This shift can reduce the power of health anxiety over your life. 5. EMBRACING LIFE DESPITE HEALTH ANXIETY Health anxiety often steals the very things we're afraid to lose—time, relationships, and enjoyment of life. The constant preoccupation with health can make us miss out on living fully. Therefore, the goal isn't just to reduce anxiety but to reclaim your life. Engage in activities you love and focus on adding value to your life. This shift in focus is incredibly powerful and can help you live a more fulfilling life despite health anxiety. It’s not just about feeling less anxious; it’s about living more fully and enjoying the moments that matter most. CONCLUSION Health anxiety can be overwhelming, but with the right strategies, it’s possible to regain control and live a fulfilling life. Michael Steer's book, "The Complete Guide to Overcoming Health Anxiety," is a fantastic resource for those seeking further support and information. Additionally, his website, overcominghealthanxiety.com, offers a wealth of resources, including a free virtual support group. Remember, while health anxiety can take a toll on your life, effective strategies and a focus on meaningful activities can help you reclaim your joy and well-being. TRANSCRIPT: Kimberley: [00:00:00] Welcome back, everybody. Today I have Michael Steer here talking about the five things you need to know about health anxiety and how to recover from it. So welcome, Michael. Michael: Thanks for me. I'm really excited to be here and talk a little bit about health Kimberley: Yes. It's actually a very, very requested topic. It there's always questions about it. So I think this is really, really wonderful that we're doing it. Okay. So first of all, what is health anxiety? Let's just do a little bit of a, you know, intro, uh, tell me what it is and then tell me what it isn't. Cause that's point number one. Michael: Absolutely. Yeah. So we'll jump into point number one, which is I kind of was breaking down if I could have people know five things about health anxiety, what would I want them to know? Or people that support people with health anxiety. And number one point that you're going to bring it up is the first thing that I would want [00:01:00] people to know is exactly what health anxiety is. I feel like health anxiety is one of those things where, you know, you see somebody on their phone looking up symptoms and everybody kind of knows, right? They're like, Oh, I've been there before, right? We all kind of know what health anxiety is, but sometimes we don't know exactly like what it looks like or even more so that there's actually treatment that people can get that actually works. Not medical treatment, but maybe psychological treatment. So, um, I break down health anxiety in a couple of different ways, which is one is that. if you actually have a medical condition, so if you were diagnosed with cancer or, you know, whatever that might be. Um, there can still be anxiety around those types of things, but that's not exactly what we would be calling health anxiety. Uh, you know, kind of in a professional community, that would be an adjustment, Kimberley: Yeah. Michael: a massive adjustment, right? It's like you get this scary diagnosis, you're trying to go undergo treatment, those types of things. So that's kind of one category. And then, We also have this other category, maybe [00:02:00] what we would love them to call health anxiety, which actually is kind of awkward, too, because there's really no such thing as health anxiety, like, oops. Um, but there are some categories under health anxiety that we would say, these are actually what we're talking about. One of them is what we call illness anxiety disorder. Um, the other one is what we call somatic symptom disorder. And, uh, these are kind of the two things that we would call health anxiety. Now, Illness Anxiety Disorder is really a very basic way to break that down, is a preoccupation with your health, but you don't have a lot of symptoms that go along with it. I mean, you might have some here or there, and it's like, Oh, one day, like maybe my vision is a little bit more blurry, or I got a kind of weird pain over here. But the, usually the symptoms kind of come and go pretty, pretty quickly. Um, now, Somatic Symptom Disorder is still the preoccupation with your health. But the one big difference that people run into is usually the symptoms are pretty severe. They're [00:03:00] pretty significant, and they're usually a little bit long lasting. So, you know, maybe people are dealing with, you know, chronic stomach pain or pains in their stomach that they really become preoccupied about, but those symptoms are pretty significant where it's like impacting life, those types of things. Um, and then the other category that we can just throw in there real quick is also OCD. Um, and what we'll talk about here and, uh, maybe towards the end of this part is a lot of times I put health anxiety and OCD kind of as hand in hand. Uh, they're not the same thing, but they share so many of the similarities and how they work. And, um, if you ever look through some of the OCD literature. OCD can have health themes and so those would be times where we can be very, become very, you know, have the obsession and compulsion cycle go around health. So that's, that's really what health anxiety is, is usually one of those three things, which is either you don't really have many symptoms and you really worry [00:04:00] about it. You're actually having a lot of symptoms. you're worrying about it, or it may be a bigger dynamic of OCD, where maybe you have other obsessions and compulsions, and then maybe one of them is also just the obsessions and compulsions around your health. Kimberley: Amazing. Michael: yeah. Kimberley: What about hypochondria? Do we, where would you put that? Michael: So that's an older term. Kimberley: Yeah. Michael: So we've kind of, you know, and a lot of times, um, I feel like I'm kind of glad that that term has kind of shifted as just kind of like, you know, illness, anxiety, and somatic symptom. Um, just because there's a lot of judgment and a lot of negativity also around kind of, you know, as soon as somebody is like hypochondria, right? And it's kind of like, it comes with this like really negative experience and like, Oh, you know, they're, they just worry about their health all the Kimberley: Right. Michael: it kind of gets dismissed pretty quickly. So, um, that's just, if you ever see hypochondria, um, it's just an older term or sometimes it's still used in the medical community. [00:05:00] I think it's, even when you look up in some of the, um, Um, things to, uh, you know, for some of the coding, it still comes up as hypochondriasis. Um, however, it's just, it's the same, it's a different terminology just for what we would now call illness, anxiety disorder and somatic symptom disorder. Kimberley Quinlan, Thank you for sharing that too. Cause I think Googling, because that term has been used for decades, that is often what people are looking for. And I think, as you said, people get dismissed like, Oh, you're being such a hypochondriac about it. You know, that. I think is, I'm glad that you, you shared that. Okay. So that was number one. Number two, um, what is the second thing we need to know about health anxiety? Michael: So number two is kind of going right off of what you're saying is a lot of times, you know, what I would really want people to know is to, a lot of times people do get this mess. and even clients that I'm working with, because I work with a lot of health anxiety clients are still trying to navigate [00:06:00] that relationship between, they probably really do have some anxiety around their health, but they're also trying to work with the medical community. and that makes it quite challenging, um, because you know, there can, um, there can be some times where it can be challenging. People can get written kind of off of like, well, this person, you know, they've, they've been anxious about their health before, and then they've sort of become. Um, what could be an obsessive worry but also could be a very realistic worry of I go back into my doctor and they kind of know that I deal with anxiety around my health, they going to take me seriously? Michael: know, if I come in and I say, wow, I've been really having a pain here or here, are they really going to be listening to me? Like really take me seriously and investigating this or are they just kind of writing it off You know, this is, you know, awful, you know, this person has been anxious about a lot of those different things. So the one thing I, I think that we, um, that I think, I think is really important for people to know [00:07:00] is you're working with a medical provider and you don't feel like they're listening to you, they're not validating some of your concerns, they're, they're, you don't feel like they're really invested in some of these things. Um, it's always okay to go find somebody Kimberley: Mm hmm. Michael: That is totally okay to do. You can take it from me. Hell, like, you know, what I would, I don't know if there's no delineation of a health anxiety specialist, but I think there can be some of those times where things are not taken serious. So Kimberley: Yep. Michael: do feel like that is a relationship that you're having with a health provider, find somebody new. Go find somebody that really does listen to you, right? Now if you're also working with somebody that you feel like you really trust, you feel like They feel like they got your back, like they're, they're, you know, but maybe you're kind of running to the end of the road of like, I, don't know really what else we could test for. That's something different, right? Because at least there's that level of trust. So the second thing that we like when it goes into this piece of, you know, like Val or validating people's [00:08:00] symptoms is we also have to realize that there is a difference between physical symptoms, medical symptoms and then also psychological symptoms. And so here's how I break these things down. Medical symptoms is usually the ones we're really afraid of. medical symptom could be like if I have chest pain. And a medical symptom would be I need to go to the hospital because I'm having a heart attack. That is an explanation, a medical explanation of a symptom that I'm Kimberley: Mm hmm. Mm hmm. Mm. Mm. Mm. Mm. Michael: ER, those types of things. one category or one bucket that sometimes we put those in. A second bucket is what we call physical symptoms. And a physical symptom is something that's actually really happening in our body, probably don't need to run to the ER or the urgent care because of that. So like, for instance, if I went and did a bunch of yard work over the weekend, and my back really hurts, um, arguably because I'm getting [00:09:00] older or because I've done a lot of yard work, who knows? Um, Um, I don't, that's a real physical symptom that a lot of times our mind could try to catastrophize, but it's probably not something that I need to go and run to the doctor about. I probably need to take it easy, put a little bit of ice on my back, et cetera, et cetera. So we have medical symptoms, we have physical symptoms, but then also we have psychological symptoms and this is the way that our mental health can also affect our physical body. So for instance, if we're becoming anxious, I'm sure that, you know, if anybody has ever been anxious before, which I'm going to assume everyone has, If we become anxious, sometimes our chest gets tight. That's a real physical symptom. That's a real symptom that we have. But the origins of the conclusions of that is from a psychological standpoint. Now, here's why I think these buckets are important, why I want people to know about them. Surprise, surprise, health anxiety always usually goes to one bucket. Medical symptoms, right? It's like, Lower back pain, medical. You know, my chest is tight, medical. This weird kind of [00:10:00] feeling in the back of my head, medical. You know, all of those different types of things. And one of the things is being able to have this context of if I could start to separate some of these symptoms out to maybe there are some symptoms that I could have that are medical, but maybe there's also physical symptoms that are just happening. There's a great article that I always like to give all my clients The Noisy Body by, uh, Abramowitz, that's just a wonderful handout, a wonderful article. And it just speaks to the nature of like, well, we get signs and symptoms and weird feelings and burps and farts and all these things all the time. The hard thing is, is when our mind gets really preoccupied and starts to put them into the category of, oh no, what if, could this be this really negative thing? So I'd like to, that's the second point that I would really want people to know is. We have to realize that even though there is always this scary explanation of symptoms, it's important to have this perspective of noticing that there could be, there could [00:11:00] be medical symptoms that I need to really do something about, physical symptoms that I need to do to some TLC, and then also psychological symptoms. And then one last thing I just throw in there real quick before we can go on to the third one is, um, the most important part about this is regardless of what bucket you put this in, all of them are valid and real symptoms. that's the other piece that we get into this kind of like stigma or negativity, that sometimes people will talk about a real symptom that they're having, and then they'll be like, Oh, well, that's just your anxiety as almost as if the symptom is not happening. And so I think what I would really want people to know with health anxiety is regardless of what bucket it's coming from, it's always real. You're always valid and feeling it. The one question that we have to just ask, which is going to lead us into number three at some point is. Or can we trust that the explanation for the symptom that our brain has brought us really the explanation of what's happening? Kimberley: Mm. [00:12:00] So, I have a question, which you might answer it in, you can even use this for the, for an example. So, a lot of my followers know that I, in, um, in 2018 was diagnosed with Postural Orthostatic Tachycardic Syndrome. Michael: Mm. Mm Kimberley: one of the main symptoms of that is that you faint and a lot of, I'm very well in recovery of this right now, but one of the things was me without using this terminology, which you've beautifully put out. And I actually learned this terminology from you is it was about passing out, passing, like not, not, not passing out, like, uh, differentiating, sorry, my accent got it, differentiating. Um, is this dizziness from my anxiety? Is this dizziness evidence that I'm going to pass out, like faint? Um, Michael: hmm. Kimberley: because a lot of [00:13:00] having this condition is tolerating dizziness 24 seven of the day. Like it's a symptom of the condition. Um, so in that case, just as that as an example, how would you, which bucket would you put this in? Michael: For sure. Good. Great question. And this is where, like, health anxiety, I think that's why it's really important to, to really notice the stickiness of Kimberley: Mm. Michael: Because, you know, as an, also as an OCD specialist, a lot of times when we deal with OCD themes, not often having people, like, deal with, uh, you know, harm obsession. And also undergoing evaluations to see if they're a Kimberley: Yes. Yes. Michael: Uh, that doesn't really make sense. health anxiety starts to become this kind of interesting dynamic of, well, what happens if we have anxiety around medical Kimberley: Yeah. Michael: And also we have to like, go get evaluations and other things that are actually Kimberley: Yep.[00:14:00] Michael: that's a great point. And it's like, okay, so what if the, um, Um, you know, the symptoms that I'm feeling could be an explanation of a medical condition that's happening, or it also could be, you know, from the place of, um, you know, from my anxiety. Um, think the answer comes down to, um, is going to this, what I usually like try to call a pretty, a best guess. Which is, now, when we're thinking about passing out, the one thing I think is always important. as a person that works on a lot of needle phobias and blood phobias is that if you feel like you're going to pass out, get yourself in a safe place, right? Like sit down, make sure you don't hit your head. You know, Kimberley: Yep. Yep. Yep. Michael: But also there's this kind of conclusion that we can come through with our experience that says, know, um, if I, if I think about the symptoms that I'm having right now, where would I put my best guess on those, right? And if we're putting this, that medical side, then we could say, okay, well, [00:15:00] Um, I need to do whatever the doctor has recommended that I do in those situations because that's just what's most helpful. If I'm feeling like it's more on the anxiety side, that's maybe where I could use some of my tools that we learned in therapy to be able to manage that. Now is it a perfect system? No it's not, right? Because there's always this little piece of uncertainty and the unknown there Kimberley: hmm. Mm hmm. Mm hmm. Mm hmm. Mm hmm. Mm hmm. Michael: that's, I think that's what's also really important about being able to kind of discuss those things either with your doctor or a therapist to be able to really walk those muddy lines. Um, I have quite a few clients that we try to walk that line all the time where, I've had clients where thought that maybe this was or maybe it was assessed as like, Oh, this is just something anxiety related. That's why you're having symptoms. And then it's like, months later, surprise, I'm allergic to this, right? And so, that's why we don't always know the answers to all of [00:16:00] those things. Um, but as we kind of go, we can kind of walk that line to say, could I make my best guess about what this is at this current period of time? And if that was the case, what would I do in that Kimberley: Yeah. Michael: You know, and so do I need to go a medical route? Do I need to go to a psychological Kimberley: Yeah. Which I think takes us to next step number three so beautifully. So go ahead and share what is the third thing we need to know. Michael: Absolutely. So number three talks about. Um, a lot of times our brain can bring us to a lot of different conclusions and we just talked about the conclusions that a lot of times our brain Kimberley: Yeah. Michael: into in terms of medical, physical, psychological. And a lot of times we just take those conclusions as the truth. go with them because they're terrifying, they're scary, right? And they feel really threatening. And so one of the things that I think is important for people to recognize is I like to use the example of a spam email. is I'm sure we've all gotten spam emails. And if you haven't gotten a spam email, please let me know your trick because that would be I could clear out like [00:17:00] 75 percent of my email box. So but a spam email to me is kind of walking this line between is a spam email real? Oh, of course, we all get them in our email box, right? Like they actually come through to us. They have a time stamp, et cetera, et cetera, right? But the one question that we have to start to kind of wrestle with with health anxiety is. is the conclusion or email that I'm getting a reliable source of information. so if you get an email from tomjones1973 at AOL. com that claims to be from the FBI, why would the FBI be sending you from AOL? That doesn't make Kimberley: No. Michael: Now, is that email real? You betcha. However, if we can question its reliability to say, can, you know, do I trust this email to be what I think it is? Kimberley: Mm hmm. Michael: Then that can really start to dictate some of the actions that we take. So when we think about health anxiety, right, is your brain can give you a lot of really scary a lot of really unknown possibilities that could be going on with you. And [00:18:00] so, you know, one of the things that I think we have to really kind of start to become curious about is, do I just go with them? You know, am I there just responding to all of my spam emails in my email box? And if you do, we probably need to help like. Credit monitoring and all those Kimberley: Yeah. Michael: besides, from that point, do we get ourselves into a lot of actions that could be very unhelpful when we take these emails as as reliable? So, like, for instance, if you, you know, you have the dizziness, right? And you're, you're, you know, the initial evaluation or conclusion that your brain comes up with, aka what we could also call an obsession, right? Is like this could be an aneurysm, right? Or maybe you have a stroke or all these different types of really scary things. If we take that as a reliable piece of information, it starts to make Kimberley: Mm hmm. Michael: that we would be like, well, I need to figure that out. I need to be like, look up some symptoms of online or I need to go to the urgent care, whatever those things are, right? but if we get a, oh, by the way, I should have included this earlier, but [00:19:00] that's okay. We'll include it Michael: This is all on the premise that we have a relatively good answer. if you don't. If you're getting dizzy for no reason, and you have no idea why, I don't want you practicing anxiety Kimberley: Yes. Michael: Go to the doctor, right? Like, explore those things, figure those things out, try to get a pretty good answer. However, if we get a pretty good answer about something, and we are going to say it's like, I think this is because of my anxiety, but my brain wants to really convince me of all these other conclusions. can we use some of those tools in terms of, you know, Becoming curious about, can I really trust my brain sending me right Kimberley: Mm hmm. Mm Michael:  if this is like the 937th time that I'm convinced that I've had a stroke, what's the chances the 938th time is going to be it? Probably not. so, I could go look on things online, or probably got a lot of other things to do, too, that I could go and get involved with as well. So, that's it. One of those tools is, is really being [00:20:00] curious about, yeah, your brain's going to give you a lot of really scary medical possibilities. If we can ask that question of not if it's real or not, because those things are totally real, but can I trust the message that I'm being sent? It can start that process. Now, the other tool that I really like to use with people is diffusion. Um, and, and to kind of give it a quick breakdown of cognitive fusion, even though some people may be like some of the listeners may know, is just being able to like what kind of relationship that we have with some of our scary thoughts. so sometimes I kind of describe as like, well, it's not really necessarily getting away from them. It's just about changing our perspective towards them. So like, I kind of think about this example. It's like if you go out into like a really busy highway, you set up a lawn chair right in the middle of a busy highway and you have cars whizzing by you, you can see the traffic, but man, oh man, is it overwhelming. And so if we can use some diffusion skills and those would all be the great things, like, you know. Uh, just repeating or thanking our mind or my favorite is always just [00:21:00] singing, like, you know, the tune to happy birthday, Kimberley: Yep, Michael:  be right is sometimes those start to kind of be able to take us from this position of, could you just take your chair and put it on the side of the highway? And if we can do that, we can still see the traffic that's out in front of us, but it's much less overwhelming at that point because you don't have cars whizzing by Kimberley: all right Michael:  these cognitive interventions, I think, can be really helpful. Um, because a lot of times our brain is leading us to all of these conclusions, giving us these really scary ideas, and it might really start to go against the information that we have at that time, at least medically. Kimberley: Amazing. And I, the reason I love this is that was a big piece of it for me, just to sort of give a real example of me having health anxiety and a chronic illness when you are you're dizzy. My brain was like, this is it. You're going down, you're going down. And I had to get used to just having the thought like, yeah, you're dizzy. It could be it. But we know the symptoms of when you are, and you're just, you know, again, like you [00:22:00] often say, like, it's about being uncertain and being able to just to have the thoughts whenever they show up. So would you add anything to that or, Michael:  Know it. And I think what's important with that is, there's a piece of uncertainty Kimberley: um, Michael:  but we can also act within a reasonable Kimberley: yes, Michael:  right? It is like, you know, we can, we can always make those, you know, I always love delay in these situations Kimberley: um, Michael:  is if I start to become dizzy and I'm concerned that like this is going to be, this is me passing out, right? And if you just like, if you're dizzy and you remain dizzy and you remain dizzy, you know, those types of things and it, you know, you're just kind of like working through it and it's like, okay, maybe that's one thing if you're dizzy and then the wall start closing in, right? And you start to get tunnel Kimberley: yeah, Michael:  Well, that's what you can always make a different, Kimberley: yes, yes, um, Michael: I think the lay, but. nothing about health anxiety that likes delay, right? Because whenever these [00:23:00] symptoms come up, it's always going to be about you need to do this Kimberley urgent, Michael:  to the E. R. Currently, like right Kimberley: yeah, Michael:  wait, Kimberley: yeah, yeah, Michael:  if even if we're able to kind of like practice some type of delay, right? We'll be like, okay, this is what this feels like now. I understand the concerns my brain has, like not quite sure if I can trust it. I don't know. It's giving me some bad advice before. I But could I just wait that out and kind of see how that Kimberley yeah, Michael:  And, you know, if it continues to get worse or you start to get tunnel vision, go take care of it. There's probably something going on. But if those experiences, you know, I think what happens a lot of times for people is they, they try to move themselves on to something else, right? They get back to dinner or whatever it might be. And then they kind of have that reflection point or like later of being like, Oh yeah, I was like dizzy Kimberley: um, Michael:  earlier. And it's like, Oh, Kimberley: um. Michael:  to that? Right? So I think delay can be a really helpful Kimberley: Fantastic. Quickly, just because I have a couple of people in mind, and I know what their questions would be here, is in regards to [00:24:00] the, the point number two, where we were talking about the difference between medical, physical, and psychological. Let's say somebody. Um, has just intrusive thoughts about like, what if, actually maybe no, let's say they have a headache, a physical symptom and their brain is just constantly telling them like, this is a brain aneurysm, or this is a brain tumor, like this is cancer and it doesn't quit, um, Um, and the person also experiences this sort of intuition that this is what it is. What, how would you, what, what bucket would you put that in and would you use the same skills? Michael:  So, yeah, so the, the questions that I would have for that situation, which is number one, have you been to the doctor? You know, have you gotten it checked out? Have you like evaluated some of these, you know, headaches that you've been Kimberley: Mm. Michael:  Now if they say, uh, no, I've never been to the doctor about that. I'm, I'm not a doctor. I'm going to say would be [00:25:00] kind of silly of me at that point to be like, you're Kimberley: Yeah. Michael:  You know, that's Kimberley:  Just tolerate the uncertainty. Michael:  Yeah, that'd be good, right? We're like, that's probably not great. So because nobody would do Kimberley: No. Michael:  Like we, well, hopefully most people would not do that because if there is, so that's the first question I would always Kimberley: Mm. Michael:  is if you're having a physical symptom that's different, that's changed, that's more significant, whatever it might be, question needs to always be, have you gotten this Kimberley: Mm. Mm. Michael:  part that it's, I really wish there was a better answer to this. but there's not the least that I found, which is like how much is too much, you know? So if you're like, okay, so let's say the answer is yes, I have gotten it looked at and they can't find anything. Um, sometimes the conversation starts to become, well, how much, like, should I go for a second opinion or third or fourth or fifth or sixth? Um, and what's really difficult about that [00:26:00] is no one really knows that answer. Okay. And, um, what I try to really do to level with people, too, is that, you know, if you were having that headache and you're like, I don't know, Mike, like, this is like, I've seen like four doctors, still feel like there's something, like the intuition Kimberley: Mm hmm. Michael:  feel like there's something wrong. There's something going on. I can't, I can't fight you on that and being like, no, you shouldn't, right? Because I, the fifth time might actually be the time where it's like something comes back and you're like, oh my goodness, like, I'm so glad they found that. So. always this kind of difficult time that I get these questions where people would say like, what, what, what is too much now getting like a fourth or fifth or sixth opinion, whatever that might be, could just be reassurance Kimberley: Mm hmm. Mm hmm. Michael:  you know, getting another clear scan or whatever that might be. And it just kind of gives us that temporary relief of like, okay, goodness, like nothing's going on. But I think it's reasonable for us to know it's like it's not a very clear cut kimberley-_1_06-04-2024_101032: Mm hmm. Michael:  Of saying, like, [00:27:00] everybody's in their right to go get another opinion. you know, to, you know, however much you want to pursue that. We have to be on board and somewhat of being like, okay, like, go do that. But the other thing that I would always throw in there, too, that I like to try to work with people is, there's going to be productive ways that we can pursue that, there's going to be unproductive Kimberley: Mm. Michael:  you're having those headaches, and you're, and you're like, I've seen three people, I kind of want to go see four, I would say, I can't fight you on that. You should go see that fourth person, see what they say, but that's a productive method of trying to figure something out, right? Like, cause you could possibly, they could give you some scan, right? And be like, Oh my goodness, like right here, we found something, right? also other unproductive behaviors that sometimes people get into, um, that like your brain at 3 a. in the morning while you're ruminating about if there could be something going on in your brain or not, right? have no access to scans, like you're not gonna figure anything [00:28:00] out. You're not gonna come to some revelation of like, Oh, now that I can see inside my brain, I can see what the problem is, right? So, there's, there's kind of an encouragement that I try to give to people, too, is if you really feel like there's something wrong, and even though you've gotten a lot of things that have said maybe nothing is wrong, if you want, if you feel like it's necessary to continue to pursue those productive ways, set an appointment with a doctor. Go to that appointment when it's the time, right? Great, go do those. But some of these other things when we're thinking about like, but are we like ruminating about this for hours on end during the day? never going to become anything Kimberley: Mm. Michael:  not going to come to some insight of like, ah, I see everything clearly now, I see what's wrong. And so we try to practice those tools in those situations of saying, you know, if that's kind of an unhelpful thing to do, could I find something better to do? Uh, to do with my time than just endlessly going over this in my Kimberley: Yeah. Amazing. Which [00:29:00] ties us right into the thing number four. Um, tell us. Michael:  four, the four, I almost held up five, so that's good. Number four is, now, when we think of like, like, you know, for some of the viewers who might be a little bit more familiar with OCD, a lot of times I just use the terminology of TOs Kimberley: Mm. Michael:  triggers, obsessions, and Kimberley: Mm. Michael:  you might be saying, it's like, well, I didn't think health anxiety was really OCD. It's not. But. The functionality of these things kind of operate in the exact same way. So number four is talking about compulsions, or if you just wanted to view it as safety behaviors, that's cool, too. They kind of do the same thing, which is there's going to be physical or behavioral compulsions that we could do or mental. and one of the things that we really have to account for is just their ability to not really be able to give us an answer that we really want. and how sometimes it actually, especially with health anxiety, one of the things that I'll point with health anxiety. Usually makes things [00:30:00] worse. So there's always like pretty classic different mental or behavioral compulsions, you know, googling or, you know, going on Web and D and clicking on the little body right and being like, you know, we get the huge list, you know, you put in fatigue and it's like, gives you all these terrible things, right? It's like, Oh, maybe I don't Kimberley: There's like cancer at the bottom of every single Urban D article. Michael:  Yeah. Yeah, it's just like this. Just put it on the Kimberley: Yeah. Michael: you know, it'll be there. Um, the one thing I think is really important to consider specifically with health anxiety is the tendency for us to become really inwardly focused. And I think this makes it really difficult people to be able to have any chance of being able to move on from any of their health worries. a lot of times what we all want to do is the one thing that we want to monitor is the thing that's wrong. And so for instance, if you go back to your dizziness, right, we might continue to check in on that being like, well, my dizzy now or my dizzy now. How about now? [00:31:00] But the problem is, is that now you're like now you're swapping buckets, Because we have the medical that we have the physical and we have the psychological bucket. But what's a, um, I don't know. You feel dizzy because you drank a little bit too much coffee this morning. You're kind of feeling a little whoa, right? That's a physical symptom. not medical. You don't need to go to the doctor and be like, I've drank too much coffee and be like, great, just go run around for a little bit. Work it off. Right. Um, but the hard part about that is like, so that's a physical symptom. However, then we could start to get that conclusion that we talked about of like, Oh, my goodness, like, what does this mean? And maybe the conclusion is medical. You know, it's like, Oh, maybe I'm gonna pass out. but then the result of that is psychological. We start to get anxious about it. We're like, Oh my goodness, like this could be really bad and like, I don't want this to happen. However, now the byproduct of anxiety a lot of times is lightheadedness, right? And so we work into this catch 22. The [00:32:00] hard part about it is we keep checking in on those and there's a lot of body monitoring with health anxiety that really gets people stuck, um, paying attention to feelings and sensations and symptoms. And the hard part is it keeps going back and forth between these two things of we get really concerned about a symptom. It makes us feel anxious, which increases symptoms, which we notice more. And when we notice more, it makes us feel more anxious. And when we get more anxious, and so we just keep getting into the step ladder. So one of the things that I think is important when we think about this Catch 22 that starts to happen, is I try to really encourage people to think about, If often you get, start to get stuck within your body, your, your focus is inward thinking about how do I feel, what do I notice all of these different things? biggest goal that we can do with any of these things is how do we become more outwardly focused? That doesn't mean that you have to like [00:33:00] pretend that you're not feeling some of these things. Um, I'm a huge fan of dialectics in terms of using and Kimberley: Yes. Michael:  which is noticing like I'm feeling dizzy right now. And also I could try to be as best of my ability really involved in whatever is going on around me. Um, and so think it is, like there's a lot of different compulsions and things that we could talk about, but the biggest one I would want to bring up, at least for people to be aware of. it's becoming more inwardly focused, gets us stuck Kimberley: Yeah. Michael:  And, and it's, and understandably it's scary. to direct ourselves away from those, right? Because then it starts to feel terrifying of like, oh my goodness, if there's something that's really going wrong with me and I'm not paying attention to it? And that's where we start to get to the feared consequence, Kimberley: Yeah. Tell Michael:  some of the work starts to become, which is if I can recognize I have a pretty good answer about [00:34:00] this, maybe my brain isn't being all that reliable. I think this is just a psychological symptom. Um, maybe I'm willing to take the risk that maybe it could be something bigger, better. Um, but in service of being able to get back to my life do the things that I would like to be able to do, maybe that's a risk I'd be willing to take. Kimberley: me about number five. Michael:  That leads into number five. realize whenever I wrote these out, these were going to blend so well, but Kimberley: It's like we're flowing. We're in, we're jiving today. Michael: I know, right? The number five just goes back to this piece of The hardest thing about health anxiety is that one of the things it's not always about death because that sometimes that's what people always think is like, Oh, you're just afraid to die. Um, Kimberley: Mmm. Michael: people's faces whenever I always had the pre face, know, we always like to ask that question of like, what would be the worst thing about that? And health anxiety is always the really like, [00:35:00] uh, interesting one where it's like, well, I'd probably die and be like, what would be the worst thing about that? And people look at me and they're like, Kimberley: I'd be dead. Michael:  that'd be dead. And I'd be like, yeah, I know, but what would be the worst? And so for some people it is, Kimberley: Yeah. Michael:  death. But there's a variety of different, um, feared consequences that I think it's important for people to wrestle with too, which is some people it's around Kimberley: Mmm. Michael:  Some people it's about just the struggle. It's about treatment. It's about just how miserable it'd Kimberley: Mm. squadcaster-48hd_1_06-04-2024_121032: You know, uh, it would be about, you know, the whole process around, you know, getting treated and. You know, saying goodbye to people. For some people, it's not just about death, but it's also about, um, like, the impact that they would see a huge increase in health anxiety when people usually have, like, big life events. Uh, not just in terms of stress, but like, they get married, and now it's kind of like, it's up the ante of their health anxiety. It's like, well, now it would be kind of bad if you Kimberley: Yeah. Michael:  But it would be even [00:36:00] worse because now you'd leave like your spouse behind or even worse like Kimberley:  Yeah. Michael:  kids search into the picture, right? And it's like, Oh my goodness. And so I think it's really important to kind of start to look at is a lot of things that we could really fear to lose. The dirty trick that health anxiety plays it kind of makes us lose those things before we've even lost Kimberley: Yeah. Michael:  And what I mean by that is that sometimes we become so preoccupied with our health. Going to the ER, you know, running to the doctor again or, uh, just ruminating her mind or, you know, the family's around or you're having dinner and you're on your phone, right? Like looking up symptoms, right? things that we're afraid to lose might already be Kimberley: Yeah. Michael:  they're there in front of you to be able to engage in. the really hard thing is, is we're afraid that those would go away, but they've already gone Kimberley: Yeah. Umm. Michael: other process. So. think the one thing we have to kind of really wrestle with is [00:37:00] it's not just about trying to get rid of anxiety. I mean, that's part of the picture. Um, I'm sure for anybody that's ever in the helping profession, they'll always have somebody come in and saying, I really want, you know, this to go away, to be less pain, to feel less anxious, to feel less sad, whatever that might be. And those are cool goals. Like I'm on board with those, right? Like, I don't want people to feel more anxious. Um, I want people to feel less anxious. But if that's the extent of our goals for ourselves is just to, like, worry about my health less, I mean, that's kind of good, but we're missing a big part of the picture here, which is really, what can we add? You know, because health anxiety wants to steal all these things away from you in your life, The things that we're so scared to lose in the first place. And so a big part of number five, I think, is important for people to really recognize, is that Health anxiety is going to want to take those things away from you. And I wouldn't want people to work just like feel less anxious about their Kimberley: Yeah. Michael:  I would want them [00:38:00] to work in what are the things that you're really afraid to lose. I want you doing more of Kimberley: Yeah. Michael:  Right. And that is going to get to the point of having to work to give up some of the things that often would make us feel like we need to do to be able to keep ourselves safe. And that's hard. That is, that's the Kimberley: Yeah. Michael:  Is being able to lean into those things. But, the work also becomes, also gets with the reward, which is, we're actually being able to live life and be able to do those really meaningful and valuable things that we really are afraid to lose in the first Kimberley: Yeah. And when you start living your life, you tend to be focused less inward on all the symptoms as well. So it's sort of like a reverse snowball effect. Michael:  That one of the, absolutely. Good, I'm glad you bring up that point, right? Because that's what happens, Kimberley: Yeah. Michael: we get involved in something else, we start having fun, and then it's that tendency for our mind to want to go back to be like, well, how does this[00:39:00] Kimberley: Yes. Michael:  How does this feel? And so my encouragement for anybody is that about trying to get away from those. I try to draw a quick, line between distraction and redirection, which is a distraction is like an escape, right? Be like, I can't think about this. I got to get away from it. You know, like, let me focus on this movie, Kimberley: Mm hmm. Michael:  Where a redirection is really just trying to make a place for that of just noting of like, yeah, I am feeling this way. I noticed my brain is like yelling at me to be like, look this up on Google right Kimberley:  Yes. Michael: I could notice that. And also, I know it's going to be more helpful for me to make a place for that. Get back to the movie. Really try to get into that. Pay attention to it. that gives us a chance to do, just like what you said, is now we're focusing outside Kimberley:  Yeah. Michael: Instead of all the things that could be going on in our body, which some of them could possibly be serious, but most of them are probably just our bodies being Kimberley: and I think that's cool too is like our bodies will be bodies there, especially as we [00:40:00] age. I see a lot of people's health anxiety go up as aging. You said aches and pains, sleep issues, like it's so common. Yes. Yes. Okay. Yeah. Michael: and it's like sleeping on like something like really uncomfortable floor and And then like, I'm like, oh, I slept really good. And then like me, as I got older and there was like a sock in your bed that you slept on and you're like, oh my goodness. Like, and, and age is gonna Kimberley: Yeah. squadcaster-48hd_1_06-04-2024_121032: had to remember as, as age goes up, health kimberley-_1_06-04-2024_101032: Yes. Yeah. Yeah. Michael: you know, the question real quick, I'd just like to add with this is a lot of times I do get the question of like, well, what if you've had cancer in the past? Right? Like, is that still health anxiety? And it's like, well, you know, if you're in remission you're doing all the things that you need to do, you know, you're probably getting more frequent scans, all those different types of things. We can still become preoccupied with the [00:41:00] possibility of like, what if this new thing, whatever we're feeling is cancer again, right? And that's, I think we have to walk that, that piece of like, that's an incredibly understandable place. And also we go back to number three. which is, is like, are we getting information from our brain that's reliable? And if all the other information that we have in the current period of time, working with an oncologist, whatever it might be, is saying, Hey, your markers look good. Blood work looks good. Your scans look great. Then that's maybe what we challenge ourselves to say, maybe I need to get back the things that are most important. Kimberley:  I love this so much. Thank you so much for sharing these points and bringing so many applicable skills and tools as well. Tell us where people can hear about you. Tell us about your book. All the things. Michael: Yeah, absolutely. So, um, A couple different things with that. One is we did release a book in the mid December. Um, [00:42:00] it's right here. The Complete Guide to Overcoming Health Anxiety. Uh, How to Live Life to the Fullest Because You're Not Dead Yet. Kimberley:  Punchy little yes. Michael: Still here. So, um, there is a book out on Amazon. You can get it, uh, soft cover or you can get a Kindle version. It's written, wanted to write it. Uh, so the, my coauthor. Uh, Josh Kimberley:  Yes. Michael: and I wrote it, um, and we really wanted to write a book that didn't feel too clinical, didn't feel too like, um, you know, that, you know, like you're reading like a, an academic book or something like that. So I think if you appreciate maybe a little bit of a lighter approach, at sometimes funny, some points, uh, cringy, maybe not cringy, I'll just blame it on Josh. Maybe that was all his cringy points. I, I did all the good jokes. Uh, just kidding, Josh. I love you. Um, uh, it is, it's just written in a little bit of a different way that I hope that, you know, some of the feedback [00:43:00] is for people have said that like it's written differently, but it's just written and they feel like they can connect Kimberley: Yeah. Kimberley:  make sense. Um, but that's also very back to, you know, number three that we talked about in terms of cognitive interventions is that you know, it's really important to start to change our relationship with those. So the book is out there, but also we, we also started a website, um, overcoming health anxiety. com. Um, and it has a ton of different resources. We just redid it and try to add a bunch of different other stuff. So we have a health anxiety one on one section. We have treatment resources. have videos, you know, different podcasts. Um, we have a link to our free virtual support group that meets every Thursday of the month. Michael: So, um, uh, so, uh, we have a link to there. Because we really just want to be able to try to reach out. And like I said when we first started [00:44:00] is, a lot of people know that this is a thing, right? Because they, they know and there's even the term cyberchondria out there, right? Like people know about health anxiety. But very people do know that you can actually like get Michael: this not necessarily just through a doctor in terms of like, Oh, here's your medical treatment, but there's psychological tools that you can use that with that. So, yeah, those are our resources. We got that website. We got the book. Um, and, um, we're just trying to connect with health anxiety sufferers to show them that there's some hope to feel better. Kimberley: So good. Thank you. So many wonderful resources and amazing book. Thank you so much for coming on. Um, those folks are the five things you need to know about health anxiety. Thank you so much, Mike, for being here with us today. Michael: Thanks for having me. I appreciate it.

Today, we’re going to go through the six reasons you procrastinate so that you can make a plan and hopefully end that procrastination so you can get back to doing the things you want to do.  Recognizing the reasons why you procrastinate is so important. I want to make sure I cover one key point before we get into the six reasons, and that is: you’re not lazy, and you’re not faulty. It’s not a bad personality trait that you procrastinate. I want to dispel that myth right out of the gate so that we can beat the self-criticism, the self-judgment, and the self-punishment that you may be doing or have done in the past. The fact that you procrastinate does not mean that there’s anything wrong with you. You’re not broken.  We engage in these patterns and safety behaviors to manage distress in our bodies. Procrastination is an avoidant behavior to avoid having to be uncomfortable and to work through the deep stuff that’s going on in our brain, mind, and body. First, I wanted to review that this is not your fault. You’re not bad because you do this. I’m even going to reframe a couple of those things here. A PERSPECTIVE SHIFT ON PROCRASTINATION As we talk about why you procrastinate, I want to tell you a story that changed my thoughts about procrastination. As an intern, I had a supervisor when I first became a therapist who supervised us and all our cases. A lot of the interns were talking about how we were so behind on all of our research and our study. We had all these tests, we had all these assignments, and we had to see clients. She questioned us by saying, “Procrastination isn’t necessarily a problem. First, you’ve got to look at the function of procrastination.” She said that if procrastination is working for you and it means you get the work done, you complete it in time, and you’re happy with the product you’ve created, procrastination isn’t a problem. In our society, we tell ourselves that we should be organized and calm when handing in the assignment instead of pressing the button right at the very last minute or sliding into work right as we should start.  Now, she said, if it’s working for you, go ahead and keep doing it. But so many of you, particularly those with anxiety, say, “No, Kimberley, that’s not the case. It is not working for me.” If that’s the case for you, let’s first look at the effects of procrastination. Suppose you are somebody who has an extreme amount of anxiety when you procrastinate, and it’s coming from a place of anxiety. In that case, it increases your panic and stress at the last minute, and you melt down. Then, this is why we want to explore the causes and why you procrastinate so that we can come up with a solution and a strategy that does help you.  The Six Reasons We Procrastinate Fear of Failure This is true for many people because we fear making mistakes. Our society has become allergic to making mistakes and failures. So we create such a story in our heads about how it’s going to be so bad if we fail, and it’s going to be so bad if it doesn’t go right, and how we are going to look stupid and how we are going to feel terrible. But much of that comes from this entrenched belief that we are not supposed to fail. I took a whole year and practiced failing for an entire year. I tried to fail a hundred times, which completely changed my thinking about failure in everything I do. I got good at things because I failed repeatedly and changed how I looked at failure.  Now, I understand that we are expected to perform at such a high level in today's society. But what I want to have you do is act from the place of a B-. What I mean by that is, instead of going for an A+ all the time, try a B-. You will find that if you just drop the bar and let it be imperfect, you’ll have so much less anxiety. It is much easier to practice being gentle and kind to yourself when you mess up or fail. I’ve had so many patients and students tell me, “Failing is not the problem; it’s the beat-up I give myself when I fail that I do not want to do and do not want to experience. That’s why I avoid it. I don’t want to beat myself up if I fail.” We want to make sure we change the way we look at failure. Not Wanting to Be Uncomfortable This could cover all of these categories because all of the reasons we procrastinate are ultimately just trying to avoid discomfort. So often, I procrastinate while recording this episode of Your Anxiety Toolkit, or I avoid and procrastinate while working out. It’s not because I don’t want to do those things. I love making these videos and exercising, but what I do is avoid the uncomfortable feeling that I have. Ultimately, I’m avoiding the hard work stage of any product or anything we do.  So many positive things in our lives that fulfill us require hard work. Nobody likes hard work. It’s not that fun. It’s uncomfortable. As a human species, or any species, we love to avoid discomfort. We do what we can to cut corners, and procrastination is one of those things. Often, we’re scrolling on Instagram or checking our email to avoid having to propel ourselves into doing the hard thing.  The tip is to break things down into small, manageable, tiny, doable steps and open up our willingness to allow for some discomfort. Willingness is a mindfulness skill that will help you so much in your anxiety recovery. I talk about it a lot here on Your Anxiety Toolkit because it is crucial for the management of anxiety. The more we’re willing to lean in, be open, and release the tension we hold from feeling discomfort, the more we get to embrace that discomfort, overcome that discomfort, and, in many cases, recover from anxiety. Willingness will be necessary regarding the discomfort we feel from doing the hard, scary thing. Perfectionism Perfectionism is so similar to the fear of failure. Perfectionism is all through our society. We are told that we have to be perfect, that we have to do it perfectly, and that we can’t make those mistakes. I want to offer you here that if you struggle with perfectionism, we want to adopt the B- mentality. We want to adopt kindness. We also want to pause and acknowledge how our society has created this because the truth is human beings are inherently imperfect. It is impossible to be perfect, yet we’re striving for it. We’re so committed to it as if it’s a reality, and it’s not. We won’t be perfect. Even if you achieve a perfect score on a test, you’ll still have to look in the eye for imperfections three minutes later. We will have to see the other things we’re not perfect at. It’s essential to see that. If your goal is perfection, you’re chaining yourself to having consistent anxiety.  When I was suffering from an eating disorder, I was constantly going for perfection with my body, with my diet, and with my exercise. That kept me stuck, and even when I did get to this “perfect goal,” I had anxiety about maintaining the perfect goal. Even once I achieved it, anxiety was still there. Anxiety was still running the show, and I was in panic mode all the time, either trying to be perfect or fearing that I’d lose this idea of perfection, which I never had anyway. But again, it’s all something like a construct in our brain that keeps us stuck and anxious. It’s essential to understand how that impacts us and the fact that we will never be perfect.  Thank God, I love imperfect people. I find it hard to befriend these “close to perfect” people. I don’t relate to them, and I don’t feel safe with them. I actually sometimes feel uncomfortable around them. You probably think the same way, but I feel so much better when I’m with real people who are comfortable or willing to admit their imperfections, share their imperfections, and connect with our humanness together when we settle into that imperfection.  Feelings of Overwhelm If you have anxiety, yes, overwhelm is a thing. I think of being overwhelmed like there are papers, things, and phones swirling around in my head. All I want in that moment is just a moment of inner peace and outer peace, where I want everything to slow down and stop so I can catch up in my mind. However, that’s probably not going to happen.  There often needs to be a physical way to get everything clear when we have a deadline or something we must do. The only thing I have found helpful with this is to simply write down the steps I need to take and how I will do them. That is the only thing. But at the end of the day, similar to the discomforts, a lot of the work we have to do with overwhelm is to be willing to feel it, slow down, and identify catastrophization. When we catastrophize, we increase our feelings of overwhelm, and that’s a cognitive error we engage in. If you catastrophize a lot, you’ll probably feel overwhelmed frequently. That’s just the way that it goes, unfortunately. We want to create a system where you have something to do that you can break down into small steps. I’m visual, so I like to draw, write circles around it, and put numbers one and two. If you’ve been following me here on Your Anxiety Toolkit, I want a step-by-step process. I like the five reasons for this so that I can comprehend it in my mind. If you need that, lean into it and use it to help you create small baby steps.  Another thing to do here is to breathe. When we’re overwhelmed, we often stop breathing. When overwhelmed, we often clench and hold all this tension in our brain and body. Our main goal here is to slow it down. You’re still going to be uncomfortable. You’re still going to be anxious. You will still be overwhelmed. But can you reduce the problematic response to that? Remember, we can’t control our experience and how it shows up, but we can control how we respond to it. We can control how we react to it. We don’t want to clench as much as we can. Again, we’re going to move slowly into the activity over time. Set some time limits. Maybe you do it for 10 minutes. There are so many Pomodoro apps that you can set a timer for three minutes and say, “I’m just going to do this for three minutes, then I’m going to take a break.” Do some breathing. But you’re moving in small, baby steps. Lack of Motivation If you’re someone who suffers from depression or you’re just not very motivated today, that’s another reason it’s difficult to launch yourself into something. An essential tool to remember when it comes to motivation is that we often rely on motivation to get us started, and that’s fine. That’s actually helpful if we have it. However, we want to flip the script on motivation. If you lack motivation, the only thing that’s going to generate motivation is to get moving. I know what you’re thinking. You’re probably thinking, ‘Yeah, but if I had motivation, I could get going. So I just need motivation to get going.” But I’m here to say no. Sometimes, you just need to go back to creating small baby steps. Once you start, you start having positive feelings about yourself. You begin to have positive feelings about what you’ve generated. And that is what creates motivation. Again, tiny baby steps. That is a very encouraging mindset.  Try to be your inner bestie. Encourage yourself. “You’ve got this. You can do it.” “I believe in you. Just a little more.” “Just get started. I know you can.” You’ll feel so much better when you do. Just keep talking to yourself, coaching yourself, and embracing yourself with that motivational best friend voice that encourages you. That can be very beneficial, as you’re doing this daunting thing that you really don’t want to do.  Poor Time Management This is one of the most important, especially if you have something that has a deadline. If you don’t have time management skills and aren’t good at really understanding how long the activity will take, you’re probably going to procrastinate and miss the deadline. We talk all about this in our online course called Time Management for Optimum Mental Health. We actually sit down and, step by step, plan your day. Not compulsively, but what we do is actually plan pleasure first. That’s the first thing we put on the schedule.  One of the main reasons people procrastinate is that they want pleasure. We want to feel good. We want to have great, fun things in our lives. So we spend a lot of time going back and forth, “I have to do this assignment, but I want to relax. But I have to do this assignment.” Because we haven’t planned our time and scheduled pleasure, we end up negotiating and spending a lot of our time going back and forth.  You plan and schedule your pleasure first so that you know you’ve given yourself what you need. And then you’re so much more likely to do the hard thing because you’ve already promised yourself and followed through that you would do the pleasurable thing so that you can get that more challenging thing done. In addition, you might want to be someone who schedules pleasure, hard, pleasure, hard, pleasure, hard, and gives yourself lots of breaks where you have lots of pleasure and things that bring you fulfillment and joy as you do this hard thing. I often do this with household chores. As I’m doing the hard thing, I’m listening to a podcast that I like. I’ve planned that. For example, I know that there’s a podcast that comes out on Friday, Your Anxiety Toolkit. On Saturday morning, when I know I have to do the laundry and fold the laundry, which I hate doing and often procrastinate with, I go, “Okay, Saturday morning when I want to listen to that podcast, I’m going to marry the positive and that difficult together.” Time management is so important. If you’re interested in taking the Time Management course, it is a deal. It is reasonably priced for something that will help you run your week and your day much more easily. You can go to CBT School or click the link in the show notes to get access to that course.  Those are the six reasons we procrastinate. I hope that this has helped you identify where you’re getting into trouble so that you can make changes and get your life going so that you don’t have to panic and be stuck in that absolute last-minute frantic panic. You can just schedule your time, break it into small steps, be as gentle and kind and motivating and encouraging as you can, and get the things you want done so that you can go and live your life.  Don’t forget, as I always say, today is a beautiful day to do hard things. I want you to remember that none of this is easy breezy. I never want to make it sound like it’s easy breezy. It’s hard work, but we must remind ourselves that hard work is a part of being human. It is a beautiful day to do hard things. I don’t want you to buy into society’s idea that life should be easy. “This should be easy for you. What’s wrong with you?” Nothing’s wrong with you. It’s hard. No one wants to do hard things, but you can do those hard things.  I hope you have a wonderful day. I’ll see you in the next episode.

I have a new best friend just for you.  I know that might sound a little strange, so hang with me here because this was mind-blowing to me, and I hope it is for you as well.  Let's talk about best friends. What does a good best friend look like?  It will be different for everybody, but generally, the way I see a best friend is that they're fun to be with. They're interested in fun things or things that you're interested in. They are there for you. They show up for you. They celebrate your birthday. They want to know how you're doing. They have a genuine interest in you. They're willing to pour into you. But in addition to that, they are also there for you when things get crappy.  It's so important because sometimes we feel vulnerable when sharing with people. But when we do share and are vulnerable, we can be held, and some space is created. There's this beautiful relationship where you share how you're doing, and they hold space for that. They encourage you. They ask how they can support you. Maybe they can give you some helpful advice. They're there for you when things are really hard. When you start to be hard on yourself, they pull you up.    THE BENEFITS OF BEST FRIENDS Best friends can also be brutally honest but in the most beautiful way.  I have two best friends. One is my husband, and one is a friend who lives quite a distance away. It's all via technology—voice chat, FaceTime, phone calls, and so forth. My best friends, not only do they support me, not only are they kind and lovely, but they also do call me out on my crap. They often say, "I don't think you've thought about this one well enough," or "Kimberley, I think you're going a little too urgent here. I think that your anxiety might be getting in the way." Or "Kimberley, have you taken care of yourself today? I'm noticing you mentioned you haven't been getting a lot of sleep. Could that be why this is hard for you?" Best friends aren't just all flowers and roses. They are honest and real. They're there for you when things aren't going well, but they champion you too. They believe in you like nobody else. When you're at your lowest, best friends will be like, "You could do totally that." Or if you're beating yourself up for not being good enough, they're like, "Oh my god, are you kidding me? Look at all the things that you've done." They're so ready to celebrate you, and they see you for way more than you can see yourself.  That is what I want for you so I will introduce you to your new best friend, and it's you. Your new best friend is you. I want you to think about this because you haven't developed a relationship with YOU enough to be your own best friend. It's something you're going to have to invest in. Your new best friend is YOU, whom I'd like you to meet. Hello friend. This new bestie that you're creating is going to be the person who is there for you no matter what.  AN INNER BESTIE VS. THE KIND COACH Let me tell you why I've been thinking about it this way. I wrote a book called The Self-Compassion Workbook for OCD, and I talked about the Kind Coach concept. The kind coach is this warm voice inside you that coaches you through hard things. If you were to think about the mean coach you probably had in high school, he's like, "Get down and give me 20," or "Get going, you loser. Run faster." He or she motivates you through criticism and harsh comments and uses a very aggressive voice.  We don't want that because we know,, based on the research,, that it decreases motivation, increases procrastination, increases punishment, and wreaks havoc on the nervous system and the immune system. We don't want that. Instead, we use this Kind Coach. The Kind Coach encourages us. They know our strengths, and they encourage us based on our strengths. They know our weaknesses, and they don't use our weaknesses to get you moving forward. The kind coach is constantly there, encouraging you to keep going. I love this concept. But as I recently went through a difficult time, I was using this tool,, and I kept thinking, 'Something isn't landing here. This feels a little too professional.' I didn't want it at that time. While the kind coach has helped me through so many things, I didn't want a coach around when things fell apart for me. What I needed was a bestie, a best friend. I needed somebody who was more like a pal, someone who could be in my pocket. Someone who I felt a little sassier with, someone who I could use my humor with because I needed humor to get through this hard thing.  THE INNER BESTIE: THE UNCONDITIONAL FRIEND I was thinking, 'What is it that I need?' This is the golden self-compassion question that you should be asking yourself all the time. What do I need? When I checked in, I was like, "I do. I really need my best friends around." But sometimes my best friends weren't around. My husband would be at work, and my best friend lives far away in a different time zone. They weren't even awake at the time that I needed them. Who do I go to when my best friends aren't there? Some people would say, "It's fine; just go to the next best person." But I needed to be there for myself.  I giggle as I say this to you because practicing leaning on my inner bestie or my inner mate has been so powerful because there's a playfulness to this where you get to goof off with them a little. You get to make fun of it. I really do. I make fun of myself quite regularly, but not in a critical way—in a way where I'm like, "It's really cute and goofy that I do that." Often,, when I think of things that I'm not super proud of, I go, "I love that I am a little goofy." My family always makes fun of me because I love taking bites out of things, like everything. There's often something like a banana that's got a little piece cut off, or if we get a box of chocolates, I take a bite out of every single one and put it back in there because I just want to taste all of them. I'm okay to giggle at that. I want to be able to giggle with my best friends about how that's my little quirky thing.  A best friend is someone who is always there for you. They're okay to giggle. They're okay to warm, be warm, and connect. They're okay to be firm and redirect you when you're totally off track. Over the last few months, I've befriended this friend so much. I call this friend 'babe,' and babe and I have conversations together. As I'm getting ready, I'll be like, "Okay, babe, it's cool. We're doing this together. It's going to be a hard day. You've got this, this, and this to go through. What do you need, babe?" We have a conversation, and it's me. It's not anybody else. It's not the voice of a coach; it's me—my inner bestie, the one who's always going to be there for myself.  THE VOICE OF THE INNER BESTIE As I've gone through these challenging times, I think this voice feels so grounding. I trust her more than I've ever trusted the kind coach. I'm not saying there's no place for the kind coach, but this is the next level for me.  Here's what I want you to do: I want you to find a piece of paper, and I want you to either draw and/or write what this inner bestie is for you and what they look like. They're you, but how they sound, how they look. What do they say to you? How do they say it? What's their body language? How do you talk to it? For me, it's a different way of relating to myself. Now I'm talking to myself like, "Hey, babe, I got you." It's a little more conversational, a little bit more interactive. But that's what best friends are.  Let's also think about how we treat our best friends. One thing I have learned mostly through therapy is how to be a good wife. When I say good wife, I mean, just for me, how to stand next to my husband and encourage him. Even if I'm slightly annoyed, how can I pour into him? How can I show him how much I appreciate him? Even if that doesn't come naturally in the season that I'm in, how can I encourage him? How can I check in with him? I have to think about that consciously.  What I want you to do is think about how you can relate to your new best friend—you, your inner bestie—and also how you can pour into your best friend this inner bestie. Can you check in with it more often? Can you send it love more often? Can you ask how we can be in a relationship? What does it need? I want you to practice having a daily check-in. You can't just have a best friend and take the benefits but ignore them and their needs as well. This is what I want you to journal down.  I am also fine if you want to give it a name. I call mine 'babe,' as I said before. "Hey babe, how are you doing? What do you need?" It calls me babe, and we talk to each other that way. In fact, that's how I talk to most of my friends. I call them babe. Then, I want you to check in with them as much as you can. I want you to start having conversations.  When I was struggling, I started recording myself talking to Babe on my phone and saving it. As I'm getting ready, I'm saying, "Hey babe, you've got a hard day." This is babe talking to me; I'm talking to it. "You've got a hard day. I'm so sorry you're going through this. That sucks. This is just so much. I'm proud of how you got up today. Even though you didn't sleep very well, I'm proud that you didn't lose it on that one person who ran into you at the supermarket because you're so overwhelmed and you have so much going on. That was pretty impressive." Or, "Hey babe, it is so cool how you regulated your emotions at that moment. That was impressive." "Hey babe, I know you didn't do so well at that moment, but I love how you're coming to me and aligning again. you've come back to me. that's cool." Some days I might go, "Hey babe, anxiety's here today.  Alright, we know what to do. We should have expected it, but it's all good. we're going to go with anxiety. it's going to come along with it. what do you need?" This conversation that we're having back and forth doesn't make you crazy. It doesn't mean anything's wrong. What it means is that you are starting to talk to yourself in a way that you deserve, that you need to be respected, and that you deserve to have that person. This is what we want to do.  The cool thing is, if you follow me on Instagram or YouTube, I'm starting to do way more videos where I talk to myself through the lens of my inner bestie. I'm having those conversations. I'm brushing my hair as I talk to myself. I am brushing my teeth. I'm doing the dishes. I'm writing checks if I have to be writing checks. I'm practicing it in all the little places, and I'm trying to show you how to do it so you can go follow me there and see for yourself. But I want you to think about this. The new best friend is here, and you get out what you pour into it. Give it a try. I really, really believe in this.  If this is a bit awkward for you, that's okay. There's no problem with the awkwardness. Let it be awkward. If it feels a little wrong or weird, that's okay too. Let it be weird and awkward and strange and uncomfortable. There's nothing wrong with getting used to these feelings. You might even say, "Hey, babe, it's weird to talk to you. This feels odd. I'm not so sure about this." Then you might even listen and be like, "Yeah, it's okay that it's uncomfortable."  You might even have your babe in my accent, and that's fine as well. What we are really trying to do is get an inner dialogue that is kind, that's got a little sass to it, and that's got a little punk to it, whatever you like. That is exactly what you need, because what I need in a best friend might be different from what you need. Sometimes your best friend needs to be total sassy, like doesn't take crap from anybody and stands up for you no matter what. If that's what you need your babe to be, go ahead. Let your babe be that.  Take what you need. Leave the rest. Play around with this. But I would say give it a full 30 days. Practice having an inner bestie, connecting with and pouring into that inner bestie for 30 days, and you'll be shocked at how your inner narrative changes.  Have fun with your best friends. I cannot wait to hear how this aligns with you and how it's helping with any struggles that you're having. Please let me know on social media if you have any questions. You can catch me on Your Anxiety Toolkit on Instagram or YouTube. Have a great day, everybody, and it's a beautiful day to do hard things.

Imagine being able to walk into a crowded room without feeling your heart pound out of your chest. Envision yourself confidently striking up conversations with strangers or going about your day without being overwhelmed with the fear of being judged by others.  If social anxiety has been holding you back from enjoying life, it's time to take on an exposure challenge and learn how to feel more confident in your skin when you are in public. In this episode of Your Anxiety Toolkit, we will explore one of the most well-known, science-based, and effective strategies for overcoming social anxiety. From gradual exposure to uncomfortable social situations to building a support network, you'll discover practical steps to overcome the grip of social anxiety. Recently, I overheard a therapist (of all people) say that letting our clients experience distress is harmful.  When I heard this, I gasped.  This idea and this narrative concerned me so much.  We have become so fixated on never feeling distressed that we fuel our anxiety and emotions.   Now, I get it. I am not in the business of being a therapist to make people feel terrible. Quite the opposite. However, one of the most powerful messages I give my clients is that we can learn to compassionately and effectively navigate distress because distress is a natural part of being a human.   If we have anxiety and we are committed to not feeling it, it will control every aspect of our lives. If you have social anxiety and you are committed to never being uncomfortable, social anxiety will take everything you love from you, including your future.  Today, we are focusing on pushing yourself outside of your comfort zone and facing your fears.  What you will learn is that you'll gradually build your confidence and become more at ease in social settings.  With each small success, you'll grow more robust and more resilient, expanding your social circle and embracing new opportunities. My hope is that you don't let social anxiety hold you back any longer.  Today, I am going to give you a 30-day Social Anxiety Challenge.  I have seen this work for my clients repeatedly, and I am confident it will change your life, too.  Before we get started, let's first make sure you have a good understanding of social anxiety.  UNDERSTANDING SOCIAL ANXIETY Social anxiety, also known as social phobia, is a common mental health condition characterized by an intense fear and anxiety in social situations. It goes beyond mere shyness and can significantly impact an individual's daily life. People with social anxiety often experience excessive worry about being judged, embarrassed, or humiliated in social settings. This fear can be so overwhelming that it leads to avoidance of social situations altogether. One thing I always share with my students and clients is that while Social anxiety is considered an anxiety disorder, I agree with Christopher Germer, a well-known psychologist who has been on the show (episode 199), that social anxiety is as much a shame disorder as it is an anxiety disorder.   From my experience, people with Social anxiety struggle immensely with shame, and this powerfully painful emotion can disrupt so much of someone's life. It can increase the incidence of depression and even suicidal ideation.  Having social anxiety can leave you feeling like a fool, awkward, and alone.  Commonly, people with social anxiety withdraw and isolate, only making themselves feel more alone, defective, and often more depressed.  Social anxiety can have a profound impact on various aspects of a person's life. It can hinder their ability to form and maintain relationships, limit their career prospects, and diminish their overall quality of life. Simple tasks such as making a phone call, attending social gatherings, or speaking in public can elicit intense anxiety, leading to avoidance behaviors and missed opportunities. The constant fear of being evaluated negatively by others can create a cycle of self-doubt and isolation. But today, we will put our entire attention to turning this around for you.  Today, I am going to give you a 30-day Social Anxiety Exposure challenge where you face your fears and take your life back from social anxiety.   The 30-day Social Anxiety Exposure Challenge: What is it and how does it work The exposure challenge is a science-based therapeutic technique widely used in the treatment of social anxiety. It involves deliberately facing feared social situations in a gradual and controlled manner. The goal is to help you habituate to your anxiety-provoking situations and develop a sense of mastery and confidence.  Exposure can be done in real-life situations or through imaginal exposure, where you vividly imagine yourself in anxiety-inducing scenarios. Today, we are going to focus on real-life situations because I wholeheartedly believe that is where the money is. I have seen it work with hundreds of my clients.  Exposure works by activating the fear response and allowing you to experience the anxiety you feel. Over time, repeated exposure to the feared situations helps retrain your brain, reducing the anxiety response and building resilience and confidence. It is important to note that exposure should always be done at a pace that feels manageable for you, and seeking professional guidance can be beneficial in designing an exposure plan tailored to your specific needs. What are the Benefits of doing a 30-day social anxiety exposure challenge? Facing your social anxiety through exposure can have numerous benefits. Firstly, it allows you to confront and challenge your irrational beliefs about social situations. By repeatedly exposing yourself to feared situations, you'll begin to gather evidence that contradicts your negative thoughts (such as “everyone hates me,” “They will think I am an idiot,” or “I will make a fool out of myself”), gradually reshaping your perception of social interactions. This process can lead to increased self-confidence and a more positive self-image. Exposure also provides an opportunity for skill-building and learning. As you face your fears and navigate social situations, you'll develop new coping strategies and important social skills. These skills will help you manage anxiety and enhance your ability to connect with others and build meaningful relationships in ways that feel authentic to you. The more you expose yourself to different social scenarios, the more adaptable and resilient you become in handling various social challenges. THE 30-DAY SOCIAL ANXIETY EXPOSURE CHALLENGE RULES Okay, before we get started, please know that you can either do these in the exact order or you can put them in the order of easiest to hardest.   My only tip is to make sure you do at least one of these exposures per day. You get extra points if you do them many many times, as this is how you will really learn the most.  Tracking your progress and celebrating small victories is essential for maintaining motivation and building confidence. Keep a record of your exposure activities, noting the level of anxiety experienced and any positive outcomes or insights gained. Reflecting on your progress can help you see how far you've come and provide a sense of accomplishment. Celebrate each small victory, no matter how insignificant it may seem. Recognize that every step forward is a step closer to overcoming social anxiety and living a fulfilling life. Other tips:  Plan ahead.  Some of these exposures will require some planning and arranging.  Do not let fear stop you or make too many excuses.  You will only get out what you put in. Do these exposures with kindness ONLY.  The biggest goal is to not criticize yourself at all. Do the best you can. Catch yourself when you are going down the self-loathing rabbit hole.  Challenge your negative thoughts about yourself and be your biggest cheerleader.  Once the exposure is over, you are not allowed to think about what happened. Try not to ruminate about it.   Celebrate your wins.  Set up a reward for completing the challenge.  Or several rewards throughout hte 30 days.  If you find one of them easy, try to double up and add something challenge to the challenge.    THE 30 DAY SOCIAL ANXIETY CHALLENGE PLAN Day 1: Take a walk in public and give eye contact to 5 people.  Day 2: Take a walk in public and give eye contact and a smile to 5 people.  Day 3: Take a walk in public, make eye contact, smile, and greet five people.  Day 4: Go to the mall or a store and make small talk with a cashier. Day 5: Ask a stranger for directions. Day 6: Order food at a restaurant without rehearsing. Day 7: Compliment 5 strangers. One Week Check-in: What thoughts are you having?  Day 8: Attend a social event without a close friend. Day 9: Speak up in a meeting at work or school. Day 10: Join a club or group related to a hobby. Day 11: Make a phone call instead of sending a text or email. Day 12: Practice introducing yourself to 2 new people. Day 13: Start a conversation with someone in a waiting room. Day 14: Sit in the front row during a presentation or class or at the movies. Day 15: HALF WAY: Join a public speaking group, like Toastmasters. Day 16: Share a personal opinion in a group setting. Day 17: Attend a social gathering and stay for a set amount of time. Day 18: Initiate a conversation with someone you find intimidating. Day 19: Go to a party and introduce yourself to at least three new people. Day 20: Take a class in improv or acting. Day 21: Sing karaoke in front of others or sing as you walk down the street. Day 22: Ask someone for help in a store. Day 23: Participate in a team sport or group exercise class. Day 24: Initiate a conversation with someone sitting alone. Day 25: Practice saying “no” in various social situations. Day 26: Give a compliment to a coworker or classmate. Day 27: Ask someone to coffee or a casual outing. Day 28: Go to a new place and ask a stranger about the best things to do there. Day 29: Introduce yourself to your neighbors. Day 30: Share a positive personal achievement with others. There you go!  There is your 30-day Social Anxiety  Life after the Exposure Challenge. As you continue to face your fears and engage in exposure activities, you'll gradually notice a shift in your confidence and ability to navigate social situations. Embrace this newfound confidence and allow it to propel you forward in life.  Your social world will expand with each successful exposure, and opportunities for personal and professional growth will arise.  Remember that overcoming social anxiety is a journey, and setbacks may occur along the way. Be kind to yourself, celebrate your progress, and continue to challenge yourself to reach new heights of confidence and self-assurance. Don't let social anxiety hold you back any longer. Step out of your comfort zone, face your fears, and embrace the incredible potential that lies within you. I always say, “Today is a beautiful day to do hard thing.” You deserve to live a life free from the shackles of social anxiety.  Get going with this challenge as soon as you can. I promise that you will not regret it.

Behind every smile, there can be hidden struggles and pain. You might even be one of those people struggling so much but puts on a smiling face even though you feel like you are sinking.   Smiling depression, a somewhat new term to describe people who are struggling with high-functioning depression, is a lonely battle that many individuals face. In today’s episode, we dive into the topic of smiling depression, exploring what it is and how it affects those who suffer from it. IS SMILING DEPRESSION A DIAGNOSIS? First of all, let me be clear. Smiling Depression is not a specific mental health diagnosis.  Instead, it is a presentation of depression. Unlike well-known symptoms of depression, those with smiling depression put on a facade of happiness. They may appear perfectly fine on the surface, leaving their inner turmoil hidden from the outside world. Unfortunately, this masks the severity of their emotional struggles, making it difficult for others to offer support or understanding. It is important to acknowledge the hidden struggles of smiling depression and offer compassion and support to those who are silently battling this condition. They are not lying or faking it to deceive you.  Instead, they feel completely trapped. They often see no way but to keep going and keep pretending. They just keep smiling, even though they see an end in sight. They put a smile on their face, and they push through.  Even just saying that makes me want to cry, as I have been in this situation too many times.  I completely understand the pressure (often self-induced pressure) just to keep going and “not complain,” “look at the bright side,” or “be grateful for what I have,” even though I was being crushed with hopelessness, helpfulness and worthlessness.  My hope is by addressing this topic, we can create an environment where you feel safe to express your true emotions and seek help.  You are not broken. You are not wrong for feeling this way.  And asking for help does not make you weak or bad.  You deserve to have support, love, compassion, and time to recover.  SIGNS AND SYMPTOMS OF SMILING DEPRESSION Smiling depression can be difficult to identify, as those who experience it often mask their true emotions behind a smile. However, there are certain signs and symptoms that can help us recognize this hidden condition.  One common characteristic of smiling depression is the apparent contradiction between a person's outward demeanor and their inner emotional state. While they may appear cheerful, happy, and successful, they may be struggling with feelings of hopelessness, helpfulness, worthlessness, emptiness, sadness, or even thoughts of self-harm or suicide. Another smiling depression symptom is the tendency to keep their struggles hidden from others. Individuals with smiling depression often feel the need to maintain a facade of happiness, fearing that opening up about their inner turmoil will burden or disappoint those around them. This can lead to a sense of isolation and loneliness, further exacerbating their emotional struggles. Furthermore, individuals with smiling depression often experience a lack of motivation and interest in activities they once enjoyed. They may withdraw socially, have difficulty concentrating, and experience changes in appetite and sleep patterns. These symptoms, when combined with the constant pressure to maintain a happy facade, can take a toll on their overall well-being. What I think is very interested is the overlap of Smiling depression and perfectly hidden depression.  We previously did an episode with Margaret Rutherford about perfectly hidden depression which is a form of depression where people become hyper fixated on being perfect to mask their experience of depression.  You can listen that episode on the show notes to learn more.  THE HIDDEN STRUGGLES OF SMILING DEPRESSION Smiling depression is not simply a case of "putting on a brave face." It is a complex mental health condition that can have severe consequences if left untreated. While individuals with smiling depression may appear perfectly fine on the surface, they often battle with intense emotional pain behind closed doors. One of the hidden struggles of smiling depression is the constant pressure to maintain a happy facade. Society often expects individuals to be cheerful and optimistic, making it difficult for those with smiling depression to express their true feelings. This can lead to shame, guilt, and a sense of being misunderstood. Additionally, the internal conflict between the outward appearance of happiness and the inner turmoil can be mentally and emotionally exhausting. Individuals with smiling depression often feel like they are living a double life, constantly hiding their pain while wearing a smile. This internal struggle can affect their self-esteem and overall mental well-being. Furthermore, the lack of understanding and awareness surrounding smiling depression can make it difficult for individuals to seek help. Since they appear to function well in their daily lives, others often dismiss or overlook their struggles. This can further isolate them and prevent them from receiving their desperately needed support. THE RELATIONSHIP BETWEEN SOCIAL MEDIA AND SMILING DEPRESSION Social media has become an integral part of our lives in today's digital age. While it has its benefits, it can also contribute to the development and exacerbation of mental health conditions such as smiling depression. Social media platforms often present a distorted reality where everyone appears to be living their best lives. This constant exposure to curated and idealized versions of other people's lives can create a sense of inadequacy and comparison for individuals with smiling depression. They may feel like they are not living up to the standards set by others, further fueling their feelings of emptiness and sadness. Furthermore, the pressure to maintain a positive online presence can be overwhelming for those with smiling depression. They may feel compelled to post happy and upbeat content, even when struggling internally. This can perpetuate the cycle of hiding their emotions and feeling isolated from their online communities. If this is true for you, remember that social media is almost always fake.  It is not the real life of the people you follow. I love seeing posts where people show pictures of themselves looking all glamorous and then show them crying just a few minutes later. Even though I hate that they are struggling, some people are showing what real life is like behind the scenes and I think we all need to remember that.  COPING STRATEGIES FOR INDIVIDUALS WITH SMILING DEPRESSION While overcoming smiling depression can be a challenging journey, there are coping strategies that can help individuals navigate their inner struggles and find some relief. The first coping strategy is to practice self-care. This involves prioritizing your physical, emotional, and mental well-being. Engaging in activities that bring joy and relaxation, such as exercise, hobbies, or spending time in nature, can help alleviate symptoms of smiling depression. Building a routine with healthy habits, such as getting enough sleep and maintaining a balanced diet, can also contribute to overall well-being. If you want to learn more about health routines for depression, we covered that in a recent podcast episode called Living with Depression: Daily Routines for Mental Wellness. The link to that episode will be in the show notes.  Seeking social support is another crucial coping strategy for individuals with smiling depression. Opening up to trusted friends, family members, or mental health professionals can provide a safe space to express emotions and receive support.  Joining support groups or engaging in therapy sessions can also help individuals develop healthy coping mechanisms and learn from others who have faced similar challenges. In addition, practicing mindfulness and self-reflection can be beneficial for individuals with smiling depression. This involves being present in the moment, accepting one's emotions without judgment, and exploring the underlying causes of their struggles. Techniques such as meditation, journaling, or engaging in creative outlets can aid in self-discovery and promote emotional healing. It is important to note that coping strategies may vary from person to person, and what works for one individual may not work for another. The key is to explore different techniques and find a personalized approach that best suits one's needs and preferences. TREATMENT FOR SMILING DEPRESSION While coping strategies can be helpful, it is important to acknowledge that smiling depression is still simply a term to describe a serious mental health condition that often requires professional intervention. Seeking help from a mental health professional, such as a therapist or psychiatrist, can provide individuals with the necessary support and guidance to navigate their journey toward recovery. A mental health professional can help individuals with smiling depression by providing evidence-based treatments, such as cognitive-behavioral therapy (CBT) or medication. To start, the main treatment goal might be to offer a safe and non-judgmental space for individuals to express their emotions and come to terms with the fact that smiling through their pain is not working anymore.  This can be painful and very scary.  It is crucial to remember that seeking professional help is not a sign of weakness, but rather a courageous step towards healing. With the guidance and support of a mental health professional, individuals with smiling depression can find the strength to overcome their inner struggles and live a fulfilling life. CBT treatment will involve addressing any errors in their thinking and also addressing the behaviors that are contributing to their depression.  The real goal of CBT is to compassionately help the person with smiling depression to find new and effective coping techniques, and kind, and move them towards long-term recovery and healing.  If you are looking for help with depression and do not have access to professional mental health care, or if you are interested in learning new ways to manage your depression, you may want to consider our online course called OVERCOMING DEPRESSION.  Overcoming depression is an on-demand online course that will walk you through the exact steps I take my clients through when they have depression.  I will first help you fully understand the science behind why you have depression, and then I will teach you all about how to create a plan of attack to overcome your depression.  Treatment for depression involves learning a lot about self-compassion and mindfulness. These skills will help you manage strong emotions and the depressive thoughts that you have.  I will teach you how to correct the errors in your thinking, create a schedule that will help you reduce overwhelm and hopelessness, and increase your motivation to get the things that you need to get done I will give you printouts and video training to show you just how to do it all.  If you are interested, go to www.cbtschool.com/depression.  Just remember, it is not therapy. This is a home study course to show you the steps others have taken to overcome their depression.  SUPPORT SYSTEMS FOR THOSE WITH SMILING DEPRESSION Building a strong support system is vital for individuals with smiling depression. Having a network of understanding and empathetic individuals can provide a sense of validation and belonging, helping to counteract the feelings of isolation that often accompany this condition. Support can come from various sources, including friends, family members, support groups, and online communities. It is important for individuals with smiling depression to reach out and connect with others who have similar experiences. This can provide a safe space for sharing emotions, exchanging coping strategies, and offering mutual support. Additionally, it is crucial for loved ones to educate themselves about smiling depression and understand the unique challenges faced by those who suffer from it. By learning about the condition, they can provide the necessary support and validation, helping individuals feel heard and understood. CONCLUSION AND ENCOURAGEMENT FOR THOSE WITH SMILING DEPRESSION Smiling depression is a hidden battle that many individuals face. Behind their smiles, they may be struggling with intense emotional pain and a sense of isolation.  If you or someone you know is experiencing smiling depression, remember that you are not alone. Reach out to trusted friends, family members, or mental health professionals. Seek help and support, and remember that there is hope for recovery.

In today's fast-paced and demanding world, it's easy to forget to show ourselves the same compassion and empathy we extend to others. But what if I told you that embracing self-compassion could lead to a happier, more fulfilling life? It's true, and in this article, we will explore the power of self-compassion and how it can positively impact your overall well-being. Self-compassion is about treating ourselves with the same kindness, care, and understanding that we would show to a loved one. It involves acknowledging our imperfections and mistakes without judgment, and embracing our humanity. When we practice self-compassion, we cultivate a positive relationship with ourselves. We learn to be more understanding and forgiving, and that inner critic inside us gradually softens. We become more resilient in the face of challenges, and our self-esteem and self-worth improve. So how can we embrace self-compassion in our daily lives? We will delve into practical strategies and techniques that can help us cultivate self-compassion and create a more loving and compassionate relationship with ourselves. Join us on this journey of self-discovery and learn how to harness the power of self-compassion for a happier and more fulfilling life. Understanding Self-Compassion Self-compassion is about treating ourselves with the same kindness, care, and understanding that we would show to a loved one. It involves acknowledging our imperfections and mistakes without judgment, and embracing our humanity. When we practice self-compassion, we cultivate a positive relationship with ourselves. We learn to be more understanding and forgiving, and that inner critic inside us gradually softens. We become more resilient in the face of challenges, and our self-esteem and self-worth improve. Self-compassion is not about self-pity or self-indulgence. It is about recognizing our common humanity and understanding that we all make mistakes and face challenges. It is about being kind and supportive to ourselves, especially during difficult times. By embracing self-compassion, we can free ourselves from the constant pressure to be perfect and allow ourselves to be authentic and vulnerable. The Benefits of Practicing Self-Compassion The benefits of practicing self-compassion are numerous and far-reaching. Research has shown that individuals who regularly practice self-compassion experience higher levels of well-being and life satisfaction. They are more likely to engage in healthy behaviors, have better mental health, and experience lower levels of stress and anxiety. One of the key benefits of self-compassion is its role in fostering resilience. When we are kind and understanding towards ourselves, we are better able to bounce back from setbacks and failures. Instead of beating ourselves up over mistakes, we can learn from them and grow stronger. Self-compassion also plays a crucial role in our relationships with others. When we are compassionate towards ourselves, we are more likely to show compassion towards others. We become better listeners, more empathetic, and more understanding. This, in turn, leads to healthier and more fulfilling relationships. Self-Compassion vs. Self-Esteem While self-compassion and self-esteem are related, they are not the same thing. Self-esteem is about evaluating ourselves positively and feeling good about our worth and abilities. It is often based on external factors such as achievements, appearance, or social status. On the other hand, self-compassion is about being kind and understanding towards ourselves, regardless of our achievements or external circumstances. It is about accepting ourselves as flawed human beings and embracing our imperfections. Self-compassion is not contingent on success or meeting certain standards; it is a constant source of support and care. Research suggests that self-compassion may be a more stable and nurturing source of self-worth compared to self-esteem. While self-esteem can fluctuate depending on external factors, self-compassion provides a consistent and unconditional sense of acceptance and love. The Science Behind Self-Compassion The benefits of self-compassion have been extensively studied and documented in the field of psychology. Researchers have found that practicing self-compassion activates areas of the brain associated with positive emotions and well-being. It also reduces activity in the areas of the brain associated with self-criticism and negative emotions. Furthermore, studies have shown that self-compassion is linked to lower levels of stress hormones, such as cortisol. It has also been found to enhance the functioning of the immune system, improve cardiovascular health, and promote overall physical well-being. The scientific evidence supports the idea that self-compassion is not just a fluffy concept; it has real, tangible benefits for our physical and mental health. How to Cultivate Self-Compassion Cultivating self-compassion is a journey that requires practice and patience. Here are some practical strategies and techniques that can help you cultivate self-compassion in your daily life: Practice mindfulness: Mindfulness involves being present in the moment and non-judgmentally observing our thoughts and emotions. By practicing mindfulness, we can become aware of our self-critical thoughts and replace them with more compassionate and supportive ones. Challenge your inner critic: Notice when your inner critic is being harsh and judgmental towards yourself. Challenge those negative thoughts by asking yourself if you would say the same things to a loved one. Replace self-criticism with self-compassionate statements. Practice self-care: Take time to prioritize your physical, emotional, and mental well-being. Engage in activities that bring you joy and relaxation. Be kind to yourself by getting enough rest, eating nourishing foods, and engaging in self-care rituals. Cultivate gratitude: Develop a gratitude practice by regularly reflecting on the things you are grateful for. This can help shift your focus from self-criticism to appreciation and self-compassion. Seek support: Reach out to trusted friends, family, or professionals who can provide a compassionate ear and support. Sometimes, sharing our struggles with others can help us gain a fresh perspective and find solace in knowing we are not alone. Remember, cultivating self-compassion is an ongoing process. Be patient with yourself and embrace the journey of self-discovery and self-acceptance. Integrating Self-Compassion into Daily Life Integrating self-compassion into our daily lives requires conscious effort and intention. Here are some practical ways to incorporate self-compassion into your daily routine: Start your day with self-compassion: Set aside a few minutes each morning to practice self-compassion. This could be through meditation, journaling, or simply reminding yourself of your inherent worth and embracing the day with kindness and love. Practice self-compassion during challenging moments: When faced with difficulties or setbacks, pause and offer yourself words of encouragement and support. Remind yourself that mistakes and failures are a natural part of life, and treat yourself with the same kindness and understanding you would offer to a friend. Create a self-compassion mantra: Develop a mantra or affirmation that embodies self-compassion for you. Repeat it to yourself throughout the day as a reminder to be kind and gentle with yourself. Practice self-compassion in self-talk: Pay attention to your inner dialogue and notice when self-critical thoughts arise. Replace them with self-compassionate statements and affirmations. Be your own best friend and cheerleader. Engage in self-compassionate acts: Engage in acts of self-care and self-compassion regularly. This could be treating yourself to a relaxing bath, taking a walk in nature, or engaging in a hobby you love. Prioritize activities that nourish your soul and remind yourself that you deserve kindness and care. Remember, self-compassion is a skill that can be developed and strengthened over time. With practice, it becomes a natural and integral part of your daily life. The Role of Self-Compassion in Relationships Self-compassion not only benefits our relationship with ourselves but also has a profound impact on our relationships with others. When we are kind and compassionate towards ourselves, we are better able to extend that kindness and compassion to others. Self-compassion allows us to be more empathetic and understanding towards others. It helps us recognize that everyone has their own struggles and imperfections, just like we do. Instead of judging or criticizing others, we can approach them with empathy and kindness. Furthermore, self-compassion helps us set healthy boundaries in our relationships. We learn to prioritize our own well-being and recognize when we need to say no or take a step back. This allows us to maintain healthier and more balanced relationships. In romantic relationships, self-compassion plays a crucial role in fostering intimacy and connection. When we are kind and accepting towards ourselves, we are more likely to be vulnerable and open with our partners. This, in turn, creates a safe space for emotional intimacy and strengthens the bond between partners. Self-Compassion Exercises and Techniques There are numerous exercises and techniques that can help us cultivate self-compassion. Here are a few to get you started: Self-compassion meditation: Set aside a few minutes each day to practice self-compassion meditation. This involves directing kind and loving thoughts towards yourself, acknowledging your struggles, and offering yourself comfort and support. There are guided self-compassion meditations available online that can help you get started. Writing a self-compassion letter: Write a letter to yourself from a place of self-compassion. Acknowledge your struggles, validate your emotions, and offer yourself words of kindness and understanding. Read the letter whenever you need a reminder of your own self-worth and compassion. Body scan meditation: Practice a body scan meditation to cultivate self-compassion towards your body. Bring attention to each part of your body, noticing any tension or discomfort, and offering words of kindness and acceptance to each area. Self-compassion journaling: Start a self-compassion journal where you can write down your thoughts, emotions, and experiences with self-compassion. Use this journal as a safe space to explore your feelings and practice self-compassion towards yourself. Remember, these exercises are tools to help you develop and strengthen your self-compassion practice. Explore and experiment with different techniques to find what resonates with you. Self-Compassion Resources and Books If you're interested in delving deeper into the topic of self-compassion, here are some recommended resources and books: "Self-Compassion: The Proven Power of Being Kind to Yourself" by Dr. Kristin Neff: This book explores the science and practice of self-compassion, offering practical exercises and techniques to cultivate self-compassion in daily life. "The Gifts of Imperfection" by Brené Brown: Although not solely focused on self-compassion, this book emphasizes the importance of embracing our imperfections and cultivating self-compassion as a path to wholehearted living. "Radical Acceptance: Embracing Your Life With the Heart of a Buddha" by Tara Brach: This book explores the concept of radical acceptance and offers mindfulness and self-compassion practices to cultivate a deeper sense of self-acceptance and compassion. Online courses and workshops: Many mindfulness and self-compassion experts offer online courses and workshops on cultivating self-compassion. These resources can provide guidance and support as you embark on your self-compassion journey. Remember, self-compassion is a personal and individual experience. Explore different resources and find what resonates with you and supports your own self-compassion practice. Conclusion: Embracing Self-Compassion for a Happier and More Fulfilling Life In a world that often values achievement and perfection, it's easy to forget the importance of self-compassion. However, by embracing self-compassion, we can unlock the power to live a happier and more fulfilling life. Self-compassion allows us to be kind and understanding towards ourselves, even in the face of challenges and setbacks. It helps us develop resilience, improve our relationships, and enhance our overall well-being. Remember, self-compassion is not a destination; it is an ongoing journey. It requires practice, patience, and self-acceptance. Embrace the power of self-compassion and experience the transformative impact it can have on your life. Start today, and be kind and gentle with yourself every step of the way.

If you need an anxiety routine to help you get through the day, you’re in the right place.  My name is Kimberley Quinlan. I am an anxiety specialist. I’m an OCD therapist. I specialize in cognitive behavioral therapy, and I’m here to help you create an anxiety routine that keeps you functioning, keeps your day effective, and improves the quality of your life. Because if you’re someone who has anxiety, you know it can take those things away.  Now, it’s so important to understand that generalized anxiety disorder impacts 6.8 million American adults every single day. That’s about 3.1% of the population. And if that is you, you’re probably going to agree that anxiety can hijack your day. It can take away the things that you love to do, it can impact your ability to get things done.  And so, one of the tools we use—I mean myself as a clinician—is what we call activity scheduling. This is where we create a routine or a schedule or a set of sequences that can help you get the most out of your day and make it so that anxiety doesn’t take over. So if you’re interested, let’s go do that.  Again, if you have anxiety, you know that anxiety has a way of messing up your day. You had a plan. You had goals. You had things you wanted to achieve. And then along comes anxiety, and it can sometimes decimate that plan.  AN ANXIETY SCHEDULE And so the first thing I want you to be thinking about as we go through putting together this schedule is to plan for anxiety to show up. Those of you who show up in the morning and think, “How can I not have anxiety impact my day?” Those are the folks who usually have it impact them the most. So we want to start by reframing how we look at our lives instead of planning, like, “Oh gosh, I hope it’s not here. I hope it doesn’t come.” Instead, we want to focus on planning for anxiety to show up because it will. And our goal is to have a great plan of attack when it does. MORNING ROUTINE FOR ANXIETY First of all, what we want to look at is our morning routine for anxiety. We want to have an anxiety routine specifically for the morning. There will be folks who have more anxiety in the morning. There will be folks who have more anxiety in the evening. You can apply these skills to whatever is the most difficult for you. But for the morning routine, the first thing we need to do is the minute we wake up, we want to be prepared for negative thoughts. Thoughts like, “I can’t handle this. I don’t want to do this. The day will go bad.” We want to be prepared for those and have a strategic plan of attack.  COGNITIVE RESTRUCTURING Now, what we want to do instead of going down the rabbit hole of negative thinking is use what we call cognitive restructuring or reframing. During the day, at a time where you’ve scheduled, I would encourage my patients to sit down and create a planned response for how we’re going to respond to these thoughts. So if your brain says, “You can’t handle the day,” your response will be, “I’ll take one step at a time.” If your brain says, “Bad things are going to happen,” you have already planned to say, “Maybe, maybe not, but I’m not tending to that right now.” Let’s say your brain is going to tell you that this is going to be so painful and, “What’s the point? Don’t do it,” absolutely not. I’m going to show up however I can in my lifetime. I’m not going to let those thoughts dictate how I show up. I’m going to dictate how I show up. So we want to be prepared and have a plan of attack for that negative thinking. MINDFULNESS PRACTICE The second thing we want to do is have a solid mindfulness for anxiety practice. Again, you’re going to start today, and you’ll start to see the benefits of this over the weeks and months, but a mindfulness practice will be where you are able to have a healthier relationship with the thoughts, the feelings, the sensations, the urges, the images that come along with anxiety.  A big piece of mindfulness is learning how to stay present. As you are brushing your teeth in the morning, you’re noticing the taste of the toothpaste, the feeling of it on your gums, the smell of the fluoride, and the toothpaste that you have. A solid mindfulness practice will help you move through each part of the day’s routine that we’re creating in a way that reduces the judgment, reduces the suffering, reduces the self-punishment, reduces the reactions that you would typically have.  Now, one of the most helpful mindfulness skills I use and I tell my patients to use—we actually have a whole episode on this. It’s Episode 3. It’s really early on, but it’s talking about being aware of the five senses. Again, as you’re brushing your teeth, what do you smell? What do you see? What do you taste? What do you hear? What does it feel like? And you’re going through systematically these different senses so that you can be as present as you can. And this will help you with panic attacks, anxiety attacks, or just general anxiety that you’re feeling.  If you’re wanting to deep dive into mindfulness and have a mindful meditation practice, we have an entire vault of meditations that are guided by me that you can look into by going to CBTSchool.com, or I’ll leave the link in the show notes. There is an entire vault specifically for people with anxiety of guided meditations to help you with different emotions, different sensations, different experiences, different struggles that you may be having. That’s there for you.  4. GET SOME EXERCISE  Now the next thing I want you to do in the morning is get some kind of movement activity going. Again, this doesn’t have to be going for a run, but it could be a light walk, some stretching, some yoga. It could be going to the gym and lifting weights, but try to get your body moving. There is a lot of research to show that exercise can be as effective as medication. That’s mind-blowing, and it’s free. It’s something you can do from home, and it’s something that doesn’t have huge side effects except for the fact that it’s not as fun as we would like it to be. But create a routine. It doesn’t have to be every day, either. You might put in your schedule that you just do it a couple of days a week, and that’s a great start. But try to at least stretch, move your body, maybe move around the house, light dancing, whatever floats your boat, but get your body moving.  5. NOURISH YOUR BODY WITH FOOD   The next morning routine activity that I really want to stress is to nourish your body with food. And I picked the word “nourish” very intentionally. I’m not just saying put breakfast in your mouth because I want you to be thinking of food as something that’s fueling your body so that you can be at your best. Again, I believe strongly there is no right or wrong food or good or bad food, but I want you to think about, “How can I nourish my body? Do I need some water? Would it be nourishing to have too much coffee?” Again, coffee is not super helpful if you’re someone with anxiety, and it’s something you should limit as well. So, really be intentional about the food that you nourish in your body. 6. SET AN INTENTION FOR THE DAY And then the last piece of the morning routine for anxiety is to set an intention for a day of kindness. You are committing to kindness all day. If that doesn’t feel good to you, flip it to “I am committing to no self-punishment, no self-judgment, no self-criticism.” That can be a really effective goal. “Okay, if I’m going to do one thing today, I’m committing to no judging,” because literally, there is no benefit to any of those things. Criticism, punishment, judgment, self-loathing, none of it. There’s no benefit. It doesn’t motivate you if you think that is true. It’s actually been proven incorrect by science. These things are not the motivators. We want to work at reducing those. And there are tons of other episodes on the podcast talking about that.  So, that’s what we’re going to focus on for the morning routine.  STRUCTURING YOUR DAY FOR ANXIETY ROUTINE Now we’re going to move on to structuring your day and creating an anxiety routine that is effective for you throughout the day. Now I want to first acknowledge that I don’t know how much you have going on in the day. Some of you are working two jobs, some of you are a stay-at-home mom, some of you don’t have a job at all, some of you are at school. Everybody’s schedule is going to be different, but I want you all to be thinking about these ideas.  WHAT WOULD YOU DO IF YOU DID NOT HAVE ANXIETY?  The first one is plan and organize your day around what you would do if you didn’t have anxiety. Sit down and really think about it. “If I didn’t have anxiety today, what would I get done? How would I show up? What activities would I do?” And make sure you schedule those into your schedule because the main thing that you have to know about someone with anxiety is anxiety will interrupt your day and take you away from the things that you value. So please, please, please, think about this question: What would I do if I didn’t have anxiety? And your job is to schedule and try and get as many of those things done as you could. We don’t want anxiety to run the show here.  PLAN YOUR DAY  The next thing I want you to do is use a planner to activity schedule these things. There are apps to help track tasks and appointments. Do your best to plan and to have structure. People with anxiety and depression need structure. It helps us to be so overwhelmed and chaotic in our brain to have some structure. And believe me, some people will say, “No, it feels too controlled, and it takes away my creativity.” No. In fact, people who have structure tend to report feeling more creative because their day isn’t so overwhelming and they have a little bit of control over where they’re doing, what they’re doing, and where they’re going. Now, if you struggle with this, we have an entire course for this as well. It’s called The Optimum Time Management for Mental Health. I walk you through specifically how to manage time, specifically for those who have anxiety, depression, and OCD. I had to create this for myself. I had to read a whole ton of books and take courses. I found none of them really approached it from the perspective of those who had a mental health or a medical issue. And so I created that course specifically for those who struggle in that area. You again can go to CBTSchool.com to get information about that.  SET REALISTIC GOALS  Now, as you are structuring your day and planning your day, you have to be really intentional about setting realistic goals and prioritizing what’s important. Sometimes when I look at the things I want to get done, there could be like 15, 20, 30 things to do. I know I’m not going to get all of those done, so I have to sit down and go, “Okay, which are the most urgent? Which are the things that must take priority?” and work at prioritizing those. Again, as you do those things, you’re going to be using those mindfulness skills that we’ve already talked about. staying present. You’re going to be using your willingness skills that we often talk about here on Your Anxiety Toolkit. Bringing compassion, radical acceptance, willingness to be uncomfortable—you’re going to bring those with you throughout the day. Again, we are planning for anxiety to come with us every part of the day.   SCHEDULE BREAKS IN YOUR DAY  Now another important thing to do here is to schedule breaks. If you have anxiety, you know as much as anybody that anxiety is exhausting. Schedule breaks, but no breaks where you’re scrolling on Instagram. That’s not a true break. That doesn’t actually give your brain a break. Go outside, sit in nature, listen to some music, read a book, do something that doesn’t drain your battery, do something that increases your battery. It might be taking a walk or doing something active, but make sure you plan those breaks.  SCHEDULE THERAPY HOMEWORK  The next thing to do, and you have to do this every day, specifically if you have an anxiety disorder, is schedule your therapy homework. If you’re not in therapy, still schedule time to be doing something that helps you to work on your mental health, even if it’s correcting those thoughts that we talked about at the beginning of this episode. We want to make sure that with planning times to do exposure and response prevention, with planning time to do our mindfulness practice, with planning time to do our, again, cognitive restructuring, making sure that you’ve scheduled that helps you with your long-term recovery. Not just the recovery of today, not just getting through today, but when we schedule time to do our homework, it means that we push the needle forward in our recovery.  EVENING ANXIETY ROUTINE Now we’re going to move on to the evening anxiety routine. This is where we prioritize unwinding for the day. You’ve used all your energy, you’ve taken anxiety with you, you’re exhausted.  CELEBRATE YOUR WINS  Number one, you have to celebrate. Celebrate what you did get done. Write down what you got done. Because so often, when we have anxiety, we go, “Oh, it’s not a big deal. Everyone can do that. I shouldn’t be celebrating.” No, you’ve got to celebrate this stuff. You’re working your butt off. And so we have to make sure that we’re celebrating every win, even if it’s just one teeny win for the day.  WIND DOWN FOR SLEEP (SLEEP HYGIENE)  The evening is where we must prioritize winding down for sleep. Sleep hygiene is maybe the most important part of your recovery in that it will set you up to do well tomorrow. If you’re like me, not having a good night’s sleep means your mental health hits the trash tomorrow. So we want to start the evening on how can we reduce the impact of being on technology. Do a digital detox if you can, at least an hour before bed. Do something relaxing. Do something pleasurable. Read, take a warm bath, take a walk, garden, talk to a friend, connect with them—anything you can do. Make a lovely meal, watch a funny TV show, whatever you can do to bring yourself down and rest and repair for the day so that you can be ready for bed and moving into the nighttime routine.  CREATE A NIGHTTIME ROUTINE WITH A CONSISTENT WAKETIME You will need a nighttime routine. Have a time or an alarm. You could get an Apple Watch or set an alarm on your phone to prompt you to moving towards the bedroom routine where you brush your teeth or you wash your face or you light a candle or you brush your hair or you start reading, turn the sheets down. Whatever that is, set a timer so that you are prompted to go to bed on time.  What we want to do with anxiety is have a very solid routine of waking up at the same time and falling asleep at the same time, as much as possible that you can achieve. That internal body clock of yours really benefits by having it be as balanced and as routine as we can. LIFESTYLE CONSIDERATIONS FOR YOUR ANXIETY ROUTINE Now, there are some lifestyle considerations you have to consider here if you have anxiety. Number one, you have to also make sure that you’ve had some time for connection. And some of you are like, “No problem. I’ve had connection during the day or my colleagues at work or my family or my partners or my friends.” That’s great. But if you’re somebody who has anxiety and it’s kept you home alone and it’s kept you in avoidance, now that’s going to be really important that you do some type of connection, have a support system, whether it be a support group that you attend or a therapist that you go to because that again is so important for your long-term recovery. MEDICATION AND THERAPY In terms of overall, we may want to incorporate some kind of medication or therapy into your day or into your week. You may need to set alarms to remind you to take your medication. That’s okay, too. Please, please utilize as many alarms as you need to help this go as well as you can. Because again, I want to emphasize, anxiety can make all of this routine go out the window. Before you know it, you’ve spent four hours on TikTok, or you’ve gotten into bed and pulled the sheets up and hidden there, or it could be disrupting your day by having you go into avoidance behaviors. Absolutely, I understand that. Please be gentle with yourself. But if you’re somebody who’s really struggling, please do not hesitate to reach out to a cognitive behavioral therapist who treats anxiety. They will be able to help you set up more structure and create a plan specifically for you.  FIND A STRATEGY THAT WORKS FOR YOU So, what do we need to remember here? Number one, your routine should have some strategy to it. You will have to sit down and plan for it. I spend about an hour a week planning my week. And while that might sometimes feel like a waste of time, having a plan, knowing what I need to do, making sure I’ve prioritized me makes me so much more effective, makes my anxiety management and my recovery so much better. So, sit down and make a plan. BE WILLING TO HAVE SOME HARD DAYS Remember, anxiety will come along the way. We actually want to invite it. Tell it, “Come on, anxiety, we’re going to get groceries right now. Come on, anxiety, it’s time to have a coffee. Come on, anxiety, let’s go and do the hard thing or do my homework and my exposures.” That is a positive thing.  BE GENTLE WITH YOURSELF/ PRACTICE SELF-COMPASSION The last thing I want to incorporate here is to be gentle with yourself. There will be days where this falls apart, and that’s okay. Self-compassion for anxiety is so important.  We’re all learning here. So when it does fall apart, because it will, your job is to take a look and see what happened, what got in the way, how can I plan for that tomorrow so that that doesn’t happen again.  CONCLUSION So there you have it. There is the routine that I want you guys to consider. Some things will work for you, some will not. Just take what you need and leave the rest. But this is an anxiety routine that you can play around with, experiment with, and see what works for you.  Before we end, let’s do the “I did a hard thing” segment. I’m going to try my best to bring this back. This one is from Lindsay, and Lindsay said:  “I’ve been going through a lapse, or what I like to call a flare-up, for the last month. There have been decent days, blah days, and downright crappy days.”  We can agree with you, Lindsay.  “The hard thing I’ve done is to decide it’s time for an ERP refresher, and I have started that this week. I will admit that I’m terrified to be venturing into ERP again. However, I refuse to let fear control me. To anyone who’s going through a lapse or a flare-up, embrace where you are, love yourself, and fight for yourself because you are so worth it.” And I agree with you, Lindsay. Again, if there’s anything we can do to support you on your journey, go to CBTSchool.com. We have all kinds of courses there that can help you get back into the swing of things or get started. So go to CBTSchool.com, and thank you so much for being here with me today.

Helping children navigate the complexities of Obsessive-Compulsive Disorder (OCD) requires a delicate balance of understanding, patience, and empowerment. Natasha Daniels, a renowned expert in this field, shares invaluable insights into how parents can support their children in overcoming OCD with positivity and resilience. Normalizing OCD: One of the first steps in supporting children with OCD is normalizing the condition. Both parents and children need to understand that they are not alone in this journey. Natasha emphasizes the importance of taking things one step at a time and not allowing the overwhelming nature of OCD to overshadow the progress being made. Education is Key: Understanding OCD is crucial for effective support. Natasha urges parents to educate themselves about the condition, its symptoms, and the most effective treatment approaches. By arming themselves with knowledge, parents can better support their children through the challenges of OCD. The Concept of "Crushing" OCD: Natasha introduces the empowering concept of "crushing" OCD.” Instead of viewing OCD as an insurmountable obstacle, children are encouraged to see it as something conquerable. This shift in perspective can be transformative, instilling a sense of empowerment and resilience. Making Treatment Fun: To engage children in treatment, Natasha suggests incorporating fun activities. By turning exposures into games or playful challenges, children are more likely to participate actively in their own recovery journey. This approach not only makes treatment more enjoyable but also fosters a positive attitude towards facing fears. Bravery Points: Natasha introduces the idea of "bravery points" as a motivational tool for children. By rewarding bravery in facing OCD-related fears, children are incentivized to confront their anxieties and engage in exposure exercises. This gamified approach can be highly effective in encouraging progress. Adapting for Teens and Adults: While bravery points may resonate well with children, Natasha also offers insights into adapting these strategies for teenagers and adults. Creative incentives tailored to different age groups can help individuals of all ages stay motivated and committed to their treatment goals. Creative Exposures: Incorporating creative exposures into treatment can make confronting fears more engaging and less daunting for children. By turning exposures into interactive experiences, such as games or role-playing exercises, children can develop essential coping skills in a supportive environment. Collaborative Approach: Natasha emphasizes the importance of collaboration between parents and children in the treatment process. By working together to develop coping strategies and respond to OCD-related behaviors, families can create a supportive and empowering environment for children with OCD. Addressing Parenting Challenges: Managing the emotional challenges of parenting a child with OCD can be overwhelming. Natasha offers insights into coping with feelings of anger, frustration, and helplessness, providing strategies for maintaining patience and support during difficult moments. Long-Term Perspective: Supporting children with OCD requires a long-term perspective. Building resilience and fostering a family culture that promotes bravery and resilience are essential for long-term success. By focusing on progress rather than perfection, families can navigate the challenges of OCD with hope and determination. Conclusion: Natasha Daniels' insights offer a beacon of hope for families navigating the complexities of OCD. By normalizing the condition, educating themselves, and adopting creative and empowering approaches to treatment, parents can support their children in overcoming OCD with positivity and resilience. TRANSCRIPTION:  Kimberley: Welcome everybody. Today we have Natasha Daniels. She's the go to person for the kiddos who are struggling with anxiety and OCD. And I'm so grateful to have her here. We are going to talk about helping your kid crush OCD and how we can make it fun and how we can get them across the finish line. So welcome Natasha. Natasha:  Thanks for having me. I appreciate it. Kimberley okay. We've had you on before and I think so much so highly of you. I'm so honored to have you on here again talking. We were talking about kids as well last time but first of all let's just talk about the kiddo, right? The kiddo who has OCD. They're starting this process. Let's sort of even say like they're ready for help, like they want to get better, but at the same [00:01:00] time getting better feels like a huge mountain that they have to climb. What might you say to the kiddo and the parents at that beginning stage of treatment? Natasha: A lot of times I think kids don't even realize that they're not alone. They think they have like these really bizarre thoughts and that they'll never be able to stop those bizarre thoughts. So I the first step is really normalizing it for both the parent and the child and letting them know that lots of people have this struggle and that they are able to get through it and have a healthy, productive life. And for parents in particular. about tunnel vision, you know, because it can feel so big. And it's like, let's just, what's your next move? What's your next step that tunnel vision so that the overwhelm doesn't skew your perspective Kimberley: Yeah, what might be those steps? Like what, what, [00:02:00] what, how would you, how would you have that conversation? I mean, I know for parents, I think there's some relief in getting a diagnosis and being like, Oh, okay, so we know now what this is. And we're here to get treatment and we're assuming this is the right treatment. But they're still just, you know, it's such a mountain to climb. So what might you say to them? Natasha: The first step is really educating yourself. I think parents learn a little bit and they just like want to jump into the deep end. They learn a little bit, like, Oh, you shouldn't be accommodating the OCD. So they're like, well, now I don't know what to do because I was doing something that at least help my child in the, in the moment. But now I'm hearing that that actually makes it worse. And so they start to feel really overwhelmed by the little bit of information they get. So I would say. You know, get some education, whether you read a parent book, or you take a course, or you just watch a bunch of videos, but [00:03:00] like, get some basic foundation of what OCD is because it's going to shift and morph and change and look different. And so understanding, like, lay of the land of like, oh, okay, this is what OCD is. You know, it, it's demanding and it wants me, my child to do or avoid something to get that brief relief. And sometimes that hooks me in and the more they do or avoid that, the bigger it grows, like understanding it would be the first step. Kimberley: So you wrote an amazing workbook called Crushing OCD Workbook for Kids. Let's talk about this term crushing like crushing OCD and that's sort of the title of our episode as well Like do we want that mindset if we're gonna crush it? Like what does that look like? How does that change our mindset? Do we need to really think of it like crushing it? Can you kind of share a little bit more about that mindset shift? Natasha  Yeah. I do use the word crushing a lot. [00:04:00] My courses are all about crushing. My, my book is crushing um, we're not getting rid of. Um, and so. There is a reason why I use crushing versus like overcoming or getting rid of, it is a powerful, kind of aggressive word. And, and I do feel like seeing OCD as kind of like this adversarial thing that you are crushing. Um, 1 can be very therapeutic and empowering for the child, especially when it's externalized and it's personified. So it's this Mr. OCD or this O cloud is us and we're going to crush it. Um, and then physiologically, do see it differently than anxiety. And I think sometimes with anxiety. we talk about, I kind of equate anxiety as like the overreactive lifeguard, and he's trying to, he's trying to look out for you, but just kind of, [00:05:00] he's sending the emergency alarm bells all the time. So maybe he needs some retraining. Maybe we crush him too, but that I think has more flexibility physiologically. Where I feel like OCD is like this foreign thought that's coming into my brain that is so incongruent with who I am, depending on the theme. And there's no part of it that feels like protective or aligned, um, in the way that OCD can show up. And it's very glitchy, you know, and physiologically, a different part of the brain. And it is. It's a, you know, it's more of a glitch versus an overreactive. So I do feel like about crushing it is a good analogy. Kimberley Well, I think too it's OCD can be so powerful and make us feel like we have to kind of like gulp down and, and wither it. Right. And so it does kind of require our kiddos to stand up to it. And I think crushing it [00:06:00] really gives that metaphor of like, we're going to stand up to it. We're going to win. This is like, we're going, you know, it's point systems or something like that. Like who's going to win this baseball match, but we're going to beat it against OCD. So I think that that is really helpful. And I think kids get behind it too, like Kids want to crush things. Natasha: Yeah. And, and they really need to feel empowered because it is so overpowering more than really any other disorder. It is just, it's they're being bombarded with these thoughts and feelings and to, to sit in a storm. And not do what OCD wants you to do a, is a really brave thing to do. And I do feel like kids can really get behind the idea of overcoming and crushing, not overcoming, but crushing it and feeling empowered that they have more strength than OCD does. Kimberley: Okay. So in the workbook, you talk about these fun activities and I have found having my own [00:07:00] children, but also being a clinician, if it's not fun, they're not that interested. What's the payoff really? So, so can you share with us some of the fun activities or ways in which we can start to approach this topic with our kids? Natasha: Yeah, I think anything can be fun and we want our kids to, to have fun and we want to gamify it. So a lot of the workbook talks about One, how to view OCD in a really fun way. So I use a lot of cartoons and a lot of metaphors so they can see it. Um, also talking about incentivizing them and, you know, adding points or bravery points to do, do scary things. And so it becomes kind of this, Gamified version of, of, of crushing their OCD. Kimberley: So bravery points. What does that mean? Natasha: So bravery points can be different for different families. Um, and we use them in my, my house as well for [00:08:00] my own kids with OCD, where we set up kind of like a virtual store. And there are certain things you can have this pretty structured or not structured where you points and, um, you know, kids can do things that OCD will not. Want them to do or do things or not do things that OCD wants them to do, whichever way OCD is working or do exposures they're purposely triggering OCD and then they earn points and they can cash those points in and so Even at my house, you know, my child does not get Roebucks unless he cashes his points in There's like a direct line there. My daughter doesn't get slime from very expensive place, unless she wants to cash her points in. And those are done through steps that are, that's crushing their anxiety and OCD. Kimberley: And so I was actually going to ask this in terms of bravery points. This is not just for kids. This is for teens too. So you might be doing this for like, how might this apply to [00:09:00] teens or do we use bravery reward points for teens as well? Natasha: Yeah. I think it can be used for anyone. I mean, I think even adults can, can gamify their battles with anxiety and OCD. Um, I mean, I've set that up for myself where I've done something that would be really hard. And then I've offered myself incentives, you know, ironically, or not really ironically, but interestingly. Intrinsic incentive does start to happen. You start to get traction. Um, I know for, for the kids that I've worked with in my practice and even my own kids, I've seen the, the pride when they've done something really scary and the relief of like, Oh my gosh, that was not nearly as bad as I thought it was going to be. And then the empowerment. So I kind of want to preface this with. can have these external reinforcers, but they're there to celebrate those brave moves. They're there to make the association of this is really fun, but the internal motivation does start to get some traction down the [00:10:00] road. And so even with teens offer them incentives, and that might look different. I know, um, I've used this example a lot, like for my older daughter, she would net, she would not be driving today. Absolutely not be driving. If it wasn't for me. ordering her Starbucks. And I would just order her Starbucks and I'd be like, okay, it's ordered, you know, you just need to go pick it up. And she, she has social anxiety as well. So she'd like, and she feels bad about spending money. So there was all sorts of things that were actually working in my favor. Cause she felt so bad. She's like, mom, you just ordered it. But I said, I wasn't ready to drive. And I was like, you don't have to pick it up. It'll just be sitting there. It'll just be wastey wastey. And she would go there. I mean, she had three. cycles of driving school before I did this. Natasha: She was well skilled, but I mean, that's a very basic incentive. It was like, I'm going to reward you. Here's an extent, you know, an incentive to go do it. And, you can be creative with teens, [00:11:00] whether it is. I mean, in my practice, I would get like Xbox controls or like one girl wanted a green screen for her YouTube channel. Like, and it was just that weren't like far, far down the road, but little incentives to celebrate and say, you know, you're doing really hard stuff and it doesn't have to be all boring and, and miserable. It can be fun too. Kimberley: Yeah. In our house, it's Taylor Swift records. We're working our way to get every single one of them. Um, right. And, and, and you get them after you, you know, achieve a certain amount of things. So I think I love this. Um, and I think it, it can, again, it can be age dependent. My son is working towards Pokemon cards as well for different things as well. So I love that. Natasha: Yeah. Kimbelrey: So, okay. So bravery rewards. What about, um, The, the other work of treatment and crushing OCD, are there other [00:12:00] fun activities that you have found to be really powerful, whether it's more in how we educate and conceptualize OCD or get them to do the scary thing? Natasha: Yeah. I think you can get creative and really anything that you're doing, uh, exposures can be fun as far as creating things that are triggering the OCD on purpose. They don't always have to be serious and boring. Um, you can create. Fun things, um, you can do interesting exposures, whether you create a game and you're playing games around it, like go fish, but you change the go fish to different names related to what they're struggling with. Or used, like, um, jelly beans, you know, that tastes gross for my child that has, like, metaphobia and issues. And so thinking out of the box, um, in my practice, I would use, like. like two truths and a [00:13:00] lie they had moral OCD. And so we talk about, you know, I'm going to tell you two truths, but one and the, the third one will be a lie and you have to guess which one it is. And that's a fun game in general, uh, but very overwhelming for someone with moral OCD. And so I think sometimes we think it all has to be serious, but there are a lot of creative ways that we can do exposures that. that can make us laugh. And even when we're responding to our kids, and let's say you don't want to feed the OCD. And so, um, let's just use a concrete example. Like if your child has moral or scrupulosity OCD, and they're always saying, I'm sorry, I'm sorry, I'm sorry. You know, repetitively, that's kind of a compulsive thing and you know that you're not going to feed it. And so you come up with a plan of, I'm not going to accept your sorry. You can even do something silly with that, um, and I've had parents who like, they would say it in a different accent or they would sing it or they'd say, you know, sarcastically, I'm sorry. [00:14:00] You're sorry is not accepted or, you know, like you can, you can even come up with fun, sarcastic things in your response to OCD as long as you're partnering with your child. Kimberley: Tell me about the partnering though, right? So in an example of where you're like, you know, let's say you use your most funny Donald Duck accent, um, in saying, I don't, I don't want to, you're sorry. Um, um, You know, how, how, what if that doesn't feel like partnering to them? What if that feels like, you know, uh, like a, a betrayal to them or they, they're very invested in getting that compulsion done? What would you suggest? Natasha: Yeah. You definitely want to collaborate with your child first and say, you know, I know either they bring it to you or you bring it to them. Like I noticed that when you say this, it's actually your OCD saying that to me. And because I love you, I'm not going to give what OCD wants [00:15:00] anymore. So prefacing it with, I'm noticing that this is a compulsion that I'm part of, and I'm, I love you. And so I'm not going to be part of that compulsion. And can respond in these ways, how would you like me to be, or how do you, how would you like me to respond so you can partner if they can come up with a creative way? Um, like, for instance, in my case with my son, he said, tell me, say, I'm sorry, is not accepted. Like, he literally scripted it for me. when I said it in the moment, he wasn't happy with that because then he was panicking and he was feeling overwhelmed. And so he, I don't like when you say that, but that was our agreement. Um, I might pivot in that moment if he's looking really overwhelmed and I might not say anything because maybe it's not a time to be funny or maybe poking back in a really aggressive way isn't being well received in that moment, but that doesn't mean I'm going to feed the OCD. Okay. you might have a child that doesn't want to partner with you that says, I want you to do this and this makes me feel better. And [00:16:00] why are you being mean? Um, and in that case, humor is not appropriate. You know, you're not going to use humor. You might just say, well, I love you. And so I'm not going to respond and you let them know you're going to respond, but the humor part, if we're the only ones laughing, then it's not really funny. So we have to be very careful about that. Kimberley: Yeah. So, and I mean, it's true that crushing OCD or any, you know, mental health disorder is like a family affair. And so as a, as a parent, What is the training for them in this sort of idea of crushing it and making it fun? What, what personal work would you recommend they do, um, on their own in their own therapy, whether they're with a parenting coach or a therapist or with each other as partners, what would you suggest a parent do to prep for this [00:17:00] sort of marathon that we're on? Natasha: It's a great question because there is so much parenting work that, that needs to be done because it's our journey too. And so I feel like the parent journey is unique in and of itself, you know, raising a child with OCD Um, it's not for the faint hearted. So learning, how do you sit in discomfort when your child is sitting in discomfort? you handle your child being triggered and not swooping in and doing what your child's OCD wants? hard to, to be a witness to your child's struggles, to know that in the short term, you can do something. Some of the time. appeases the OCD, but then grows it long term. And so, um, getting your own support or finding your own way to ground or your own coping skills of how do you handle that when you're, when the child's OCD is having a tantrum. Um, and it will try to kind of break you down so that you [00:18:00] give in so that there's work in that area. I think also, how do we handle our own, how do we handle our own mental health when our child is having mental health issues? Because We are not a blank slate. We come with a lens and that lens has our own childhood. It has our own experiences, has our own mental health issues. And and so we're seeing our child's mental health issues through our lens no one can have a clear lens, but to have some awareness of I'm bringing this to the table, When my child does this, it triggers this for me, which is actually not about my child, but that's about my dad, or that's about my childhood experience. And how do I work through that so that it's not impeding how I'm my child. I'm not dealing with that. Yeah. Kimberley: Yeah, for sure. What's, what's interesting for me. is I was thinking about this about parenting in general is [00:19:00] sometimes I parent the way my parents parented without even Questioning. Is that the way I want to parent like it'd be sometimes I'll catch myself Parenting my child in the way my parents was when I'm like didn't help me like that wasn't helpful You know what? I mean? And and it's so automatic. It really takes slowing down and being like wait I'm What did I need during that time? How can I be that for my child? It's so automatic sometimes. And I think that, um, so many parents, I mean, I wish we were given a manual, but like, it's a lot of emotional regulation work of our own to sit while your child is struggling. Um, especially with anxiety, cause you know, we just, it's so easy to fix it by giving them the compulsion or. You know, so I really feel for the parents that I, you know, that we treat in that it's so much emotional regulation. Would there be a specific [00:20:00] set of tools that you would give them or do you think it's very much dependent on the person? Natasha: I think it's dependent on the person as far as what they're bringing. What they're bringing in the moment. Um, but I do talk about lovingly detach and, and a lot of times parents hear that and they get concerned because they think detachment means that I'm not present for my child. And it's actually the opposite to me. It's like, how can I be? 99 percent or 95 percent there for my child. I'm like, I'm an anchor for them and I'm not bringing anything to the equation. Kimberley: Yeah, Natasha: And that is hard. And a lot of it actually is this. It may seem really weird, but I feel like a lot of it is building up your skills. Through like mindfulness, you know, how do I stay in the moment? I'm only eating this food. I'm only petting my dog and that training like that mental training of your brain of like being Literally only in the [00:21:00] moment and learning how to fine tune that is actually a great survival tool because I find that When I'm in the moment with my kids and I have been working on that muscle in my brain, I'm able to not see as much through that lens of my own childhood or my own triggers. And I'm just like, what does she need from me right now? And that's the question I always tell parents to ask. What do they need from me right now? Like, what is my job in this moment right now? And sometimes it is to ignore them because I know with my daughter, at least, she doesn't like the attention of anxiety. Like when I can tell clearly she's having an anxiety attack, she doesn't want me to hover. And that's really hard because. Inside, you're feeling really anxious about it, but you know that your anxiety or your, your energy is contagious. And so yourself and be like, in this moment, she needs me to go, you know, about the morning routine and just act like nothing's happening. Or it might be the opposite for your child, right? But knowing it's not about us, what do they need in [00:22:00] that moment? Um, and that is a powerful skill that has to be, it's a daily practice. Kimberley: and different for each kid. Natasha: Right. Vastly Kimberley: Yeah, Natasha: Yeah. Kimberley: where it gets complicated. I think he's like because you know, we go Okay, this is the way we do it This is how we do it from now on and then you have another kid and you're like wait that doesn't work for them Natasha: Yup. Kimberley: let's shift it up and let's change it I'm wondering if we, you can quickly speak to a couple of emotions that I know show up with parents, you know, cause again, it's as much the parent game as it is the kids game. So where as clinicians and as parents, where they're to really champion our kids to ride the wave of discomfort and to use their skills and to manage it. What about for the parent they might be experiencing? I know a lot of parents report. anger that shows up at the, you know, when their kid isn't [00:23:00] using their skills and so forth. Um, do you have any, any advice to them when anger does show up or frustration? Yeah. Yeah. And Natasha: being angry then we're like, Oh, I responded angrily or I'm feeling frustrated and I shouldn't. And being accepting of the fact that it's okay, it's normal for me to feel angry. This is a frustrating situation and I want to change it and I want to steer the ship and I can't. Yup. You know, my child's not picking up their part. And so I think just validating that anger, um, which I can be, I think can be sometimes hard because we want to. Kind of we feel guilty about the anger, but then understanding where it's coming from and and again going inward There's so much inward work I think when you're raising a child with anxiety and OCD because it brings out all sorts of stuff for us So asking oh, it's interesting that I'm angry or that made me really [00:24:00] angry or sometimes I'll even say to myself like in my head like Natasha, that was like a huge response. why did you blow up so big on that? That was more than what was actually just happening then. And then do some self diving of like, what was that about it? Oh, that reminded me of this. Or I feel like I'm doing 99 percent of this and he's doing 1%. And what do we, what can we control? And so maybe if I'm feeling that way, then it's a shift of, to pull back. If I'm feeling like I'm doing 99 percent and that's making me angry. I can't control the pace of my child and their ability to use their skills because that's their journey, but I can control invested I am. And so if I'm doing 99 percent of this, then I'm going to pull back a little bit give, you know, invite them to meet me more in the middle. Kimberley: often I find under the fear is, I mean, so under the anger is the fear that we're going to be managing this for a while, or, you know, the parents grief [00:25:00] of This is interrupted the family system. So I think it's so normal. Um, I agree with you just to normalize that as a normal part of parenting, a kiddo who's struggling. Um, yeah. Okay. So in terms of getting that kid across the finish line or setting them up better things like setting them up for success, is there anything that you would tell the parents? as a mindset shift, like, you know, again, this is a marathon, not a sprint. What would you tell them in terms of the whole family system? How, what are skills and tools that they can be using to help set up a system or a family that can help this child crush OCD? Natasha: Yeah. I think mindset's really important because a lot of times is a perception of, I need to cure this, you know, or we need to get the skills and that they can overcome this and OCD is a chronic [00:26:00] condition. so we're wired, you know, if we're going to have anxiety or OCD, that this is going to pop up possibly in our life periodically. yeah, Yeah. So instead of thinking, like, how do I, you know, get rid of this cold or give them the skills and then we've we're done with this because that sets you and your child up for failure. I think having an idea of I'm going to create a home a family culture where we. Where we know we have the skills. We know what OCD is. We know how to identify it. Um, we live a life of exposures. We live a life of doing brave things. we talk about it and it doesn't have to be, I mean, I think once you're in maintenance, and you've really kind of. Learned all the skills that you have learned. I mean, we live in my house. It's a, it's a culture of anxiety. And OCD is kind of just part of our family culture. Like we do scary things or my kids might say that was an exposure or they earn points periodically. And so developing that in your, in your family as a system of like, just part of [00:27:00] your family, just the way your family functions and it works can be really helpful. And there's, there's, Brave things that anyone in the family can do. And so it can be a family affair where I had to go present at work and I didn't really want to present, you know, but I did it. It was really brave. And so using those analogy, using those examples, I think can be really. Normalizing for the child with with OCD. Kimberley: Yeah. So even, even for the non OCD kiddos, you would use that in terms of if they had to do a violin recital or a math. a national math test or that kind of thing. Natasha: Yeah, I mean, I think it can go way beyond OCD. It's how to build resilience because really at the crux of OCD is resilience. It's how to sit with discomfort, how to sit with uncertainty of not being 100 percent of something how to how to deal with something that feels uncomfortable and do it anyway. And so those are those are resiliency [00:28:00] tools that anyone Kimberley: Yeah. And it's such a great mind shift for everyone because parents are doing exposures. They are doing scary things by not accommodating their child as well. That's an exposure for a parent pretty well. Um, so you can conceptualize it that way. I love that. Yeah. Um, What does it look like? I love that you also mentioned in terms of like this is a long term thing. Like this is just a family culture thing. This is how we exist in the world. What does it look long term though? You know, do we do, I've had so many parents say to me, I don't want to give, but you know, the, the, um, The bravery points forever. I don't want to over saturate extrinsic motivation. Like, do you have any thoughts on that in terms of long term use of that method? Natasha: mean, it depends on your child's age and like where they are as far as building up skills. we have it in the background because I don't, [00:29:00] I don't give my kids money for chores, I don't. And so it's just been part of our thing where if they want, I guess what they would call in the UK pocket money, you know, if they want, they want spending money. In general, that really works for me for them to do brave things in general. Um, and so that is just part of the way that we have that now, my 20 year old's not earning like bravery points, you know, across, you know, state lines in California where she's in college, you know, but she's, she's, doing that lifestyle. And so I don't feel like you necessarily have to have these systems or incentives. Um, you might hit a bump and you might say, you want to earn something to overcome this thing that you're working on. Um, you know, a new struggle that they're having. So you might pull it out periodically for me. I don't want I'm like, I'm trying to teach my kids the idea of earning in general. And so it kind of. Fits well, because it's like, [00:30:00] you're not going to get things for free. And then there's this pride of like, oh, I earned that. Or let me work really hard at something. So you can get very ambiguous about it. You can have it be of just kind of your, your regular family incentives and how you're doing it, or you don't do it at all. I mean, It does eventually, um, get stale and so you have to either change it up or you take a break from it or your child is motivated by intrinsic motivation that they're feeling really great that they're able to go to school again or sleep on their own or do the things that were overwhelming for them. Kimberley: Right. Exactly. Yeah. I think that's the beauty is once you've done some exposures, you see that it works. There's a buy in. Um, but that buy in is hard at the beginning, which is why you do have to make it fun. And sometimes you do have to have it be sort of outside motivators to get you there. Yeah. Excellent. So, um, tell me about [00:31:00] your workbook where people can get it, where people can hear about you. Um, cause I know you have so many awesome resources. Natasha: Yeah. Well, I wrote, um, OCD workbook for kids because I wanted people to be able to have a book that was very simplistic that would walk them through basically what I would do in a therapy session, or therapy sessions. And so it just kind of walks them through OCD treatment. So it could be a great supplement to therapy. It could be great for a therapist to use, but it can also be a great standalone. Um, and it's meant for kids to be able to do either on their own or navigate with a parent depending on their age. And starts off with educating them on what is OCD because I told you, I feel like that's so important. Many disguises of OCD, um, normalizing it all the way to understanding how OCD works and then offense and defense about if OCD is knocking versus [00:32:00] knocking on OCD. How to do exposures at home and then how to, how to maintain that. And I also touch on like self esteem as well, because I feel like. OCD can really hurt the self esteem. So there's a little bit of empowerment and self identity in there as well. Kimberley: So important too. OCD can be mean, right? So, and knock people down. So I love that you're talking about that. And where can people find out more about you? Natasha: Um, well they can get the book on Amazon. They can find anything about me at my website at at parenting survival school. com. I mean, nope. At parenting survival, at parenting survival. com too many websites. Kimberley: No, I understand. I'm in the same boat. Well, thank you so much for coming on and talking about crushing OCD with kids. Is there anything you would leave parents and children with a little bit of inspiration or? One last point that you think that you really [00:33:00] want them to know. Natasha: Well, I think there's always hope. I mean, I have seen kids in very acute stages of struggling with OCD and I have seen kids make such big project progress. So there is always hope. And our kids are more than our, their OCD and kids with OCD tend to be the most, of the most compassionate, kindhearted, out of the box thinkers. And, and so I wouldn't even trade that with my own kids because I feel like the, the positive personality traits that, are underneath all those struggles are, are beautiful. So Kimberley: Yeah. Natasha: that's important to do. Track 1: And, and I think from, from my experience is nurture those parts that are not OCD, like what are their hobbies? How can we really build a life around OCD in terms of, you know, the instruments and the hobbies and the talents and the sports and the, you know, the community and that. So forth. So yeah, thank you so much Natasha for coming on. I am so I [00:34:00] love, I love your book. Thank you for writing it. I know writing a book is no easy feat. So congratulations on your book. Um, and I'm excited because you've got more on the, on the coming down the pipeline. I know you have a memoir coming out, so we'll be having you back on later in the year. Natasha: appreciate that. Thanks.

Navigating the intricate landscape of mental health can often feel like deciphering a complex puzzle, especially when differentiating between conditions ADHD vs.anxiety. This challenge is further compounded by the similarities in symptoms and the potential for misdiagnosis. However, understanding the nuances and interconnections between these conditions can empower individuals to seek appropriate treatment and improve their quality of life. ADHD, or Attention Deficit Hyperactivity Disorder, is a neurodevelopmental condition characterized by symptoms of inattention, hyperactivity, and impulsivity. While commonly diagnosed in childhood, ADHD persists into adulthood for many individuals, affecting various aspects of their daily lives, from academic performance to personal relationships. On the other hand, anxiety disorders encompass a range of conditions marked by excessive fear, worry, and physical symptoms such as heart palpitations and dizziness. The intersection of ADHD and anxiety is a topic of significant interest within the mental health community. Individuals with ADHD often experience anxiety, partly due to the challenges and frustrations stemming from ADHD symptoms. Similarly, the constant struggle with focus and organization can exacerbate feelings of anxiety, creating a cyclical relationship between the two conditions. A critical aspect of differentiating ADHD from anxiety involves examining the onset and progression of symptoms. ADHD is present from an early age, with symptoms often becoming noticeable during childhood. In contrast, anxiety can develop at any point in life, triggered by stressors or traumatic events. Therefore, a thorough evaluation of an individual's history is vital in distinguishing between the two. Moreover, the manifestation of symptoms can offer clues. For example, while both ADHD and anxiety can lead to concentration difficulties, the underlying reasons differ. In ADHD, the inability to focus is often due to intrinsic attention regulation issues. In anxiety, however, the concentration problems may arise from excessive worry or fear that consumes cognitive resources. Understanding the unique and overlapping aspects of ADHD and anxiety is crucial for effective treatment. For ADHD, interventions typically include medication, such as stimulants, alongside behavioral strategies to enhance executive functioning skills. Anxiety disorders, meanwhile, may be treated with a combination of psychotherapy, such as cognitive-behavioral therapy (CBT), and, in some cases, medication to manage symptoms. The integration of treatment modalities is paramount, particularly for individuals experiencing both ADHD and anxiety. Addressing the ADHD symptoms can often alleviate anxiety by improving self-esteem and coping mechanisms. Similarly, managing anxiety can reduce the overall stress load, making ADHD symptoms more manageable. In conclusion, ADHD and anxiety represent two distinct yet interrelated conditions within the spectrum of mental health. The complexity of their relationship underscores the importance of personalized, comprehensive treatment plans. By fostering a deeper understanding of these conditions, individuals can navigate the path to wellness with greater clarity and confidence. This journey, though challenging, is a testament to the resilience and strength inherent in the human spirit, as we seek to understand and overcome the obstacles that lie within our minds. TRANSCRIPT Kimberley: Welcome, everybody. We are talking about ADHD vs anxiety, how to tell the difference, kind of get you in the know of what is what.  Today, we have Dr. Ryan Sultan. He is an Assistant Professor of Clinical Psychiatry at Columbia University. He knows all the things about ADHD and cannabis use, does a lot of research in this area, and I want to get the tea on all things ADHD and anxiety so that we can work it out. So many of you listening have either been misdiagnosed or totally feel like they don’t really understand the difference. And so, let’s talk about it. Welcome, Dr. Sultan. ADHD vs. ANXIETY  Ryan: Thank you. I really like doing these things. I think it’s fun. I think psychiatrists, which is what I am, I think one of the ways that we really fail, and medical doctors in general don’t do well at this, which is like, let’s spend some time educating the public. And before my current position, I did epidemiology and public health. And so, I learned a lot about that, and I was like, “You know how you can help people? We have a crisis here. Let’s just teach people things about how to find resources and what they can do on their own.” And so, I really enjoy these opportunities.  WHAT IS ADHD vs. WHAT IS ANXIETY?   I was thinking about your question, and I was thinking how we might want to talk about this idea of ADHD versus anxiety, which is a common thing. People come in, and they see me very commonly wanting an evaluation, and they think they have ADHD. And I understand why they think they have ADHD, but their main thing is basically reporting a concentration or focus issue, which is a not specific symptom. Just like if I’m moody today, that doesn’t mean I have a mood disorder. If I’m anxious today, it doesn’t mean I have an anxiety disorder. I might even feel depressed today; it doesn’t mean I have a depression disorder. I could even have a psychotic symptom in your voice, and it does not mean that I have a psychotic disorder. It’s more complicated than that.   I think one of the things that the DSM that we love here in the United States—but it’s the best thing we have; it’s like capitalism and democracy; it’s like the best things that we have; we don’t have better solutions yet—is that it describes these things in a way that uses plain language to try to standardize it. But it’s confusing to the general public and I think it’s also confusing to clinicians when you’re trying to learn some of these conditions.  WHEN IS ADHD vs. ANXIETY DIAGNOSED?  And certainly, one of the things that have happened in my field that people used to talk a lot about is the idea that, is pediatric, meaning kid diagnosis of ADHD, which often in my area here in the United States will be done by pediatrician, are they adequately able to do that? Because poor pediatricians have to know a lot. And ADHD, psychiatric disorders are complicated. Mental health conditions are super complicated. They’re so complicated that there are seven different types of degree programs that end up helping you with them. PsyD, PhD, MD, clinical social worker, mental health counselor, and then there’s nurse practitioner. So, like super complicated counseling. So, how do we think about this?  The first thing I try to remind everyone is, if you’re not sure what’s going on with you, please filter your self-diagnosis. You can think about it, that’s great. Write your notes down, da-da-da, but I would avoid acting purely on that. You really want to do your best to get some help from the outside. And I know that mental health treatment is not accessible to everyone. This is an enormous problem that existed before the pandemic and still exists now. I say that because I say that all the time, and I wish I had a solution for you. But if you have access to someone that you think can help you tease this throughout, you want to do that.  SYMPTOMS OF ADHD vs. ANXIETY  But what I would like us to do, instead of listing criteria, which you can all Google on WebMD, let’s think about them in a larger context. So, mental health symptoms fall into these very broad categories. And so, some of them are anxiety, which OCD used to be under, but it’s now in its own area. Another one, would be mood. You can have moods that are really high, moods that are really low. Another one you could take ADHD, you could lump it in neurodevelopmental, which would mix it with autism and learning disorders. You could lump it with attention, but the problem with that is it would also get lumped with dementia, which are processes that overlap, but they’re occurring at different ends of the spectrum.   So, let’s think about ADHD and why someone might have ADHD or why you might think someone has ADHD, because this should be easier for people to tease out, I think. ADHD is not a condition that appears in adulthood. That’s like hands down. Adult ADHD is people that had ADHD and still have ADHD as adults. And most people with ADHD will go on to still have at least an attenuated version, meaning their symptoms are a little less severe, maybe, but over 60% will still meet criteria. It’s not a disorder of children. Up until the ‘90s, we thought it was a disorder of kids only. So, you turned 18, and magically, you couldn’t have ADHD anymore, which didn’t make any sense anyway.   So, to really get a good ADHD diagnosis, you got to go backwards. If you’re not currently an eight-year-old, you have to think a little bit about or talk to your family, or look at your school records. And ideally, that’s what you want to do, is you want to see, is there evidence that you have, things that look like ADHD then? So, you were having trouble maintaining your attention for periods of time. Your attention was scattered in different ways. Things that are mentally challenging that require you to force yourself to do it, that particularly if you don’t like them, this was really hard for you. You were disorganized. People thought that things went in one year and out the other.   Now this exists on a spectrum. And depending on the difficulty of your scholastic experience and how far you pushed yourself in school, these symptoms could show up at different times. For example, it’s not uncommon for people to show up in college or in graduate school. Less so now, but historically, people were getting diagnosed as late as that, because now they have to write a dissertation. For those of you guys who don’t know, a dissertation is being asked to write a book, okay? You’re being asked to write a book. And what did you do? You went to college. Okay, you went to college, and then you had some master’s classes, and then you get assigned an advisor, and you just get told to figure out what your project is. It is completely unstructured. It is completely self-sufficient. It is absurd. I’m talking about a real academic classic PhD. That is going to bring it. If somebody has ADHD, that’s going to bring it out because of the executive functioning involved in that, the organization, the planning. I got to make an outline, I got to meet with my mentor regularly, I got to check in with them, I got to revise it, I got to plan a study or a literature review. There’s so many steps involved. So, that would be something that some people doesn’t come up with then.   Other kids, as an eight-year-old boy that I’m treating right now, who has a wonderful family that is super supportive, and they have created this beautiful environment for him that accommodates him so much that he has not needed any medication despite the fact that there’s lots of evidence that he is struggling and now starting to feel bad about himself, and he has self-esteem issues because he just doesn’t understand why he has to try so hard and why he can’t maintain his attention in this scenario, which is challenging for him.   So, ADHD kids and adults, you want to think of them as their brains as being three to five years behind everyone else in their development, okay? And they are catching up, but they’re more immature, and they’re immature in certain ways. And so, this kid’s ability to maintain his attention, manage his own behaviors, stay organized, it’s like mom is sitting with this kid doing his homework with him continuously, and if she stops at all, he can’t hold it together on his own. So, when we think about that with him, like, okay, well, that’s maybe when it’s showing up with him. That’s when it’s starting to have a struggle with him.   But let’s relate it to anxiety. One problem would be, do you have ADHD or do you have anxiety? Well, there’s another problem. Another problem is having ADHD is a major risk factor for developing an anxiety disorder, okay? So now I’m the eight-year-old boy, and this eight-year-old boy does not have the financial resources to get this evaluation, or the parents that are knowledgeable enough to know that, it might even have been years ago where there was less knowledge about this. And he’s just struggling all the time, and he feels bad about himself, and he’s constantly getting into trouble because he is losing things because he can’t keep track of things because he’s overwhelmed. And now he feels bad about himself. Okay. He has anxiety associated with that. So now we’re building this anxiety. So he might even get mood symptoms, and now we have a risk for depression.   So, this is just one of the reasons why these things are like these tangled messes. You ever like have a bunch of cords that you have one of the dealies, you keep throwing them in a box, and now you’re like, “What do I do? Do I just throw the cords out or entangle them?” It’s a very tangled mess. Of course, it takes time to sort through it. The reason I started with ADHD is that it has a clear trajectory of it when it happens. And in general, it’s a general rule, symptomatology, meaning like how severe it is and the number of symptoms you have and how impairing it is. They’re going to be decreasing as you get older. At least until main adulthood, there’s new evidence that shows there might be a higher risk for dementia in that population.   But let’s put geriatric aside. There’s a different developmental trajectory. Whereas anxiety, oh God, I wish I could simplify anxiety that much. Anxiety can happen in different ways. So, let’s start with the easy thing. Why would you confuse them in this current moment? If I am always worried about things, if I’m always ruminating about things, I’m thinking about it over and over again, I’m trying to figure out where I should live or what I should do about this, and I just keep thinking about it over and over again, and I’m in like a cycle. Like, pop-pa-pa pop-pa pop-pa-pa-pa. And then you’re asking me to do other things. I promise you, I will have difficulty concentrating. I promise you, I can’t concentrate because it’s like you’re using your computer and how many windows do you have open? How many things are you running? I mean, it doesn’t happen as much anymore, but I think most of us, I meant to remember times where you’re like, “Oh, my computer is not able to handle this anymore.” You’re using up some of your mind, and you can call that being present.   So, when people talk about mindfulness and improving attention, one of the things that they’re probably improving is this: they’re trying to get the person to stop running that 15, 20% program all the time. And it’s like your brain got upgraded because you can now devote yourself to the task in front of you. And the anxiety is not slowing you down or intruding upon you, either as an intrusive thought in an OCD way or just a sort of intrusive worry that’s probably hampering your ability to do something concentration-intensive. And then if you have anxiety problems and you’re not sleeping right, well, now your memory is impaired because of that. So, there’s this cycle that ends up happening over and over again.  IS HYPERACTIVITY ANXIETY OR ADHD? Kimberley: Yeah, I think a lot of people as well that I’ve talked to clients and listeners, also with anxiety, there’s this general physiological irritability. Like a little jitteriness, can’t sit in their chair, which I think is another maybe way that misdiagnosis can -- it’s like, “Oh, they’re hyperactive. They’re struggling to sit in their chair. That might be what’s going on for them.” Is that similar to what you’re saying?  Ryan: Yeah. So, really good example, and this one we can do a little simpler. I mean, the statement I’m going to say is not 100% true, but it’s mostly true. If you are an adult, like over 25 for sure, and you are physically jittery, it is very unlikely that that is ADHD. Because ADHD, the whole mechanism as we understand it, or one of the mechanisms causing the thing we call ADHD, which of course is like a made-up thing that we’re using to classify it, is that your prefrontal cortex is not done developing. So, it needs to get myelinated, which is essentially like -- think about it like upgrading from dial up to some great, not even a cable modem. You’re going right to Verizon Fios. Like amazing, okay. It’s much faster, and it’s growing. And that’s the part of you that makes you most human. That’s the most sophisticated part of your brain. It’s not the part that helps you breathe or some sort of physiological thing, which, by the way, is causing some of those anxiety symptoms. They’re ramped up in a sympathetic nervous system way, fight or fight way. It’s the part that’s actually slowing you down. That’s like, “Whoa, whoa, whoa, whoa, whoa, calm down, calm down, calm down.” This is why, and everyone’s is not as developed. So, we’re all developing this thing through 25, at least ADHD is through 28.   Car insurance goes down to 25 because your driving gets better, because your judgment gets better, because you can plan better, because you are less risk-taking. So, your insurance has now gone down. So, the insurance company knows this about us. And our FMRI scans, you scan people’s brains, it supports that change. These correlate to some extent with symptomology, not enough to be a diagnosis to answer the person’s question that they’re going to have that. I wish it was. It’s not a diagnosis. We haven’t been able to figure out how to do that yet.   So, by the time you’re 25, that’s developed. And the symptoms that go away first with ADHD are usually hyperactivity, because that’s the inability to manage all the impulses of your body, not in an anxious, stressed-out way, but in an excited way. You think of the happy, well-supported, running around ADHD kid is kind of silly and fun. It’s a totally different mood experience than the anxiety experience. Anxiety experience is unpleasant for the most part. Unless your anxiety is targeting you to hyper-focus to get something done, which is bumping up some of your dopamine, which is again the opposite experience of probably having ADHD, it’s a hyper-focus experience, certainly, the deficit part of ADHD, you’re going to be feeling a different physiological, the irritability you talked about 100%. You’re irritable because you are trying so hard to manage this awful feeling you have in your body. You physically feel so uncomfortable. It is intolerable.   I have this poor, anxious young man that has to do a very socially awkward thing today. Actually, not that socially awkward. He created the situation, which is one of the ways we’re working on it with him in treatment. And I’m letting him go through and do this as an exposure because it’ll be fine. And he’s literally interacting with another one of our staff members. But he finds these things intolerable. He talks about it like we are lighting him on fire. So, he’s trying to hold it together, or whatever your physiological experience is. It may not have been as dramatic as I described. You’re irritable when people are asking things of you because you don’t have much left. You’re not in some carefree mood where you’re like, “Whatever, I’m super easygoing. I don’t care.” No, you’re not feeling easygoing right now. You’re very, very stressed out.   Stress and anxiety are very linked. Just like sadness and depression are very linked, and like loneliness and depression are linked, but they’re not the same thing. Stress and anxiety are very, very linked, and they’re similar feelings, and they’re often occurring at the same time and interacting with each other. ADD vs. ADHD  Kimberley: Right. One question really quick. Just to be clear, what about ADD vs. ADHD?  Ryan: We love to change diagnostic criteria. People sit around. There’s a committee, there’s a whole bunch of studies. And we’re always trying to epidemiologically and characterologically differentiate what these different conditions are. That’s what the field is trying to do as an academic whole. And so, there’s disagreements about what should be where. So, the OCD thing moving is one of them.   The ADD thing, it’s like a nomenclature thing. So, the diagnosis got described that the new current version of the diagnosis is attention deficit hyperactivity disorder, and then you have three specifiers, okay? So, that’s the condition you have. And then you can have combined, which is hyperactive and inattentive. Just inattentive, just hyperactive. And impulsive is built in there. So, it’s really not that interesting. People love to be like, “No, no, I have ADD. No, I don’t have the hyperactive.” And I’m like, “I know, but from a billing point of view, the insurance company will not accept that code anymore. It doesn’t exist.” DOES ADHD OR ANXIETY IMPACT CONCENTRATION?  Kimberley: Yeah. So, just so that I know I have this right, and you can please correct me, is if you have this more neurological, like you said, condition of ADHD, you’ll have that first, and then you’ll get maybe some anxiety and some depression as a result of that condition. Whereas for those folks, if their primary was anxiety, it wouldn’t be so much that anxiety would cause the ADHD. It would be more the symptoms of concentration are a symptom of the anxiety. Is that what you’re saying? Ryan: Yes, and every permutation that you can imagine based on what you just said is also an option. Like almost every permutation. Like how are they interacting with each other? How are they making each other worse? How are they confusing each other? Because you can have anxiety disorders in elementary school. I mean, that is when most anxiety disorders, the first win, like the wave of them going up is then. And you think about all the anxiety you have.   I got a friend of mine who’s got infants. And it’s fun to see like as they’re developing, when they go through normal anxiety, that that is a thing that they’re going to pass. And then there’s other things where, at some point, we’re like, actually, now we’re saying this is developmentally inappropriate, which means, nope, we were supposed to have graduated from this and it’s still around.   And so, one of the earlier ways that psychiatric conditions were conceptualized, and it’s still a useful way to conceptualize them, is the normal behavior version of it versus the non-normal behavior version of it. And again, I hate non-normal, I don’t want to pathologize people, but non-normal being like, this is causing problems for you. And if you think about it from an evolutionary point of view, all of these conditions have pretty clear evolutionary bases of how they would be beneficial. Anxiety is going to save your ass, okay? Properly applied anxiety, it’ll save your tribe. You want someone who’s anxious, who’s going to be like, “We do not have enough from this winter.” An ADHD person was like, “It’ll be fine. I’m just going to go find something else.” And you’re like, “No.” And then when that winter’s really bad and you save that little bit of extra food, that 30% that the anxious person pushed for, maybe you didn’t eat all 30% of it, but you know what, it probably benefited you and it might’ve actually made the whole tribe survive or more people survive or better health condition. So, it’s approving everyone’s outcomes.   The ADHD individual, you get them excited about something—gone. They’re going to destroy it. They’re going to find all the berries. They’re going to find all the new places. They’re going to find all the new deer. They’re going to run around and explore. It’s great. Great, great, great.   Depression is like hibernation. And if you look at hibernation in a mammal, like what happens, there’s a lot of overlaps. Lower energy, maybe you store up some food for the winter. It’s related to the seasons. You’re in California, right? This is not a problem you have, but for those of us in New York, where we have seasonality, seasonal depression is a thing. It’s very much a thing. It’s very noticeable, and it’s packed on top of these conditions everyone else is having.  But the idea is that the hibernation or the pullback is like something happens to you that upsets you, which is the psychosocial event that’s kicking you in the face that might set off your depression. That’s why people always say, “Oh, depressions just don’t come out of nowhere. This biochemical thing isn’t true.” What they’re saying is something has to happen to start to kick off the depression, but that’s not enough. It’s that you then can’t recover from it.   And so, a normal version of it is that you get knocked out and you spend a week or two, you think about it. Rumination is a part of depression for many people. You reevaluate, and you say, “You know, I got kicked in the face when I did that. That was not a good plan for me. I need a new plan. I either need to do something different or I need to tackle that problem differently.” And so, that would be the adaptive version of a depressive experience. Whereas the non-adaptive version is like, you get stuck in that and you can’t get out.  Kimberley: Or you avoid.  Ryan: The avoiding doing anything about it, and then that makes it worse. So, you started withdrawing. I mean, that’s the worst thing you can do. This is a message to everyone out there. The worst thing that you can do is withdraw from society for any period of time. Look, I’m not saying you can’t have a mental health day, but systematic withdrawal, which most of us don’t even realize is happening, is going to make you worse because the best treatment for every mental health condition is community. It is really. All of them. All of them, including schizophrenia.   I used to work in Atlanta. I did my residency. There’d be these poor guys that have a psychotic disorder. They hear voices. The kinds of people that, here in New York City, are homeless, they’re not homeless there. Everyone just knows that Johnny’s just a little weird and his mom lives down the street. And if we find Johnny just in the trash can or doing something strange, or just roving, we know he’s fine, and someone just takes him back to his mom’s house and checks on him. Because there’s a community that takes care of him, even though he’s actually quite ill from our point of view. But when you put him in an environment where that community is not as strong, like a city, it does worse, which is why mental health conditions are much higher rates in urban areas. Probably why psychiatry and mental health in general is such a central thing in New York City. TREATMENT FOR ADHD vs. ANXIETY  Kimberley: Yeah. Okay, let’s talk quickly about treatment for ADHD. We’re here always talking about the treatment for anxiety, but what would the research and what’s evidence-based for ADHD if someone were to get that clinical diagnosis?  Ryan: So, you want to think about ADHD as a thing that we’re going to try to frame for that person as much as how is it an asset, because it historically has made people feel bad about themselves. And so, there are positive aspects to it, like the hyper focus and excitability, and interest in things. And so, trying to channel into that and then thinking about what their deficits are. So, they’re functional deficits. If you’re talking adult population, functional deficits are going to be usually around executive functioning and organization planning. Imagine if you’re like a parent of small children and you have untreated ADHD, you’re going to be in crazy fight-or-flight mode all the time because there’s so many things to keep track of. You have to keep track of your wife and their life. Kimberley: I see these moms. My heart goes out to them. Ryan: And they’re probably anxious. And the anxiety is probably protecting them a little bit. Because what is the anxiety doing? You think about things over and over and over again, and you double check them. You know what that’s not a bad idea for? Someone who’s not detail-oriented, who’s an ADHD person, who forgets things, and he gets disorganized. So, there’s this thing where you’re like, “Okay, there may actually be a balance going on. Can we make the balance a little bit better?” So, how do you organize yourself?  MEDICATIONS FOR ADHD Right now, there’s a stimulant shortage. Stimulants are the most effective medication for reducing ADHD symptoms. They are the most effective biological intervention we have to reduce the impact of probably any psychiatric condition, period. They are incredibly effective, like 80, 90% resolution of symptoms, which is great. I mean, that’s great. That’s great news. But you also want to be integrating some lifestyle changes and skills alongside of that. So, how do you organize yourself better? I mean, that’s like a whole talk, but like lists, prioritizing lists, taking tasks, breaking them down into smaller and smaller pieces. Where do you start? What’s the first step? Chipping away. You know what? If you only go one mile a day for 30 days, you go 30 miles. That’s still really far. I know you would have gone 30 miles that day, especially if you have ADHD, but you’re still getting somewhere.  And so, that kind of prioritization is really, really important. And so, you can create that on your own. There are CBT-based resources and things to try to help with that. There are ADHD coaches that try to help with that. It’s consistency and commitment around that. So, how do you structure your life for yourself? That poor PhD candidate really needs to structure their life because there is no structure to their life.  The other things we want to think about with that, I mean, really good sleep, physical exercise. People with ADHD, we see on FMRI scans when you scan someone’s brain, there’s less density of dopamine receptors, less dopamine activity. You want to get that dopamine up. That’s what the medications are doing, is predominantly raising the dopamine. So, physical activity, aerobic exercise, in particular, is going to do that. Get that in every day, and look, it’s good for you. It’s good for you. There is no better treatment for every condition in the world other than exercise, particularly aerobic. It basically is good for everything. If you just had surgery, we still want you to get out and walk around. Really quickly, that actually improves your outcome as fast as possible. So, those are the things I like people to start with if they can do that, depending on the severity of what’s going on, the impact, what other things have already been tried. Stimulant medications or non-stimulant medications like Wellbutrin, Strattera, Clonidine are also pretty effective. Methylphenidate products, which is what Ritalin is. Adderall products mixed in amphetamine salts, Vyvanse, these are very effective medications for it. There’s a massive shortage of these medications that people are constantly talking about, and is really problematic and does not appear to have an endpoint because the DEA doesn’t seem ready to raise the amount that they allow to be made because they are still recovering from the opioid crisis, which is ongoing. And so, they’re worried about that. Really, they want to be very thoughtful about this. These medications have a very low-risk potential for misuse. In fact, people with ADHD, they appear to reduce the risk of developing a substance use disorder. It’s the most common thing that people worry about. So, treatment actually reduces that.  That said, the worst -- I mean, I don’t want to say the worst thing. I mean, people hate me. The really not great way to get psychiatric treatment is to show up to someone once and then intermittently meet with them where they write a prescription for a medication for you that’s supposed to help you, and stimulant medications are included on that. So, that’s probably why I didn’t lead with that, even though there’s actually more science to support them, is that by themselves, it’s really going to limit how much help you’re going to get. Kimberley: Can you share why? Ryan: Because you need to understand your condition, because you need to spend time with your clinician learning about your condition and understanding how it’s affecting your life, and understanding how the medication is actually meant to be a tool. It should be like wearing glasses. It doesn’t do the work for you. It doesn’t solve all your problems, but it’s easier to read when you put your glasses on than without it. It supports you. You still need to figure out how to get these things done. It lowers the activation energy associated with it. But you also want to monitor it. You can’t take these medications 24 hours a day and just be ready to go and work, which is things that people have tried. It doesn’t work because you need to sleep, because you will die. They’ve tried this. We know that you will literally die, like not sleeping. And in the interim, you are damaging yourself significantly. So, taking it and timing it in an appropriate way, still getting sufficient sleep, prioritizing other things—they are like a piece of a puzzle, and they are a really powerful piece. But you really don’t want that to be the only thing driving your decision-making, or that be what the interaction is really about. And by the way, the same thing is true for all psychiatric medications. Kimberley: I was going to say that’s what we know about OCD and anxiety disorders too. Medication alone is not going to cut you across the line.  Ryan: And for most people, therapy alone is also not going to cut the line. You have to have a mild case for therapy alone to be okay. And I can trouble for that statement. But the other thing is lifestyle. What lifestyle changes can I make? And those together, all three, are going to mean that you get better faster, you get more better than you would have, you’re more likely to stay better. And they start to interact with each other in a good way, where you get this synergistic effect of ripples of good things happening to you and personal growth. You look back, and you’re like, “Geez, I’m on version 3.0 of me. I didn’t know that there was a new, refined personal growth version of me that could actually function much better. I didn’t actually believe that.” DOES ADHD IMPACT SELF-ESTEEM?  Kimberley: Well, especially you talked about this impact to self-esteem too. So, if you’re getting the correct treatment and now you’re improving, as you go, you’re like, “Okay, I’m actually smart,” or “I’m actually competent,” or “I’m actually creative. I had no idea.”   Ryan: Yes. “I’m not stupid.” Lots of people with ADHD think they’re stupid.   Kimberley: Yeah. So, that’s really cool. One question I have that’s just in my mind is, does --  Ryan: And that should be part of your treatment, is the working through. That was essentially a complex trauma. It’s the complex trauma of having this condition that may not have been treated that made you think that you were an idiot because you were being shoved into a situation that you did not know how to deal with because your ADHD evolved to be an advantage for you as a hunter-gatherer for the hundreds of thousands of years that we had that, and that modern world is not very compliant for. It doesn’t experience you as fitting into it well. And then you feel bad about yourself. ADHD IN MALES vs. FEMALES  Kimberley: Right. You’re the class clown, or you’re the class fool, or the dumb girl, or whatever. Now, my last question, just for my sake of curiosity, is: does ADHD look different between genders?  Ryan: This is an area of significant research. So, historically, the party line has been that ADHD is significantly more common in boys and girls. And the epidemiology, the numbers, the prevalence have always supported that. Like 3 to 1, 2 to 1, like a much more, much more common. Refining of that idea has come up with a couple of thoughts. One, for whatever reason, I don’t know how much of this is genetic. I have no idea how much of this is environmental, sociological. All other things being equal, after a certain young age, girls just always seem to be ahead of boys in their development. I mean, talk to any parent that’s had a lot of kids, and they’ll tell you that they’re like, “I don’t know why the girls are always maturing faster.” So, that’s a bias that is going to always make at any given point. The boys look worse because their brains are not developed. So, they’re going to be -- remember that immature younger thing? They’re going to be immature and younger. And so at any given marker is that.  The other thing that’s come up is that the hyperactivity seems to be something we see a lot more in males than in females. That’s another thing. And versus inattentiveness, which you see in both and is usually the predominant symptom. And the kid who gets noticed is the little boy who’s like -- I mean, not that you could do this in today’s world, but has scissors and is about to cut a kid’s cord. I’m trying to make a silly imagery. That kid’s getting a phone call. No one didn’t notice that. The whole class called that. Whereas like daydreaming, I’m not really listening—this is a more passive experience of ADHD. And they’re not disrupting the room. Forget about the gender thing. Just that presentation is also less noticed.   So, I think the answer is the symptomology presentation is a little different. It tends to be predominantly hyperactive. Are the rates different? Yes, they’re probably not as wide of a difference as we think they are, because we’re probably missing a good number of girls. Are we missing enough girls to make it 50/50? I don’t know. That would be a lot of -- it’s a big gap. It’s not close. It’s a pretty big gap. Maybe we’re certainly missing some.   And then the other aspect of it is particularly post-puberty. Even before puberty, there’s hormonal changes going on. And these hormones, particularly testosterone, which is present in everyone, we think about it as a male thing, but it’s really just like a balance thing. You have significant amounts of both. It affects a number of things, and attention is one of them. So, there’s so many complexing factors to it. That’s why I said, it’s something we’re still trying to sort out.   One of the things that’s really interesting that goes back to the hormone thing is that if you talk to young women— so postmenstrual, they’ve gone through puberty—they will tell you over and over again that their symptomology, just like we have mood symptoms tend to be worse during that time period of when you’re ovulating, the ADHD symptoms will be worse as well. And so, there’s increasing evidence that if you’re on ADHD medication and you have ADHD, which again, we’re making lots of presumptions here, go get that confirmed, guys. But if you’re on that time period just leading up to ovulation a little bit after, you may actually need a higher dose of your medication to get the same effect. That there’s something about the way progesterone and whatever is changing that it affects functionally your attention and your experience of your symptomatology.   Kimberley: Interesting. Yeah, thank you for sharing that. Is there anything you feel like we’ve missed or a point you really want to make for the folks who are listening who are trying to really untangle, like you said, that imagery of untangle, anxiety, ADHD, all of the depression, self-esteem?  Ryan: This is like a sidebar that’s related. So, one of my other areas of interest is cannabis. And here in New York, we’ve had a lot going on with cannabis. And there’s a lot of science going on around, can cannabis be used to treat things, particularly psychiatric disorders? And I know that a lot of people are interested in that.  One of the things that I’ve been really trying to caution people around with it is that the original thing that I was probably taught in the ‘90s about cannabis, marijuana being like this incredibly unsafe thing, is not true. But the narrative that it’s totally fine and benign is also not true. And that it is probably going to be effective in reducing anxiety acutely, and it will probably be effective in maybe even improving your mood. And some people with ADHD even think it improves their attention by calming their mind. I am very cautious about people starting to use that as part of their treatment plan. And I can tell you why.  Kimberley: Because you did say there’s an increase in substance use.  Ryan: The problem is that it’s not rolled out in a way that reflects an appropriate medical treatment. So, if you do it recreationally, obviously, it’s basically like alcohol. You just get what you want, and you decide what you want. If you do it medically, depending on the state, as a general rule, you just get a medical card and then you decide what you’re going to do, which just seems crazy to me. I mean, you don’t do that. You don’t send people home with an unlimited amount of something that is mind-altering and tell them to use as much as they need. And the potencies, the strength of it has gotten stronger and stronger.   And so, I really caution people around this because when you use it regularly, what ends up happening is you get this downregulation, particularly daily use. You get this downregulation of your receptors, your cannabinoid receptors. We all have cannabinoid receptors. And you have fewer and fewer of them. And because you have so much cannabinoid in your system because you’re getting high that your body says, “I don’t need these receptors.” So then when you don’t get high, those cannabinoid receptors that modulate serotonin, dopamine—so functionally, your attention, your mood, your anxiety level—there’s none of them left because they’ve been getting bound like crazy to this super strong thing. And you’re making almost none yourself, so you’re going to feel awful. You’re going to feel awful. And it’s not dosed in any kind of appropriate way. We’re not giving people guidance on this.   So, I really caution people when they’re utilizing this, which the reality is that a lot of people are, that they be thoughtful about that and thoughtful about the frequency that they’re using and the amounts that they’re using, and if they’re at a point where they’re really trying to self-medicate themselves, because that can really get out of control for people. They can get really out of control. And I think it’s unfortunate that we don’t have a better system to help people with that. That is more like the evaluation of an FDA-approved medication or something like that has a system through it.   So, I just wanted to add that because I know this is something that a lot of people are thinking about. And I think it can be hard to get really good science information on since there’s a big movement around making this change. When we’re doing a big movement around pushing for a change, we don’t want to talk about the reasons that the change might be a little problematic, and therefore slow the change down. So, we forget about that. And I think for the general public, it’s important to remember that.  Kimberley: Yeah, I’m so grateful that you did bring that up. Thank you. Where can our listeners learn more about you or be in touch with you?  Ryan: So, if they want to learn more about my practice, my clinical practice, integrativepsych -- no, integrative-psych.org. We changed. We wrote .nyc. There we go. And then if you want to learn about my science and my lab and our research, which we also love, if you just go to Sultan (my last name) lab.org, it redirects to my Columbia page, and then you can see all about that and send some positive vibes to my poor research assistants that work so hard.   Kimberley: Wonderful. I’m so grateful for you to be here. Really, I am. And just so happy that you’re here. So much more knowledgeable about something that I am not. And so, I’m so grateful that you’re here to bring some clarity to this conversation, and hopefully for people to really now go and get a correct assessment to define what’s going on for them.  Ryan: Yeah, I hope everyone is able to digest all this. I said a lot. And can hopefully make better decisions for themselves for that. Thank you so much.  Kimberley: Thank you.

Exploring the relationship between faith and recovery, especially when it comes to managing Obsessive-Compulsive Disorder (OCD), reveals a complex but fascinating landscape. It's like looking at two sides of the same coin, where faith can either be a source of immense support or a challenging factor in one’s healing journey. On one hand, faith can act like a sturdy anchor or a comforting presence, offering hope and a sense of purpose that's invaluable for many people working through OCD. This aspect of faith is not just about religious practices; it's deeply personal, providing a framework that can help individuals make sense of their struggles and find a pathway towards recovery. The sense of community and belonging that often comes with faith can also play a crucial role in supporting someone through their healing process. However, it's not always straightforward. Faith can get tangled up with the symptoms of OCD, leading to situations where religious beliefs and practices become intertwined with the compulsions and obsessions that characterize the disorder. This is where faith can start to feel like a double-edged sword, especially in cases of scrupulosity, where religious or moral obligations become sources of intense anxiety and compulsion. The conversation around integrating faith into recovery is a delicate one. It emphasizes the need for a personalized approach, recognizing the unique ways in which faith intersects with an individual's experience of OCD. This might involve collaborating with religious leaders, incorporating spiritual practices into therapy, or navigating the complex ways in which faith influences both the symptoms of OCD and the recovery process. Moreover, this discussion sheds light on a broader conversation about the intersection of psychology and spirituality. It acknowledges the historical tensions between these areas, while also pointing towards a growing interest in understanding how they can complement each other in the context of mental health treatment. In essence, the relationship between faith and recovery from OCD highlights the importance of a compassionate and holistic approach. It's about finding ways to respect and integrate an individual's spiritual beliefs into their treatment, ensuring that the journey towards healing is as supportive and effective as possible. This balance is key to harnessing the positive aspects of faith, while also navigating its challenges with care and understanding. Justin K. Hughes, MA, LPC, owner of Dallas Counseling, PLLC, is a clinician and writer, passionate about helping those impacted by OCD and Anxiety Disorders. He serves on the IOCDF's OCD & Faith Task Force and is the Dallas Ambassador for OCD Texas. Working with a diversity of clients, he also is dual-trained in psychology and theology, regularly helping anyone to understand the interaction between faith and mental health. A sought-after writer and speaker, he is currently mid-way through writing his first workbook on evidence-based care of OCD for Christians. He is seeking a collaborative agent who will help secure the best publishing house to help those most in need. Check out www.justinkhughes.com to stay in the loop and get free guides & handouts! Kimberley: Welcome, everybody. Today, we’re talking about faith and its place in recovery. Does faith help your recovery? Does it hinder your recovery? And all the things in between.  Today, we have Justin Hughes. Justin is the owner of Dallas Counseling and is a clinician and writer. He’s passionate about helping those who are impacted by OCD. He is the Dallas ambassador for OCD Texas and serves on the IOCDF’s OCD and Faith Task Force, working with a diversity of clients. He’s also dual-trained in psychology and theology, regularly helping anyone to understand the interaction between faith and OCD, most commonly Christians. But today, we’re here to talk about faith in general. Welcome, Justin. Justin: Kimberley Jayne Quinlan, howdy. Kimberley: You said howdy just perfectly from your Texas state.  Justin: Absolutely. Kimberley: Okay. This is a huge topic. And just for those who are listening, we tried to record this once before, we were just saying, but we had tech issues. And I’m so glad we did because I have thought about this so much since, and I feel like evolved a little since then too.  So, we’re here to talk about how to use faith in recovery and/or is it helpful for some people, and talk about the way that it is helpful and for some not. Can you share a little bit about your background on why this is an important topic for you? Justin: Absolutely. So, first of all, as a man of faith, I’m a Christian. I went to a Christian college, got my degree in Psychology, and very much desired to interweave studies between psychology and theology. So, I went to a seminary. A lot of people hear that, and they’re like, “Did you become a priest?” No, it was a counseling program at a seminary, Dallas Theological Seminary. I came here and then found my wife, and I stayed in Dallas.  And it’s been important to me from a personal faith standpoint. And I love the faith integration in treatment and exploring that with clients. And of course -- or maybe I shouldn’t say of course, but it’s going to be a lot of Christians, but I work with a lot of different faith backgrounds. And there are some really important conversations happening in the broader world of treatment about faith integration and its place. And we’re going to get into all those things and hopefully some of the history and psychology’s relationship to faith, which has not been the greatest at different points. For me personally, faith isn’t just an exercise. It’s not something that I just add on to make my day better. In fact, a lot of times, faith requires me to do way more difficult things than I want to do, but it’s a belief in the ultimate object of my faith in God and Christ as a Christian. I naturally come across a lot of people who not only identify that as important but find it as very essential to their treatment. And let’s get into that, the folks that find it essential, the people who find it very much not, and the people who don’t. But that’s just a little bit about me and why I find this so important. Kimberley: Yeah. It’s interesting because I was raised Episcopalian. I don’t really practice a lot of that anymore for no reason except, I don’t know, if I’m going to be really honest.  Justin: So honest. I love that.  Kimberley: Yeah, I’ve been thinking about it a lot because I had a positive experience. Sometimes I long for it, but for reasons I don’t know. Again, I’m just still on that journey, figuring that piece out and exploring that.  Where I see clients is usually on the end of their coming to me as a client, saying, “I’m a believer, but it’s all gotten messed up and mushed up and intertwined.” And I’m my job. I think of my job as helping them untangle it. Justin: Yeah. Kimberley: Not by me giving my own personal opinion either, but just letting them untangle it. How might you see that? Are you seeing that also? And what is the process of that untangling, if we were to use that word? Justin: It’s so broad and varied. So, I would imagine that just like with clients that I work with and folks that come to conferences and that I talk with, the listeners in your audience, hi listeners, are going to have a broad experience of views, and it’s so functional. So, I want people to hear right away that I don’t think that there’s just a cookie-cutter approach. There can’t be with this. And whether we’re treating OCD, anxiety disorders, or depression, or eating disorders, or BFRVs, fill in the blank, there are obviously evidence-based treatments which are effective for most, but even those can’t be a cookie cutter when it comes down to exactly what a person needs to do or what is required of them in recovery.  So, yes, let me just state this upfront for the folks that might be unduly nervous at this point. First of all, the faith piece, religious piece, does not have to enter into treatments for a lot of people to get the job done. In fact, actually, for a lot of people, it was much more healing for them, including many of my clients. I have friends and family members that sometimes look at me as scant. So like, “Wait, you went to seminary, and sometimes you don’t talk about God at all.” And it’s like, “Yeah, sometimes we’re just doing evidence-based treatment, and that is that.” And as an evidence-based practitioner, that’s important to me.  So, when people come in, I want to work with what their goals are, their values. And a lot of people have found themselves, for any number of reasons, stuck, maybe compulsions or obsessive thoughts or whatever, are stuck in all things belief, religion, or faith or whatever else. And sometimes actually, the most healing thing for them to do is sometimes get in, get out, do the job clinically, walk away, experience freedom, and then grow and develop personally.  But then I’ve also discovered that there’s this other side that some people do not find a breakthrough. Some people stay stuck. And maybe these are the people that hit the stats that we see in research of 20% or so just turn down things like ERP, (exposure and response prevention) with OCD when they’re offered. And then another 20 to 30% drop out. And we have great studies that tell us that most people who stick with it get a lot of benefits, but there’s all the other folks that didn’t. And sometimes it’s because people -- no offense, you all, but sometimes people just don’t want to put in the work and discipline.  However, we can’t minimize it to that. Sometimes it’s truly people that are willing to show up, and there’s a complex layer of things. And the cookie-cutter approach is not going to work for them. Maybe they have the intersection of complex health issues, intersection of trauma, intersection of even just family of origin things where life is really difficult, or even just right now, a loneliness epidemic that’s happening in the world.  And by the way, I’m a huge believer in the evidence base. There’s a lot in the evidence base that guides us. And as I’m talking today, I want to be really clear that when I work with folks, even when we get into the spiritual, I’m working with the evidence base. Yeah, there’s things that there’s no specific protocol for, but a lot of folks, I think, can hopefully be encouraged that there’s a strong research base to the benefits and the use and the application and also the care of practicing various spiritual practices through treatments.  So, to come back to the original question, it depends so much. It’s like if somebody asked me a question like, “Hey, Justin. Okay, so as a therapist, do you think that --” and I get these questions all the time, “Is it okay for me to...? Like, I am afraid of this.” I got this question at one point. Somebody was curious if I thought it was okay for them to travel to another city. And it’s like, it depends. It’s almost always an “it depends.”  So, that’s where I’m going to leave it, that nice, squeaky place that we all just want a dang answer, but the reality is, it is going to massively depend on the person and where they are, and what their needs are. Kimberley: Yeah, I mean, and I’ll speak to it too, sometimes I’ve seen a client. Let’s give a few examples of a client with OCD. The OCD has attacked their faith and made it very superstitious or very fear-based instead of faith-based. And I think they come in with that, “Everything’s so messy and it used to make so much sense, and now it doesn’t.”  For eating disorders, I’ve had a lot of clients who will have a faith component where there are certain religions that have ways in which you prepare foods and things, and then that has become very sticky and hard for them. The eating disorder gets involved with that as well.  And let me think more just from a general standpoint, and I’ll use me as an example, as just like a generally anxious person. I remember this really wonderful time, I’ll tell you a funny story, when my daughter was like five, out of nowhere, she insisted that we go to every church. Like she wanted to go to a Christian and a Catholic and Jewish temple and Muslim and Buddhist. She wanted to try all of them, and we were like, “Great, let’s go and do it.” And I could see how my anxious brain would go black and white on everything they said. So, if they said something really beautiful, my brain would get very perfectionistic about that and have a little tantrum. I think it would be like, “But I can’t do it that perfect,” and I would get freaked out, but also be able to catch myself. So, I think that it’s important to recognize how the disorder can get mixed up in that. Justin: Yeah, absolutely. Kimberley: Right? Let’s now flip, unless you have something you want to add, to how has faith helped people in their recovery, and what does that look like for you as a clinician, for the client, for their journey? Justin: Yeah, absolutely. Well, on the clinical side of things, the starting place is always going to be the assessments and diagnosis and treatment plan. And then the ethics of it too is going to be working with the person where they are and their beliefs and not forcing anything, of course. And so folks are naturally -- I get it, I respect it. I would be nervous of somebody of a different belief background that’s overt about things. Some people come in, they look at the wall, they see Dallas Theological Seminary, they’ve studied a few things in advance. So, yeah, the starting places, sitting down, honest, building rapport, trust, assessing, diagnosing. So, for the folks where the faith piece is significant, I’ll put it into two categories. So, one is sometimes we have to talk about aspects of faith just from a pure assessment sample. So, a common example of that is scrupulosity in OCD. So, I have worked with even a person on the, believe it or not, Faith and OCD Task Force who is atheist. And so, why in the world do we need to talk about faith? Why is that person even on the Faith and OCD Task Force? Well, they’re representing a diversity of views and opinions on the role of faith and OCD.  Kimberley: Love it. Justin: And it’s so interesting to look at it at a base level with something like OCD. But frankly, a lot of mental disorders or even just challenges in life, if clinicians, one, aren’t asking questions about, hey, do you have any religious views, background, even just in your background? Do you have spiritual practices that are important to you? We’re missing a massive component. And here’s the research piece. We know from the research that, actually, a majority of people find things of faith or spirituality important, and secondarily, that a majority of people would like to be able to talk about those things in therapy. Straight-up research. So, a couple of articles that I wrote for the IOCDF on this reference this research. So, it is evidence-based to talk about this.  And then when we get into these sticky areas of obsessions and anxiety disorders, of course, it’s going to poke on philosophy, worldview, spirituality. And so, it could be even outside of scrupulosity, beliefs that at first it just looks like we need some good shame reduction exercises, self-compassion, and so forth, but we discover that, oh, the person struggling with contamination OCD has a lot of deeper beliefs that they think that somehow, they are flawed because they’re struggling. They’re not a good enough, fill in the blank, Christian. They’re not good enough. Because if so, surely God would break through in a bigger way. If so... Wouldn’t these promises that I’m told in scriptures actually become true?  And the cool thing is, there’s a richness in the theology that helps us understand the nuance there, and it’s not that simple. But if we miss that component, and it’s essential for treatment, it’s not just like, “Oh, I feel bad about myself. And yeah, sometimes I’m critical with myself.” And if we don’t go at that level of core fear, or core distress, or core belief, oftentimes we’re missing really a central part of the treatment, which we talk about in any other domain. People just get nervous sometimes, thinking about spirituality. It’s like politics and religion, right? Nobody talks about those things. Well, if we’re having deeper conversations, we usually are. And as clinicians, those of you that are listening to the podcast as clinicians, you know that you have to work with people of different political leanings, people of different faith leanings, people who actually live in California versus [inaudible]. I love California.  So, the first category is, if we’re doing good clinical work, we’re going to be asking questions because it matters to most people. If we don’t, we’re missing a huge piece. It doesn’t mean you’re a bad therapist, but hey, start asking some questions if you’re not, at a minimum.  But then there’s the second piece that most people actually want to know, and most people have some aspects of practice or integration, or even the most religion church-averse type of person will have any number of things come up such as, “Yeah, I pray occasionally,” or “Yeah, I do this grounding exercise that puts me in touch with the universe or creation or whatever it is.”  So, there’s the second category of when it is important to a person because it’s part of the bigger picture of growth, it’s part of the bigger picture of breaking free from challenges that they have, and, frankly, finding meaning. And I’ll just make one philosophical comment here, because I’m a total nerd. Psychology can never be a worldview. Psychology tells us what. Psychology is a subset of science. And by worldview, I mean a collective set of beliefs, guidance, direction about how life should be lived. We can only say, “Hey, when you do this, you tend to feel this way, or you tend to do these behaviors more or do these behaviors less.” At the end of the day, we have to make interpretations and judgments about right and wrong, how to live life, the best way to live life. These are in the realm of interpretation.  So, surprise, surprise, we’re in the realm of at least philosophy, but we very quickly get into theology. And so back to the piece that most people care about it, most people have some sort of spiritual practice that they’ll resonate with and connect with. And then most people actually want to integrate a little bit into therapy. And then some people find that it is essential. They haven’t been able to find any lasting freedom outside of going deeper into a bigger purpose, `bigger meaning. Kimberley: You said a couple of things that really rang true for me because I really want to highlight here, I’m on the walk here as well as a client. And I love having these conversations with clients, not about me, about them, but them when they don’t have a spiritual practice, longing for one. I’ve had countless clients say, “I just wish I believed.” And I think what sometimes they’re looking for is a motivator. I have some clients who have a deep faith, and their North Star is that religion. Their North Star is following the word of that religion or the outcome of it, whether it be to go to heaven or whatever, afterlife or whatever. They believe like that’s the North Star. That’s what determines every part of their treatment. Like, “Why are we doing this exposure today?” “Because this is my North Star. I know where I’m heading. I know what the goal is.” And then I have those clients who are like, “I need a North Star. I don’t have one. I don’t get the point.” And I think that is where faith is so beautiful in recovery.  When I witness my clients who are going to do the scary thing, they don’t want to do it, but they’re so committed to this North Star, whatever it might be. And maybe there’s a better language than a North Star, again, whatever that is for that person. Like, “I’m walking towards the light of whatever that religion is.” I feel, if I’m going to be honest, envious of that. And I totally get that some people do too.  What would you say to a client who is longing for something like that? Maybe they have spiritual trauma in some respects or they’ve had bad experiences, or they’re just unsure. What would you say to them? Justin: Yeah, that’s really great. And first of all, I just want to really say that it takes a lot of vulnerability and strength to talk as you do. And one of the ways that I admire you, KQ, is through your ability to have these vulnerable conversations. So not just like the platform of expert, because at the end of the day, we’re all just people and on a journey for sure. And so thanks for being honest with that.  And I’m on a journey as well. And certainly, I realized jumping on podcasts, these things put us in the expert role and we speak at conferences and things like that. But I think that’s a bit of the answer right there, is that being where we are to start with is so huge. And I mean, you’re so good with the steps to take around acceptance and compassion. That’s it. It’s like fear presses towards a thousand different possibilities, and none of them come true exactly that way. And it can lead towards people missing a lot of personal growth stuff, spiritual growth stuff. And one of those things, I think, that we do is we sit with that. Clinically, I’m going to assess, ask a lot of questions, Socratic questions as a subset of the cognitive therapy side of doing that. Let me just come back to the simplicity. I think we get there. We sit in it for a second. And otherwise, we miss it. We’re rushing to preconceived solutions or answers, but we’re saying that we don’t necessarily have an answer for that. So, what if we take some time to actually notice it and to be with that and to actually label it and be like, “I’m not sure. I’m yearning. I’m envious. I’m wanting something, but I don’t know. So, put me in, coach.” I’ll sit with people. That’s really the first thing.  Kimberley: Yeah. What I have practiced, and I’ve encouraged clients is also being curious, like trying things out if that lines up with their values, going to a service, reading a book, listening to a podcast, and just trying it on. For me, it’s also interesting with clients, is if they’re yearning for it, try it on and observe what shows up. Is it that black-and-white thinking or perfectionism? Is it your obsessions getting involved? Is it that it just doesn’t feel good in your body? And so forth. Again, just be where you are and take it slow, I think.  I have a few other areas I want you to look at in terms of giving me your professional thoughts. If somebody wants to incorporate faith into their treatment, what can that look like? Can it look like praying together? What does that look like? Justin: You’re asking all the good questions. Yeah, absolutely. And also, one other thing to reference, I know you’re friends with Shala Nicely and Jeff Bell. And so they wrote a book. And for those that are on that, I would say, more “I’m seeking journey,” it’s When in Doubt, Make Belief: An OCD-Inspired Approach to Living with Uncertainty. And I love Shala and Jeff. They’re so great, and they’ve been really pivotal people in my own life, not just as friends, but just as personal growth too. And so, that’s an example specifically where Shala talks about the throes of her suffering. Is Fred in the Refrigerator? is her basically autobiography that goes into the clinical piece too, where at the end of the day, there was a bit of a pragmatic experience that she couldn’t -- the universe being against her, she basically always had that view and she needed something that was different. And so she got there, I think. I hope I’m reflecting her sentence as well, but got there pragmatically. “The universe is friendly” is something that she said.  Now, I just know that my Christian brothers and sisters, if they’re listening to this, they’re probably like, “What the heck is Justin talking about? The universe is friendly?” Because that’s very, very different from the language that we’ve used, but it’s just such a great example to me of just one step at a time, a person on the journey. They’re looking at those things and assessing, okay, what is obsessive, what is compulsive, what is this thing that I can believe in and I ultimately do, but maybe I’m not. I don’t want to or I’m not ready, or it doesn’t make sense to me to make a jump into an organized religious plea for whatever else. And so, how does it look for clients?  So in short, do I pray with clients? Yeah, absolutely. Do I open up the Bible? Yes, absolutely. Actually, it is a minority of sessions, which again, on my more conservative friends and family side of things are almost shocked and scratching their heads. Like, “You’re a Christian, you do counseling, and you’re not doing that.” We’re a bunch of weirdos. We’re in that realm of the inter-Christian circle in a good sense. We believe so deeply that God loves us and God has interceded and does intercede, and interacts with our present, not just a historical event here and there, and we’re left on our own, the deistic watchmaker, to use a philosophical reference there. That because we believe that so strongly, we’re not going to take no for an answer in the sense of the deeper growth and deeper faith.  So, sometimes that backfires though, especially getting into the superstitious, like, “Well, God’s got to be in everything, and I’m not feeling it,” as opposed to like, “Okay. Is it possible that I could just have a brain that gives me some pretty nasty thoughts sometimes and it doesn’t necessarily reflect that I’m in a bad state, that I can be curious about what a person getting mangled by a car might look like mentally and then be terrified by that?” And then like, “Thanks, brain, for giving me the imagination. Glad I can think through accidents so I can maybe be a safer driver.” Yeah, absolutely. But I will say that’s one of those sticky points a lot of times for Christians because we believe that thoughts matter and beliefs matter. And so there can be this overinterpretation of everything is always something really big and serious about my status and my heart, and something that’s really big and serious about spiritual things or demonic stuff, or fill in the blank.  So, the faith integration piece, I do carefully, but I’m not scared of it. I’ve done it so often. It’s through a lot of assessments. It has to be from the standpoint of the client’s wanting that. Usually, the client is asking me specifically, like, “Hey, would you pray at the end of the session?” Sure, absolutely, in most cases.  And this, such a deep topic. I’m fully aware that there are those in the camp that view faith integration as completely antithetical to what needs to happen in treatments. And they argue their case, they’re going to argue it really strongly, but the same exists on the other side as well. And I try and work in that realm of, okay, what’s good for the clients? And are there some things that I don’t do? Yeah, but I’m not really asked to do them.  I’ve had a number of Muslim clients throughout the year. I don’t join in with Ramadan with clients in various practices or fasting with a client, for example. That’s not my faith practice there. But can I walk with the client who is trying to differentiate between the lines of fasting and I had water at this point, and the sun was going down and I thought. And other people were having water, but I’m getting stuck on assessing, like, was it too early, and did I actually violate my commitment, my vow? Did I violate what I was supposed to be doing?  I can absolutely work with that person, and I need to. I can’t really work with OCD or anxiety disorders if I wanted to turn that person away at the door and be like, “Oh, well, I’m not Muslim, so I’m sorry.” No, we’re going to jump into it and be like, “Okay, so tell me about this thought and then this behavior that came up at this time, and you’re noticing that that’s a little different from your community, that other people are starting to drink water, eat food. And so, you mentioned that it was right at sunset, but what time was that?” “Well, actually, it was like 10:30 p.m. It’s two hours dark.” It’s like, “But I think I saw a glow in the distance.” And it’s like, “Okay, now we’re into a pretty classic OCD realm.” And so the simplest way that I can say that faith integration can be done in therapy is carefully, respectfully, with good assessments. Kimberley: Do you have them consult with their spiritual leader if you’re stuck on that? And does that involve you speaking with them, them speaking with them, all three of you? What have you done? Justin: Yeah, absolutely. So, there is a collaboration that goes in a number of different ways. Most of the time, people can speak with their clergy member or faith leader pretty directly, pretty separately, and that is going to work just fine. I would say in most cases, people don’t need to, especially if I’m working with OCD. A lot of folks usually have a pretty good general sense of, “Okay, I know what my faith community is going to say about this is X, but I’m scared because it feels like it’s on shaky ground, I’m obsessing,” et cetera.  So, the clarification with the clergy, for instance, or a leader is more from the standpoint of if there’s not a defined value definition practice, and that does come up for sure. So, helping that person to even find who that might be, especially if they’re not a part of that, and/or maybe a good article to read with some limits, like, okay, three articles max. Check out a more conservative view, a more liberal view, a more fill in the blank.  And then my friend and colleague Alec Pollard up at St. Louis Behavioral Medicine Institute, he’s been on scrupulosity panels with me. He uses this excellent form called the PISA, (Possibly Immoral or Sinful Act). And it’s just a great several-question guide. That or any number of things can be taken to clergyperson, leader in Christian circles a lot of times, like a Bible study or community group. Maybe flesh those things out just a little bit, maybe once, maybe twice max.  And so, back to how much others are integrated, yeah, it’s a mix and match, anything, everything. For me, with direct conversations with clergy, it’s actually because I’m pretty deep into this realm, I have pretty easy access to a lot of folks, so I don’t really need to so much talk directly or get that person on a release. But a lot of people do, especially if they don’t know that religious belief or faith traditions approach on certain topics.  Kimberley: Yeah. It’s so wonderful to talk about this with you.  Justin: Thanks, Kimberley. Same here. Kimberley: Because I really do feel, I think post-COVID, there’s more conversations with my clients about this. This could be totally just my clients, but I’ve noticed an increased longing, like you said, for that connection, the loneliness pandemic. Justin: Yeah, that’s statistical.  Kimberley: Such a need for connection, such a need for community, such a need for that, like what is your North Star? And it can be, even if we haven’t really talked about depression, it can be a really big motivator when you’re severely depressed, right? Justin: Absolutely.  Kimberley: And this is where I’m very much like so curious and loving this conversation with my clients right now in terms of, where is it helpful? Where isn’t it helpful? As you said, do you want to use this as a part of your practice here in treatment, in recovery? And what role does it play? I know I had mentioned to you, I’d even asked on Instagram and did a poll, and there were a lot of people saying, “It gave me a community. It immensely helps. It does keep me focused on the goal,” especially if it’s done intentionally without letting fear take over. Is there anything you wanted to add to this conversation before we finish up?  Justin: Yeah, I guess two things. So, one is you talked about that, and we talked about a couple of those responses before we jumped on to recording. So, in summary, the responses were all across the board, like, “Ooh.” Let me know if I’m summarizing this well, but, “I have to be really careful. That can be really compulsive or not so much. I don’t like to do that. I don’t think it’s necessary.” And then like, yeah, absolutely. This is really integral and really important. Is that a fair summary? Kimberley: Very much. Yep.  Justin: Okay. And so, I’m building this talk, Katie O'Dunne and Rabbi Noah Tile, ERP As a Spiritual Practice. We’re giving here at the Faith and OCD Conference in April, if this is out by then. And in my section that I have, I’m covering the best practices of treatments, specifically ERP (exposure and response prevention) for OCD, and clinically, but then also from a faith standpoint, what do we consider with that? And there’s this three-prong separation that I’m making. I’m not claiming a hold on the market with this, but I’m just observing. There’s one category of a person who comes into therapy, and it’s like, yeah, face stuff, whatever. It doesn’t matter, or even almost antagonistic against it. Maybe they’ve been burnt, maybe they’ve been traumatized or abused with faith. Yeah, I get it. So, that first camp is there. But then there’s also a second camp that people like to add on spiritual practices. They might mix and match, or they might follow a specific system, belief system. And whether it gets into mindfulness or meditation practices or fasting or any number of things, they find that there’s a lot of benefit, but it’s maybe not at the heart of it.  And then there’s this third prong of folks that it is part and parcel of everything they do. And I work with all three. They come up in different ways. And sometimes people cycle between those different ones as well in treatments in the process.   Kimberley: I’m glad you said that. Justin: Yeah. And so, I just thought that was interesting when you pulled folks that had come up. Really, the second thing, and maybe this is at least my ending points unless we have anything else, you had mentioned to the audience that graciously, we had some tech issues. You all, it wasn’t Kimberley’s tech issues. It was Justin’s tech issues. I spilled coffee on my computer like a week or two prior. It zapped. It’s almost like you’d see in a movie, except it wasn’t sparking. And I’m like, “Oh my goodness.” And it was in a client session. That was a whole funny story in of itself. And I’m like, “Oh my goodness.” It wasted my nice computer that I use for live streaming and all of that. And so I’m using my little budget computer at home. It’s like, “Oh, hopefully it works.” And it just couldn’t. It couldn’t keep up with all the awesomeness that KQ’s spitting out. And I shared with you, Kimberley, a little bit on the email, something deep really hit me after that. I felt a lot of shame when we tried back and forth for 30 minutes to do it, and my computer kept crashing, basically because it couldn’t stand the bandwidth and whatever else was needed. And one might think it’s just a technical thing, but I’d had some stuff happen earlier that week. I started to play in my church worship band, lead guitar, and there was something that I just wasn’t able to break through, and I was just feeling ashamed of that. And it just really hit me.  And one of my key domains that I am growing in is my own perfectionism, as a subset of my own anxiety, and perfectionism is all about shame. And I love performance, I love to perform well. I like to say, “Oh, it’s seeking excellence, and it’s seeking the best for other people’s good.” But deep down inside, perfectionism is this shame piece that anything shy of perfect is not good enough, and it just hit me. I felt like trash after that happened. I felt embarrassed. And you were so gracious, “It’s okay, we’ll reschedule.”  And so, I went for a walk, which I do. Clear my mind, get exercise. And I was just stuck on that. And one of the ways where my Christian walk really came in at that moment was, I started to do some cognitive restructuring. I started to -- for you all who don’t know, it’s looking at the bigger picture and being more realistic with negative thoughts. Like, “Ah, I can’t believe this happened. I failed this,” as opposed to like, “Okay, we’re rescheduling. It’s all right. It actually gave us more time to think about it.” And I didn’t know that then, but I could have said similar things.  I was doing a bunch of clinical tools that are helpful, but frankly, it wasn’t until I just tapped into the bigger purpose of, one, not controlling the universe. I don’t keep this globe spinning. I barely keep my own life spinning. Two, God loves me. And three, it’s okay. It’s going to work that out. Four, maybe there’s something bigger, deeper going on that I don’t know. And I can’t guarantee that it was for this reason. I’m not going to put that in God’s mouth and say that, “Oh yeah, okay, well, He gave us a couple more weeks to prepare.” I don’t know. I really don’t know. But it helped me to tap into like, “Okay, it’s all right. It’s really all right.”  And it took me about half a day, frankly. I’m slightly embarrassed to say, “No, I’m not embarrassed to say that as a clinician who works with this stuff. I have full days, I have full weeks. I have longer periods of time where I’m wrestling with this stuff.” And yeah, areas have grown. I’ve improved in my life for sure, but I’m just a hot mess some days.  Kimberley: But that’s nice to hear too, because I think, again, clients have said it looks so nice to be loved by God all the time. That must be so nice. But it’s not nice. I hate that you went through that. But I think people also need to know that people of faith also have to walk through really tough days and that it isn’t the cure-all, that faith isn’t the cure-all for struggles either. I think that’s helpful for people to know. Justin: Yeah, that’s right. So, thank you for letting me share a little bit of that. And yeah, the personalized example of why, at least for me, faith is important. If folks come into my office and they say, “Nah, no thanks,” okay, I’m going to try lightly, carefully, or just avoid it altogether if that’s what they want. But oftentimes it’s really at the center of, okay, purpose, meaning, direction, guidance, and okay, you want to do that? I’ll roll up my sleeves, and let’s go.  Kimberley: Yeah. See, I’m glad that it happened because you got to tell that beautiful story. And without that beautiful story, I would be less happy. So, thank you for sharing that and being so vulnerable. I think I shared with you in an email like I’ve had to get so good at letting people down that I get it. And I love that you have that statement, like God loves me. That is beautiful. That’s like sun on your face right there. I love that you had that moment.  Justin: Yeah, it comes up so much, so many times. In the Bible and even to -- like I wrote this article on Fear Not. So, the most common exhortation in all of the Christian Bible is fear not. So, one might think like, “Oh yeah, don’t commit adultery,” or “Don’t kill, don’t murder,” or fill in the blank. Not even close. The most common exhortation in all of scriptures is actually fear not, and then love, various manifestations all throughout. I could go on, but I know we’re out of time.  Kimberley: Well, what I will say is tell people where they can hear about you and even access that if they’re interested. I love to read that article. So, where will people hear about you and learn more about the work you do? Please tell us everything. Justin: Yeah, sure. And I’ll include some stuff for your show notes that you can send to the things referenced. And then JustinKHughes (J-U-S-T-I-N-K-H-U-G-H-E-S) .com is my base of operations where the contact, my email practice information, my blog is on there. And you can subscribe to my newsletter totally free. Totally, totally free. And I do a bunch of eBooks as well on there that are free. JustinKHughes.com/GetUnstuck to join one of four of the newsletters.  Other than that, that’s where those announcements come out for different conferences. So, Faith and OCD, if this is out in time in April, but April every year, it’s getting to be pretty big. We’re getting hundreds of people attending. We’re now in our fourth annual IOCDF (International OCD Foundation Conference), local conferences, various live streams. So, anyway, the website is that base, that hub, where you’ll actually see any number of those different announcements. Thanks for asking.  Kimberley: I’m going to make sure this is out before the conference. Can you tell people where they can go to hear about the conference? Justin: Yeah. So, IOCDF.org. And then I think it’s /conferences, but you can also type into Google conferences and there’s a series of all sorts of different conferences going on. And this is the one that’s dedicated to OCD and faith concerns. And just when you think that it’s just one specific belief system, then prepare to be surprised because we’ve done a lot of work to have a diverse group of folks, sharing and speaking and covering a lot of things, ranging from having faith-specific or non-faith nuns, support groups. So, there are literally support groups if you’re an atheist and you have OCD, and that’s actually an important part of where you are in your journey. But for Christians, for Muslims, for Jewish, et cetera, et cetera, we’re trying to really have any number of backgrounds supported along with talks and in broad general things, but then we get more specific into, “Hey, here’s for clinicians. Hey, here’s for the tips on making for effective practices.”  Kimberley: Yeah, amazing. And I’ll actually be speaking on self-compassion there as well. So, I’m honored to be there. Thank you for being here, Justin. This was so wonderful.  Justin: Yeah, this really was. Thank you.

Now fix this one error in thinking if you want to be less anxious or depressed, either one. Today, we are going to talk about why it is so important to be able to identify and challenge this one error in your thinking. It might be the difference between you suffering hard or actually being able to navigate some sticky thoughts with a little more ease. Let’s do it together. Welcome back, everybody. My name is Kimberley Quinlan. I’m an anxiety and OCD specialist, and I am so excited to talk with you about this very important cognitive error or error in thinking that you might be engaging in and that might be making your life a lot harder. This is something I catch in myself quite regularly, so I don’t want you to feel like you’re wrong or bad for doing this behavior, but I also catch it a lot in my patients and my students. So, let’s talk about it.  The one error you make is black-and-white thinking. This is a specific error in thinking, or we call it a cognitive distortion, where you think in absolutes. And I know, before you think, “Okay, I got the meat of the episode,” stay with me because it is so important that you identify the areas in your life in which you do this. You mightn’t even know you’re doing it.  Again, often we’ve been thinking this way for so long, we start to believe our thoughts. Now, one thing to know, and let’s do a quick 101: we have thoughts all day. Everybody has them. We might have all types of thoughts, some helpful, some unhelpful. But if you have a thought that’s unhelpful or untrue and you think it over and over and over and over again, you will start to believe it. It will become a belief. Just like if you have a lovely, helpful thought and you think that thought over and over and over again, you will start to believe that too.  And what I want you to know is often, for those with mental health struggles, whether that be generalized anxiety, panic disorder, depression, eating disorders, OCD, PTSD, social anxiety, the list goes on and on, one thing a lot of these disorders have in common is they all have a pretty significant level of errors in thinking that fuel the disorder, make the disorder worse, prevent them from recovering. My hope today is to help you identify where you are thinking in black and white so we can get to it and apply some tools, and hopefully get you out of that behavior as soon as possible.  Here are some examples of black-and-white thinking that you’re probably engaging in in some area of your life.  The first one is, things are all good or they’re all bad. An example might be, “My body is bad.” That there are good bodies and bad bodies. There are good people and bad people. There are good thoughts and bad thoughts. That’s very true for those folks with OCD. There are good body sizes and bad body sizes, very common in BDD and eating disorders. There are people who are good at social interaction and bad at social interaction. That often shows up with people with social anxiety. That certain sensations might be good, and certain sensations might be bad. So if you have panic disorder and you have a tight chest or a racing heart rate, you might label them as all bad. And this labeling, while it might seem harmless, is training your brain to be on high alert, is training your brain to think of things as absolutes, which does again create either anxiety or a sense of hopelessness, helplessness, and worthlessness specifically related to depression. So we’ve got to keep an eye out for the all good and the all bad.  The next one we want to keep an eye out for is always and never. “I always make this mistake. I never do things right. I will always suffer. I will never get better.” These absolutes keep us stuck in this hole of dread. “It’ll always be this way. You’re always this way.” And the thing to know here is very, very rarely is something always or never true. We can go on to talk about this here in a little bit, but I want you just to sit with that for a second. It’s almost never true that almost never is the truth. How does that sound for a little bit of a tongue twister?  Next thing is perfect versus failure. If you’re someone who is aiming for that is either perfect or “I’m a failure,” we are probably going to have a lot of anxiety and negative feelings about yourself. This idea that something is a failure. I have done episodes on failure before, and I’ll talk about that here in a second. But the truth is, there is no such thing as failure; it’s just a thought. And all of these are just thoughts. They’re just thoughts that we have. And if we think that our thoughts are facts, we can often again get into a situation where we have really high anxiety or things feel really icky.  Another absolute black-and-white thinking that we do is that this is either easy or it’s impossible. There’s only those two choices. It should be either really easy or it’s not possible at all. Again, it’s going to get us into some trouble when we go to face our fears because facing fears is hard. We’ve talked about, it’s a beautiful day to do hard things. And the reason I say that is to really challenge this idea that things should be easy. And just because they’re hard doesn’t mean they’re impossible. Often people will say, “I can’t.” Again, just because they’re hard doesn’t mean that you can’t do it. It just might take some practice.  So, these are common ways that black-and-white thinking shows up. And by now, if you’re listening, you’re probably thinking, “Oh yeah, I’ve been called out.” And that’s okay. We all do this type of thinking. But let’s talk about now tools and what you can do to target this.  Let me tell you a story. Recently, I found myself managing what I would consider a crisis, a family crisis. It took several months for us to navigate this very, very difficult time. And I often leave voice recordings to my best friend. We communicate that way quite regularly. And every now and then, I listen back to what I’ve said to her just to hear myself and what I’m saying and where my head is. And I was shocked to hear me saying, “It’s always going to be this way. It’ll never get better. This is so bad. I failed. This is impossible. I can’t do this anymore.” I was doing all of the things. And for me, that awareness is what clicked me into like, “Oh, no wonder I’m panicking. No wonder I feel dread the minute I wake up in the morning because my story about this is exacerbating and making this harder on me. It’s creating more suffering.” So the first thing I did is what I would tell my patients as well—to start with just a simple awareness training. Just being aware of when you do it. We don’t have to change anything. We’re not going to judge ourselves, but we’re just going to write down on a sticky note or an app on your phone every time you get caught in a black-and-white thinking, and we’re going to jot it down. “I always will feel this way. I will never get better. This will forever be a failure.” We want to just jot it down. And that is, in and of itself, a huge part of the work—just being aware when you catch it. We’re not here to come down hard on you for doing it. Sometimes it’s just a matter of going, “Oh, okay, Kimberley, I see that I’m doing black-and-white thinking.” And that might be all that we do.  Often, with my patients, I will have them log this for homework because, in CBT, we do a lot of homework. And so I will say, “I want you to write it down and come back to me next week because next week, we’re going to work on the next tool.”  Now this may be a little different depending on the condition, and I want to make sure I’m really thorough here. If you have GAD (generalized anxiety disorder) or panic, we do a lot of cognitive restructuring. We do a lot of cognitive restructuring about how you cope with your discomfort. And in some cases, we might even restructure the content of your thought.  However, if you have OCD, it’s a little tiny bit different. We would still correct your thoughts about your ability to tolerate discomfort or your thoughts about yourself. But we want to be careful because sometimes when we start looking too close at the thought and trying to make sense of it and trying to correct it too much, we can actually start to be doing a little nuanced, subtle compulsion where we’re getting reassurance, we’re confessing, we are reinforcing the whole importance of this by going over it and correcting it, correcting it and correcting it. So just keep an eye out for that. If you’re in therapy, bring it up with your therapist just to make sure that you’re not using this skill today in a way that could become compulsive. Sometimes it does, sometimes it doesn’t, depends on the person.   For eating disorders, I know as my recovery from eating disorder, I did a lot of this, really examining, is my body all good or all bad? Is there such a thing as a perfect body or a failed body? This food or this body size, how do we determine its goodness or its badness? And looking at how extreme it can be.  Now, another really important piece here is with depression. In depression, we use a lot of black-and-white thinking. “I’m all that. They’re all good. I’m a failure. I’ll never get better. It’ll never get better. Things will never look up. It’ll always be this way.” Depression loves to use black-and-white thinking.  And so when we talk about cognitive restructuring, what we’re not talking about is just making it all positive. So here are a couple of examples. If you have depression, and for those of you, if you have depression and you don’t have access to a therapist, we have a whole online course called Overcoming Depression, where we go through this in depth of the common errors, not just black and white thinking, but the common errors in depression. And we work at coming up with helpful ways to respond. But one of the tools and skills that we use is, we don’t want to just come up with positive thoughts. It’s going to feel crappy to you. It’s going to feel fake. It’s not going to land. But what we want to do is find corrections or rebuttals to that thought that are more evidence-based, more rational, more logical, more helpful—things that might feel truer to you, even if it’s still somewhat distorted. It’s better than thinking in these absolutes because, like I said before, if you’re thinking in absolutes, you can guarantee you’re going to feel crummy.  Another example is with GAD (generalized anxiety disorder) or with panic disorder. A lot of it is catching our appraisal of sensations and feelings in our body. Now, again, we actually have a whole course on this as well called Overcoming Anxiety and Panic. Again, we go through a whole module of cognitive restructuring where we identify the specific thoughts that people with generalized anxiety and panic have. And it will be looking for where you make these black-and-white, all-or-nothing statements that “It would be bad if that happened. I will always again feel this way. I’ll never amount to anything. This panic attack will never end. I’m not handling it well. I’m handling it all bad,” or that “This sensation is impossible, and I can’t tolerate it.” So we go through it and really look at what are the things that you’re worrying about, and how are you really bringing in black and white thinking?  There are other distortions. In fact, there are 10 other distortions which we’re not covering today. Those are all in those courses as well. But again, for today, I wanted to really double down on this one. This one is particularly pesky and problematic.  The other thing to remember as we’re looking at black-and-white thinking is to remember that usually, 99.999 % of the time, things happen in the middle, in the gray. I often will hear me say to clients, “Can you be a little more gray about that?” Not to say a little more dark and depressive. I’m saying gray in that, “Is there somewhere in the middle that is more true and factual? Is it all good or all bad or is it a little of both? Or is it none of either? Where in the middle does it land? Oh, you’re having the thought that you’re either successful or a failure? Where is everybody else in this continuum?” Most likely, they’re in the gray. Can you learn to be more comfortable accepting the gray of the world and not going to these absolute black-and-whites?  The beauty is in the gray. We know this. The beauty is being kind to yourself in the gray, which brings me to the last point here, which is to practice self-compassion. We are in the gray. This podcast episode in and of itself is neither all bad nor all good. It’s going to be a variation, and a lot of that’s going to be dependent on people’s opinion, where they are, what they’re thinking, their mood, that things are really black and white. And can we be gentle with ourselves and humble enough to allow ourselves to see that this is neither good, bad, success, failure, always, never? These skills and the awareness of when we’re thinking this way can reduce a significant amount of our suffering, especially when you catch them, label them, and redirect in a kind, compassionate way.  One thing I don’t want you to do is identify how you’re thinking in this black-and-white way and respond to that with black-and-white thinking by saying, “You’ll always think this way. You’ll never ever stop doing this.” Ironic, but we do it all the time. Almost always, when people criticize themselves, they’re using one of the two areas in thinking black and white thinking and labeling, which is like name calling. And again, we want to identify these areas in thinking.  Again, if you want to go back and take a look at those courses, we go through this immensely in depth because there’s such an important part of Overcoming Anxiety and Panic and Overcoming Depression. And again, that’s the names of the courses. You can head over and look into that in the show notes, or go to CBTSchool.com. We have all of our courses listed there.  All right, folks, that’s it. Please fix this error in thinking if you want to be less anxious. Black-and-white thinking will create so much suffering in your life. And my hope is that these episodes and the work we do here at Your Anxiety Toolkit make you suffer a little bit less each week.  Have a great day, everyone, and I’ll see you next week.

Obsessive-Compulsive Disorder (OCD) is a challenging condition, but the good news is that it's highly treatable. The key to effective management and recovery lies in understanding the condition, embracing the right treatment approaches, and adopting a supportive mindset. This article distills essential guidance and expert insights, aiming to empower those affected by OCD with knowledge and strategies for their treatment journey. YOU ARE BRAVE FOR STARTING OCD TREATMENT Taking the first step towards seeking help for OCD is a significant and brave decision. Acknowledging the courage it takes to confront one’s fears and commit to treatment is crucial. Remember, showing up for therapy or seeking help is a commendable act of bravery. YOU CAN GET BETTER WITH OCD TREATMENT OCD treatment, particularly through methods like Exposure and Response Prevention (ERP) and Cognitive Behavioral Therapy (CBT), has shown considerable success. These evidence-based approaches are supported by extensive research, indicating significant potential for individuals to reclaim their lives from OCD’s grasp. The path may not lead to a complete eradication of symptoms, but substantial improvement and regained control over one’s life are highly achievable. OCD TREATMENT IS NOT TALK THERAPY OCD therapy extends beyond the realms of conventional talk therapy, involving specific exercises, homework, and practical worksheets designed to confront and manage OCD symptoms directly. These tools are integral to the treatment process, allowing individuals to actively engage with their treatment both within and outside therapy sessions. THERE IS NO SUCH THING AS “BAD” THOUGHTS A pivotal aspect of OCD treatment involves changing how individuals perceive their thoughts and their control over them. It's essential to recognize that thoughts, regardless of their nature, do not define a person. Attempting to control or suppress thoughts often exacerbates them, which is why therapy focuses on techniques that allow individuals to accept their thoughts without judgment and reduce their impact. YOU CAN NOT CONTROL YOUR THOUGHTS, BUT YOU CAN CONTROL YOUR BEHAVIORS You will have intrusive thoughts and feelings. This is a part of being human, and it is not in your control. However, you can learn to pivot and change your reactions to these intrusive thoughts, feelings, sensations, urges, and images.  YOU HAVE MANY OCD TREATMENT OPTIONS While medication can be a valuable part of OCD treatment, particularly when combined with therapy, it's not mandatory. Decisions regarding medication should be made based on personal circumstances, preferences, and professional advice, acknowledging that progress is still possible without it. In addition to ERP and CBT, other therapies such as Acceptance and Commitment Therapy (ACT), mindfulness, and self-compassion practices have emerged as beneficial complements to OCD treatment. These approaches can offer additional strategies to cope with symptoms and improve overall well-being. The accessibility of OCD treatment has expanded significantly with the advent of online therapy and self-led courses. These digital resources provide valuable support, particularly for those unable to access traditional therapy, enabling individuals to engage with treatment tools and strategies remotely. For those without access to a therapist, self-led OCD courses and resources can offer guidance and structure. Engaging with these materials can empower individuals to take active steps towards managing their OCD, underscoring the importance of self-directed learning in the recovery process. TREATMENT WILL NEVER INVOLVE YOU DOING THINGS YOU DO NOT WANT TO DO I am usually very clear with my patients. Here are some key points I share I will never ask you to do something I do not want you to do I will never ask you to do something that I myself would not do  I will never ask you to do something that goes against your values. RECOVERY IS NOT LINEAR Recovery from OCD is not a linear process; it involves ups and downs, successes and setbacks. Embracing discomfort and challenges as part of the journey is essential. Adopting a mindset that views discomfort as an opportunity for growth can greatly enhance one’s resilience and progress in treatment. There will be good days and hard days. This is normal for OCD recovery.  There will be days when you feel like you are making no progress, but you are. Keep going at it and be as gentle as you can SETTING CLEAR TREATMENT GOALS Clarifying treatment goals is crucial for a focused and effective therapy experience. Whether it's reducing compulsions, living according to one’s values, or tackling specific fears, clear goals provide direction and motivation throughout the treatment process. BE HONEST WITH YOUR THERAPIST The success of OCD treatment is significantly influenced by the honesty and openness of the individual undergoing therapy. Without reservation, sharing one’s thoughts, fears, and experiences allows for more tailored and effective therapeutic interventions. IT IS A BEAUTIFUL DAY TO DO HARD THINGS.  No question. You can do hard things!  OCD is a complex but treatable condition. By understanding the essentials of effective treatment, including the importance of evidence-based therapies, the role of mindset, and the value of self-directed learning, individuals can embark on a journey towards recovery with confidence. Remember, every step taken towards confronting OCD is a step towards reclaiming control over one’s life and living according to one's values and aspirations. TRANSCRIPT There is so much bad advice out there about OCD treatment. So today, I wanted to share with you the 11 things I specifically tell my patients on their first day of OCD therapy.  Hello, my name is Kimberley Quinlan. I’m an OCD specialist. I specialize in cognitive behavioral therapy, and I have helped hundreds of people with OCD over the course of the 10, 15 years I have been in practice.  Now, whether you have an OCD therapist or not, my goal is to help you feel confident and feel prepared when addressing your OCD treatment and symptoms, whether you have an OCD therapist or not. That is the big goal here at CBTSchool.com and Your Anxiety Toolkit podcast.  Make sure you stick around until the end because I will also be sharing specific things that you can remember if you don’t have a therapist, because I know a lot of you don’t. And I’ll be sharing what you need to know so that you don’t feel like you’re doing it alone.  Now, if you’re watching this here on YouTube, or you follow me on social media at Your Anxiety Toolkit, let me know if there’s anything I’ve missed or anything that you were told on your first session that was particularly helpful, because I’m sure your knowledge can help someone else or another person with OCD who is in need of support and care and advice. So let’s go. Here are the 11 things that I tell my patients on their first day of OCD therapy. Number one, I congratulate them for showing up, because showing up for OCD treatment is probably one of the most brave things you can do. I really make sure I validate them that this is scary, and I’m really glad they’re here. And I’m pretty impressed with the fact that they showed up, even though it’s scary.  The second thing I tell them is that OCD treatment is successful. You can come a long way and make massive changes in your life by going through the steps of OCD treatment, showing up, being willing to take a look at what’s going on in your life, and making appropriate changes so that you can get your life back, do things you want to do, spend more time with your family, your friends, the things you love to do, like hobbies, and that OCD treatment can be very effective. We’re very lucky that OCD is a very treatable condition. It doesn’t mean it’ll go away completely, but you can have absolute success in getting your life back.  Now, one thing to know here is, how do we know this? Well, OCD treatment research and OCD treatment articles. If you go onto Google Scholar, you will find a lot of articles that show a meta-analysis of the OCD treatments available, where it shows that ERP and cognitive behavioral therapy are the gold standard of treatment. And using a meta-analysis, that basically means that they’ve surveyed all of the large, well-done research articles and found which one shows the most results and shows that they have the most repeated results over periods of time. And that’s why it is so important that you do follow the research because there is a lot of bad information out there, absolutely.  Now, the third thing I tell my patients on their first day of therapy is that OCD treatment is not talk therapy. It’s not just talking, that it requires OCD therapy exercises and homework and lots of worksheets. I have a packet that we give our patients at the center that I own in Calabasas, California. Everyone gets a welcome manual. And in the welcome manual, it’s got worksheets on identifying obsessions and compulsions. It’s got mindfulness worksheets. It’s got logging worksheets. And I will send you home with those to do for homework. You’ll come back. Let me know what worked, what didn’t work, what was helpful, what wasn’t. And you will be doing a lot of this work on your own.  Now, again, as I mentioned at the beginning, if you do not have access to OCD therapy or you don’t have the resources to get that, we have an online course called ERP School. It is a course specifically for people with OCD, where I walk you through the specific steps that I take my patients through. And all of those worksheets are there. They have worksheets on identifying your obsessions, identifying your compulsions, mindfulness, self-compassion worksheets, things that can remind you and prompt you in the direction of setting up a plan so that you can get moving and make the steps on your own. The fourth thing that you need to know on the first day of your therapy is that there is no such thing as bad thoughts. Let’s just sit with that for a second. There is no such thing as bad thoughts. Your thoughts do not define you, nor do your behaviors, that you might have these thoughts that you think are going to really freak you out. You might have this idea, these thoughts, these intrusive, repetitive, scary thoughts, and you might think, “Well, I can’t even tell Kimberley about them yet.” I will often tell my patients like there is nothing these walls haven’t heard, and you probably won’t shock me because I haven’t been shocked in many, many, many years working as an OCD therapist. I’ve heard it all. I’ve heard the most, what people perceive as the grossest thoughts. It’s a normal part of the work that we do. And your thoughts are neither good nor bad and they do not define you. And I really make that point made because, as we move forward, I want you to know that I’ve seen a lot of cases and that “your thoughts aren’t special” in that they’re not something that I would be alarmed by.  The fifth thing that I would tell my patients is that you cannot control your thoughts. And I bet you believe it because you’ve probably tried over and over again, and all you found is the more you try and control it, the more thoughts you have. The more you try to suppress your thoughts, the more thoughts you have. There are, as we’ve already discussed, OCD treatment options that will really solidify this concept. Now, the most important one is exposure and response prevention, which is the type of treatment that we use for OCD and is the type of treatment that all of those research articles I discussed before show and direct to as a really successful treatment for OCD.  Now, in addition, there are other OCD treatment options. One of those treatment options is OCD treatment with medication. Now, again, when you do that meta-analysis, we have found that a combination of CBT and ERP with medication is the most successful. Now, that doesn’t mean you have to take medication, though. I’m never going to tell my patients that they have to take medication.  So we can have OCD treatment with medication. We can have OCD treatment without medication. In fact, some of my most difficult cases, the clients, for medical reasons or for personal values reasons, chose not to go on medication. You can still get better. It might make it a little more difficult. You may want to speak with your therapist, or if you’re doing this alone, you might need to put in a little extra homework, have a team of support, and people who are really there holding you accountable. Absolutely. But medication is another treatment option that you may want to consider as you move through this process. Now there are also new treatments for OCD recovery. They might include acceptance and commitment therapy, mindfulness practices, self-compassion. We even have some research around dialectical behavioral therapy as other OCD treatment interventions. I will be implementing those as we go, depending on what roadblocks show up. And again, if you’re doing this on your own, there are amazing resources that can also help you, and I’ll share about those here in a bit. Again, as we’ve talked about, there is also OCD treatment online. Since COVID-19, we’ve done a lot of growing in terms of being able to utilize CBT via the internet, via our computers, via our smartphones. A lot of people come to us because they’ve looked for OCD treatment in Los Angeles, which is where we are. And even though they only live a few miles down the street, they’re still doing sessions online because it’s so convenient. They can do it at home between sessions with their work or between getting their kids to school. So, OCD treatment online has become a very popular way to also access treatment. And I give these to my clients as we go, because sometimes they’re going to need a little extra help.  Now, as I’ve mentioned to you earlier in there, if you don’t have access to OCD treatment, there are tons of self-led OCD courses. Again, one of the ones that we offer is ERP School. Now you can go to CBTSchool.com, or you can click the link below in the show notes, where we have all of these courses for OCD and other anxiety disorders. But there are others as well—other amazing therapists who have created similar products.  When we’re really looking at treatment depending on your age, the treatment does look very similar for OCD treatment for adults and OCD treatment for children. They are very, very similar. With children, we might play more games, have more rewards, use those strategies, but to be honest with you, adults are just big kids in adult bodies. So I really believe that we want to make this as fun as we can. Have rewards. Have there be something that you’re working towards. Make it fun. Make it a part of a game. I use a lot of games in treatment and a lot of ERP games because why do we want to make everything boring all the time? Why not make it a little bit fun if we can? Number seven, the main thing I’m going to tell you here, and this is really, really important, is I will not ask you to do something that you don’t want to do. I have this in our welcome manual. We don’t ask people to do things that go against their values, and we don’t ask people to do things that I myself would not do. There are a lot of TV shows that sort of use ERP and exposure work as sort of like doing your worst, worst, worst, worst, worst case. And that’s fine. But often we’re not doing that. We’re doing exposures, we’re facing your fears so that you can get back to functioning, so you can get back to doing the things you want to do. So again, I’m not going to have you do anything you don’t want to do. You’re in charge. If you’re taking ERP School, we do the same thing. You create your own plan. You create a hierarchy of what you want to start with, and we work our way up. And we do the same thing in therapy as well.  Now the eighth thing that I will tell you, and by then you’re probably getting a little tired and overwhelmed. We might take a little tea break really quick, but I would tell you that recovery is not linear. While we do have effective treatment for OCD, it will be an up-and-down process. You’ll have really good days, and you’ll have some hard days. And those hard days don’t mean that you’re doing anything wrong. It doesn’t mean that your treatment’s not successful. It just means we have to take a look here and see what’s going well, what’s not going well, what do we need to tweak, do we need to make a pivot here. Or do we need to reassess something and maybe apply some additional tools—mindfulness tools again, self-compassion skills, some distress tolerance skills, maybe? But just remember, your recovery will not be linear, and that is okay.  Now the ninth thing I’m going to tell you is that your OCD treatment goals must be clear. You are going to get really clear on why you’re here, what you want to do, why you’re doing this treatment because it is hard work. Again, there’s homework. I’m going to be giving you some things to do at home, and they’re going to be a little bit difficult. They’re going to cause you to feel some feelings that maybe you don’t want to feel, some sensations you don’t want to feel.  And so, really again, I will ask them, like, what are your goals for treatment? Now, some common OCD goals for OCD therapy is to reduce compulsions. “I want to be able to not be doing these compulsions for hours and hours.” Other people say, “I want to live my life according to my values. I don’t want to let fear constantly be telling me what to do.” Other people will say, “I want to learn how to tolerate this discomfort and this uncertainty because every time I try and run away from it, it just gets worse. It makes it worse. And now I’m stuck in this cycle.” So it’s important that you get really clear.  Sometimes people will come in and they’ll say, “I’ve never been to Paris. I want to be able to go to Paris with my family. And so, that’s the goal.” That’s fine too. You could have a large goal like that, or you could have a really simple goal like, “I just want to have more space in my life to paint,” or “I don’t want to feel like I’m on edge all the time, like the scariest thing is going to happen all the time.” And that’s fine too.  Now, the 10th thing that you’re going to need to know and need to remember is, our recovery is really dependent on how open and honest you are. As I said at the beginning, some people don’t feel yet like they can trust to tell me the depth of their intrusive thoughts, and that’s okay. But throughout therapy, I’m going to need you to be really honest with me and really honest with yourself, because if you’re not disclosing what’s going on and the thoughts you’re having, we can’t actually apply the skills to it. And then it puts a wrench in the success of your treatment.  So we want you to be as open, honest as you can. And I often will say to them, there is nothing I haven’t heard. In fact, if you have taken ERP School already—a lot of you have—we actually play a couple of games where we play a game called One Up, which is where no matter what thought you have, you make it a little worse or little more scary. And I give some demonstrations and show like I’m not afraid to go there. I will go to the scary, yucky place just to show you that that’s what I want you to do as well. Again, it doesn’t have to be all serious. We’re allowed to play games, and we do that in therapy as well.  Often people will ask like, how do I tell my therapist about these horrible thoughts I’m having? Like, how do I share? If you’re having a specific type of thought that you feel is particularly taboo or very scary to share, or you’re afraid of the consequences of sharing, what I would encourage you to do is do a very quick Google search. There are some amazing websites and articles online of your obsession. Print it out and bring it to your therapist, and say, “Hey, this is what I’m dealing with. I’m too scared or I’m too vulnerable to share. It’s so horrendous in my mind, but this is what I’m going through.” And chances are, again, the therapist, if they’re a trained OCD specialist, will go, “Ah, thank you for letting me know. I’ve treated that before. I’m good to go.” Again, if they’re a newer therapist, it’s still okay because they’re getting the education about really common obsessions that happen a lot in our practice.  Okay. Here we go—drum roll to the last one. And I know you guys are probably already guessing what it is. It’s something I say to my patients and to you guys all the time, and it’s this: It’s a beautiful day to do hard things.  We have been taught that life should be easy, shouldn’t be scary, shouldn’t be hard, and that you should be Instagram-ready all the time. But the truth is, life is hard. And today is a beautiful day to do those hard things. I have found that those who recover the fastest and the most successful over time are the ones who see discomfort as a challenge, something that they’re willing to have. They’ll say, “Bring it on, let’s go. Bring my shoulders back. I know it’s going to be here.” And they’re really gentle with themselves when they have this discomfort. And I want you to really walk away feeling empowered that you too can handle some pretty uncomfortable things because you already are. So again, it’s a beautiful day to do hard things.  All right, let’s round it out because I know I promised you some extra things here. Now, what have we covered? We’ve covered the mindset shifts that you need for OCD therapy, behavioral changes that you’re going to need to make. We’ve talked about complementary tools, the most important being self-compassion. And also, guys, you can also follow Your Anxiety Toolkit because we have over 380 episodes of tools and core concepts, and everything like that.  Now, for treatment, just so that you get an idea of what this would look like, I share with my patients what treatment looks like. So usually, once I’ve told them all of this, I send them home with their welcome manual, and I’ll say, “The next two to three sessions, I’m going to be training you for this treatment. And a lot of that is going to involve psychoeducation, me giving you tools, giving you strategies, putting a plan together.” And again, for those of you who don’t have therapy, we do exactly that in ERP School. So if you feel like you need some structure, you can go to CBTSchool.com and access ERP School. We can go through that.  Now, for those of you, again, who don’t have an OCD therapist, does OCD therapy and treatment work for you too? Yes. We actually have some early research to show that self-led programs can be very successful for people with OCD and with other anxiety disorders. So, if you don’t have access to therapy, you could take ERP School. You could buy some workbooks that you buy from Amazon or your local bookstore. There are a ton of workbooks out there. Shameless plug, I also wrote one called The Self-Compassion Workbook for OCD. You can get it wherever you buy books. There are also online groups. I’m a huge, huge proponent of online groups. So if there are support groups in your area, by all means, use those because just knowing other people who are struggling, what you’re struggling with can be so validating and inspiring because you’re seeing them do the hard thing as well.  But either way, treatment requires a lot of homework. So, as I say to patients, showing up here once a week isn’t going to get you better. You’re going to have to practice the skills. And if you don’t have a therapist, you’re going to be doing that anyway. So I want to really hope that you leave here with a sense of inspiration and hope that you can get better even if you don’t have OCD therapy at this time. So there you go, guys. There are the 11 things I tell my patients on the very first session. I will usually end the session by encouraging them and, again, congratulating them for coming in and doing this work with me. Let them know I’m so excited for them.  I hope that this was helpful for you, and my hope is that you too will then go on to learn all the tools that you need in your tool belt and go on to live the life that you want to live because that’s the whole mission here at Your Anxiety Toolkit.  Have a wonderful day, everybody, and I’ll talk to you next week.

In the realm of managing anxiety and panic attacks, we often find ourselves inundated with advice on what to do. However, the path to understanding and controlling these overwhelming experiences also involves recognizing what not to do. Today, we shed light on this aspect, offering invaluable insights for those grappling with panic attacks.  Stop doing these things if you are having panic attacks, and do not forget to be kind to yourself every step of the way.  1. DON'T TREAT PANIC ATTACKS AS DANGER It's a common reaction to perceive the intense symptoms of a panic attack—rapid heartbeat, dizziness, or a surge of fear—as signals of immediate danger. However, it's crucial to remind ourselves that while these sensations are incredibly uncomfortable, they are not inherently dangerous. Viewing them as mere sensations or thoughts rather than threats can create a helpful distance, allowing for more effective response strategies. 2. DON'T FLEE THE SCENE The urge to escape a situation where you're experiencing a panic attack is strong. Whether you're in a grocery store, on an airplane, or in a social setting, the instinct to run away can be overwhelming. However, leaving can reinforce the idea that relief only comes from escaping, which isn't a helpful long-term strategy. Staying put, albeit challenging, helps break this association and builds resilience. 3. DON'T ACCELERATE YOUR ACTIONS During a panic attack, there might be a tendency to speed up your actions or become hyper-vigilant in an attempt to alleviate the discomfort quickly. This response, however, can signal to your brain that there is a danger, perpetuating the cycle of panic. Slowing down your breath and movements can alter your brain's interpretation of the situation, helping to calm the storm of panic. 4. AVOID RELIANCE ON SUBSTANCES Turning to alcohol or recreational drugs as a quick fix to dampen the intensity of a panic attack can be tempting. Nonetheless, this can lead to a dependency that ultimately exacerbates the problem. It's important to let panic's intensity ebb and flow naturally, without leaning on substances that offer only a temporary and potentially harmful reprieve. 5. STOP BEATING YOURSELF UP Self-criticism and judgment can add fuel to the fire of anxiety and panic. It's vital to adopt a compassionate stance towards yourself, recognizing that experiencing panic attacks doesn't reflect personal failure or weakness. Embracing self-kindness can significantly mitigate the added stress of self-judgment, creating a more supportive environment for recovery. SEEKING SUPPORT Remember, you're not alone in this struggle. Whether through therapy, online courses, or community support, reaching out for help is a sign of strength. Resources like "Your Anxiety Toolkit" are there to remind you that it's possible to lead a fulfilling life, despite the challenges panic attacks may present. Lastly, embrace the notion that it's a beautiful day to do hard things. Facing panic with acceptance rather than resistance diminishes its hold over you, opening the door to healing and growth. TRANSCRIPT:  Stop doing these things if you have panic attacks. I often, here on Your Anxiety Toolkit, talk about all the things you need to do—you need to do more of, you need to practice skills that you can get better at. But today, we’re talking about the things you shouldn’t do if you are someone who experiences panic attacks, panic disorder, or any other disorder that you also experience panic attacks in. Let’s get to it. Let’s talk about the things not to deal. Welcome back. Stop doing these things if you have panic attacks. When I say that, in no way do I mean that the things we’re going to discuss you should beat yourself up for. If you’re doing any of the things that we talk about today, please be gentle. It is a normal human reaction to do these things. I don’t want you to beat yourself up. Please feel absolutely zero judgment from me because even I am someone who needs to keep an eye out for this, keep myself on check with these things when I am experiencing panic attacks as well. Let’s go through them.  The number one thing to stop doing if you’re having a panic attack is to stop treating them like they are dangerous. If you experience symptoms of panic or you experience panic disorder, you know that feeling. You feel like you’re going to die. You feel like your heart is going to explode or implode, or your brain will explode or implode. You’ll know that feeling of adrenaline and cortisol rushing around your body. You get it; I get it. It feels so scary. But we must remind ourselves that it’s not dangerous, and we can’t treat them like they’re dangerous. We can’t respond to these symptoms as if they’re dangerous. We want to instead treat them like they are, which is sensations in the body or thoughts that appear in your brain. Once we can do that, then we have a little bit of distance from them and we can respond effectively.  Now, the second thing I want you to stop doing if you have panic attacks is to never leave. If you are at the grocery store and you’re having a panic attack, do not leave the grocery store. If you’re on an airplane, boarding an airplane, and you’re having a panic attack, do not leave the airplane. If you’re in a room and you’re experiencing panic, don’t leave.  Now, I know in that moment, it can feel so dangerous, as we just discussed, and so scary, but when we leave, we will associate relief with running away, and we actually don’t want that. Instead, with panic, we want the relief to be that we wrote it out and we were able to tolerate that feeling and navigate that feeling effectively and compassionately and not from the place of running away and escaping. If you can do one thing, the most important thing to do is to not leave where you’re at.  Now, does that mean that you can’t take a minute to step away for a second? That’s fine. Does it mean that you can’t, if you’re in a conversation, just say, “Can I have a few minutes? I just need to run to the restroom,” or whatever it be, take some time to get yourself back together? That’s okay. We’re not here to win any races or anything, but do your best not to leave the actual environment or place that you are having the panic attack.  Now, the third thing you can not do if you’re having a panic attack is don’t speed up your actions. We talk a lot about this in our online course called Overcoming Anxiety and Panic. How you respond to a panic attack can really determine how your brain interprets the event. If you’re having a panic attack and you really speed up and you start to act frantic or in an urgent way, and you’re sort of like hypervigilant looking around or trying to urgently frantically change something, your brain will interpret that high-paced activity or that speeding up of your actions as if it is a danger, and it will keep sending out hormones like cortisol and adrenaline, which will keep the panic attack and the anxiety going. What we want to do instead is slow it down, slow your breath down, slow your actions down, really get in tune. If you can just slow it down a little and change how you respond. And what we want to do here—and we do this in Overcoming Anxiety and Panic, if you’re interested in taking this course and you don’t have access to therapy or you’re wanting a step-by-step way of working through generalized anxiety and panic, go ahead and take a look. It’s at CBTSchool.com. You can go and check it out there, but if not, you can also do this with your clinician or by yourself—is do an inventory of how you respond when you are panicking. What safety behaviors do you engage in to try and get it to go away? What do you do to respond to it as if it is dangerous? Do you leave? Do you speed up? Do you become hypervigilant? Do you seek reassurance? Do you do mental compulsions?  We can go through and do an audit of those behaviors and see what you’re doing to sort of control and manage that anxiety. And we want to really work hard at reducing those behaviors. Do an inventory and get very clear so that next time you are having a panic attack, you can instead change those behaviors or replace them with more effective behaviors. If you’re interested again in that course, you can go to CBTSchool.com/overcominganxiety.  Now, the fourth thing you need to stop doing if you have panic is to not rely on substances. And when I say substances, I mean alcohol or recreational drugs. There is a massive overlap between people with panic attacks and panic disorder and substance use, and I get it. Having a quick drink of alcohol can sometimes take the edge off a panic attack. However, once again, if that is your way of coping, you will build a reliance and a dependence on that behavior. And we want to work instead at allowing that discomfort to rise and fall on its own without intervening with ineffective behavior. And recreational substances are a really big no-no if you’re someone who is experiencing a panic attack.  Now, that is different from prescribed medications. If you have been prescribed a psychiatric medication and you’re following the doctor’s orders, that is a different story. And please do go and speak to your doctor about those specific directions. What I’m speaking about right here is substances like recreational drugs or alcohol to help manage that panic attack.  Now, the last thing you need to stop doing if you have panic disorder or panic attacks is you have to stop beating yourself up. Beating yourself up will only make it worse. In fact, we have research to show that the more you criticize yourself, beat yourself up, judge yourself, the more likely you are for your brain to release more anxiety hormones and increase the experience of anxiety and panic. And so, that goes against everything that we want and need. We don’t need to add more anxiety to the mix if you’re already experiencing a panic attack.  And so, what we want to do here is work at not beating yourself up, not criticizing yourself for having this because it’s not your fault. It doesn’t mean there’s anything wrong with you. It’s a normal human reaction to want to run away and do everything you can to make it go away, including drinking substances and doing recreational drugs. We don’t want to beat ourselves up, whether you’ve done those in the past or if you’re currently doing them. If you’re struggling, reach out for help. There are clinicians around the world who can help. We have, again, online courses, if you haven’t got access or you can’t afford those services. There are books, there are podcasts like this one that are free. Do what you can to get support and get help so that you’re not doing this alone.  You aren’t alone. Thousands and millions of people around the world struggle with panic attacks. Again, they do not mean that there’s anything wrong with you. And there are important, very effective skills you can use to manage them, and go on and live a very, very, very, very wonderful, successful, fulfilling life.  Of course, I’m always going to end with this because I always do, but do also remind yourself it is a beautiful day to do hard things. The more you can willingly have panic and allow it to rise and fall on its own, the less power it has over you. So, do remember today is a beautiful day to do hard things.  Thank you so much for being here with me. I look forward to seeing you next week on Your Anxiety Toolkit, and I’ll see you there.

Anxiety can often feel like a relentless storm, clouding your thoughts and overwhelming your sense of calm. It's during these turbulent times that finding the right words can be akin to discovering a lifeline amidst the chaos.  To aid you in navigating these stormy waters, we've curated a list of 20 empowering phrases based on expert advice. These phrases are designed to validate your feelings, soothe your inner critic, fill you with encouragement, and help you respond proactively to anxiety. Here's how you can incorporate them into your life to foster resilience, kindness, and self-compassion. VALIDATE THE DIFFICULTY "This is hard, and it's okay that it's hard for me." Acknowledge the challenge without judgment. "I'm doing the best I can in this moment." Remind yourself of your effort and resilience. "My feelings are valid and understandable." Affirm the legitimacy of your emotions. "I am human, and having a difficult day is okay." Normalize the ups and downs of human experience. "I give myself permission to feel this while being kind to myself." Embrace your feelings with compassion. SOOTHE THE CRITICAL VOICE "This is not my fault." Release unwarranted guilt and blame. "It’s okay that I’m not perfect." Celebrate your humanity and imperfections. "It's okay to make mistakes." View errors as opportunities for growth. "My challenges do not define my worth." Separate your worth from your struggles. "May I be gentle with myself as I navigate this difficult season?" Practice self-compassion and kindness. FILL YOURSELF WITH ENCOURAGEMENT "It's a beautiful day to do hard things." Empower yourself to face challenges. "I can tolerate this discomfort." Recognize your strength and resilience. "This anxiety or discomfort will not hurt me." Acknowledge your capacity to withstand anxiety. "Humans are innately resilient." Remind yourself of your inherent ability to overcome adversity. "I am more than my worst days." Focus on the breadth of your life’s narrative. GET CLEAR ON YOUR RESPONSE TO ANXIETY "I REFUSE to lead a life based on fear." Commit to acting on your values. "I choose to speak to myself with understanding and patience." Cultivate a compassionate inner dialogue. "I have already chosen how I'm going to respond, and now I'm going to honor that decision." Preemptively decide on positive actions. "I will treat myself with the same kindness that I offer others." Extend your empathy inward. "I’m going to honor my journey and respect my own pace." Accept your unique path and timing. BONUS PHRASE FOR CONTINUOUS SUPPORT "We are just going to take one step at a time." Focus on the present moment to manage overwhelm. These phrases, thoughtfully designed to address different facets of anxiety, are tools at your disposal. Use them to navigate through moments of anxiety, to remind yourself of your strength, and to cultivate a kinder relationship with yourself. Remember, it's not about employing all of them at once but finding the ones that resonate most with you. Anxiety is a complex and deeply personal experience, and thus, your approach to managing it should be equally personalized. Let these phrases be your guide as you continue on your journey toward a more peaceful and empowered state of being. TRANSCRIPTION:  Here are 20 phrases to use when you are anxious. Now I get it, when you’re anxious, sometimes it’s so hard to concentrate. It’s so hard to know where you’re going, what you want to do, and it’s so easy just to focus on anxiety and get totally stuck in the tunnel vision of anxiety or feel completely overwhelmed by it.  Today, I want to offer you 20 phrases that you can use when you’re feeling anxious or experiencing OCD. These are yours to try on and see if you like them. You don’t have to use all of them. They’re here for you to use as you wish, and hopefully, they’re incredibly helpful. All right, my loves, let’s talk about the 20 phrases you can use when you’re feeling anxious. Now, I have prepared these in four different steps. You can actually go through and pick one or several of these and go through these, write them down, and have them in your pocket or in your wallet, or whatever you want, a sticky note on your fridge to use as you need. These are to help guide you towards a life where you lean into your fear. You treat yourself kindly. You encourage yourself. You champion the direction you want to go in. And my hope is that you can use these in many different scenarios, and they can help you get to the life that you want. Let’s go and do it.  The first category is validate the difficulty. Most people, when they’re anxious, they get caught up in this wrestle of, “I shouldn’t have this. Why do I have it? It’s not fair,” and I totally get it. But what we want to do is first validate the difficulty. If you can say that, and you can do that by using one of these five phrases: Number one, “This is hard, and it’s okay that it’s hard for me.” Again, let’s say it together. “This is hard, and it’s okay that it’s hard for me.” The second phrase that I’m going to offer to you is, “I’m doing the best I can in this moment.” The truth is, you are doing the best you can with what you have and given the circumstances. I want you to remember that as best as you can as well.  Number three, “My feelings are valid and understandable.” If anybody else was in this exact situation, they’d probably be thinking, feeling, and acting in the same way. The fourth one is, “I am human, and having a difficult day is okay.” Not only is it okay, it’s normal. Humans have difficult days. This is a total normal part about being human. You might be having an immense amount of anxiety, but please do remember the millions of other human beings around the globe who are having a very similar experience to you. It doesn’t mean there’s anything wrong with you.  And then the fifth way I want you to validate the difficulty is to say, “I give myself permission to feel this while being kind to myself.” Remember I said “while.” I give myself permission to feel this way while being still kind to myself.  Let’s move on to the second category, which is soothing the critical voice. I know when we have anxiety, we can be really, really hard on ourselves. The phrase I want you to practice or trial is, number one, “This is not my fault.” And it’s not your fault. You did not ask for this. You can’t stop the fact that your brain sometimes gets hijacked and throws a bunch of anxiety or thoughts, or feelings towards your urges. It is not your fault.  The second one is, “It’s okay that I’m not perfect.” Nobody is. We want to remember that this is our first time being a human and we’re not going to get it right the first time. It’s okay that you’re not perfect, nobody is.  You might also want to try the phrase, “It’s okay to make mistakes.” That is how I learn and grow. Remember here of all the people who have succeeded in their recovery, or all the people who are succeeding in other areas of their life, they didn’t get there because of easy, breezy times. They got there by making mistakes, and they’d keep going and they keep trying, and they’d go again and they go again and they learn and they grow. The next thing you may want to try on, and another phrase you can use is, “My challenges do not define my worth.” You’re not either better or worse for having this anxiety. You’re not less than or more than depending on whether you have a mental illness or not. Your worth is not something that’s up for discussion, and it’s not up for measurement. We all have equal worth. And this challenge that you’re experiencing or this anxiety you’re experiencing does not define your worth.  Now, the last one I want you to practice here, you can actually practice more from a meditation or a meditation practice, which is a practice of loving kindness. We could call it a metta meditation or a loving-kindness meditation. And the goal from this is to actually meditate on sending yourself loving kindness.  Now, if you’re someone who wants to learn how to do this, we have an entire meditation vault called the Meditation Vault, where I have created over 30 different meditations for people, specifically with anxiety, to help you practice meditation and learn how to practice loving kindness. You can go to CBTSchool.com to learn more about that. I would, again, need to spend a whole other episode talking to you about that. But if you want to practice the art of sending yourself loving kindness, you can go there to learn more.  But for right now, to finish out this category, what we want to do is practice one of those meditations, which is to offer yourself the phrase, “May I be gentle with myself as I navigate this difficult season?” What we are doing here is we’re offering ourselves a promise per se of saying, “May I be gentle with myself?” In a true loving-kindness meditation, often what we do say is, “May I be happy? May I be well? May I live with ease?” And if you particularly like my voice and it feels very soothing to you, all of those meditations are there in the meditation vaul, and we go through that extensively.  The next section is to fill yourself up with encouragement. Now, when we are anxious, it’s easy to feel very discouraged and just want to run away and change every part of our plans for the day. But what we want to do is we want to fill yourself up with encouragement. Here are some phrases that you can use to help with that goal.  Number one, you know I’m always going to say this, “It’s a beautiful day to do hard things.” We can do hard things. We have to keep repeating this to ourselves. You may even want to add some sass to it and add a little swear word. A lot of my patients have said, “It’s a beautiful day to blank hard things.” Now that’s okay too. You can sass it up, whatever feels most empowering to you.  Another way you can fill yourself up with encouragement is to offer yourself the phrase, “I can tolerate this discomfort,” because you can, and you have, and you will. “I can tolerate this discomfort.” Another thing you can offer is, “This anxiety or this discomfort will not hurt me. I am stronger than I could ever know.” And the truth is, anxiety does not hurt you. It’s uncomfortable, and it’s painful. I understand that. But it won’t hurt you. It won’t damage you. It won’t destroy you, that we’re stronger than we could ever, ever believe we could be.  The next thing you may offer to yourself, and this is one that I particularly love, is that humans are innately resilient. They do most of their growing through hard things. And I’ve already mentioned this to you before. Most of the really successful people got there, not because it was easy and breezy; it’s because we are resilient, and that’s how we grow, and that’s how we learn, that we can get through very, very difficult things. And then the last thing is, “I am more than my worst days.” That this might be a difficult day, but I am more than this difficult day. There’s a bigger story here for me. This uncomfortable moment or this uncomfortable day is just a part of that story. But the bigger picture is that I am much more than these hard, difficult days.  And then the last category, which you have to also include, is to get very clear on how you are going to respond. This is where we get a little more firm with ourselves in the phrases. You will hear, I get a little sassy myself in this, and we get a little more decisive or confident. Even if you don’t feel confident, we want to speak in this confident, assured way.  Number one is, “I REFUSE,” and I’ve written refuse in capital letters. “I REFUSE.” And I say this to myself, I want you to say this to yourself. “I REFUSE to lead a life based on fear.” I will move forward, acting on my values and my beliefs, and who I want to be. That’s the first phrase. And we want to emphasize, “I refuse to act out on this fear.” The second is, “I choose to speak to myself with understanding and patience.” I’m choosing that because it’s so easy to fall back into criticism and blame and humiliation and critical self-punishing words. I choose to speak to myself with understanding and patience.  Now, the third one involves you being very proactive. Now, I’ll give you the phrase first, and then I’ll explain it to you. The phrase is, “I have already chosen how I’m going to respond, and now I’m going to honor that decision.” What I want you to do, if you are someone with anxiety, is to create a plan ahead of time—to have a plan on how you are going to respond to anxiety.  Now, if this is difficult for you, we have two courses that I want you to rely on. Number one is Overcoming Anxiety and Panic, and the other one is ERP School. And that’s for people with OCD and health anxiety. If you’re someone who struggles with generalized anxiety or panic or OCD, you are going to need a plan ahead practice. You’re going to need to know what fear and obsessions and thoughts and fear and all the things get you to do normally. And then you’re going to have to be able to break that cycle with a specific plan on attack on how you’re going to handle that. And we go through those steps in those two courses or any of our courses. We break it down so that you have a specific plan on how you’re going to handle this, what you’re going to do, what you’re not going to do, how you’re going to treat yourself, and so forth.  If you haven’t got a therapist and you want to learn how to do that, head over to CBTSchool.com. Those courses, there is low cost as we could make them, and they’re there for you to help you have a plan so that you can say to your anxiety when you’re struggling, “I’ve already chosen how I wish to respond, and now I’m going to honor that decision. “ Now, the reason that I say that phrase that way is when you have a plan up ahead head, that’s one part of it, but then you have to honor your plan. And what often happens is, when we have a plan and we don’t honor that plan, that’s often when we start to feel like we distrust ourselves. We feel like we’ve let ourselves down.  And so what we want to do is we want to make a plan, and then we want to choose to honor that plan. And by honoring the plan that you set out -- and I’m not going to tell you what that plan should be. The cost isn’t going to tell you what you have to do. You get to decide that for yourself based on your own core values. But once you do that, and when you follow through by honoring that decision that you made ahead of time, that’s when you start to trust yourself. That’s when you start to really feel empowered. That’s when you start to break that cycle of anxiety because you’ve stood firm on the ground on what your plan was and how you’re going to show up.   I’ll repeat it again. “I have already chosen how I want to respond, and now I’m going to honor that decision because I matter, and this is my life, and I want to follow through in the way I said I would.” Now, the fourth one is, “I will treat myself with the same kindness that I offer others in this situation.” Again, we’re speaking firmly and kindly with conviction to ourselves. “I will treat myself with the same kindness that I would offer to others.”  And then the last one is, “I’m going to honor my journey and respect my own pace.” This doesn’t have to be a straightforward, linear process. In fact, it won’t be. And we have to honor our own journey and our own pace, because sometimes it takes longer for us than it does for others. And that’s okay. We’re going to honor our journey. We’re going to respect our own pace.  And I will offer you a bonus phrase, which is, “We are just going to take one step at a time.” Just focus on one step at a time. Because if you’re looking too far ahead, it will get overwhelming. You are handling a huge, huge discomfort. And so we want to be as gentle as we can. We want to honor our values. We want to lead with our values, not lead with fear. And my hope is one or many of these phrases will help you get there. I hope this has been helpful.  Again, I want to remind you, some of these won’t land for you, and that’s entirely okay. Just practice and try the ones that you feel will be helpful, and leave the rest. This is your journey. You get to choose it. I just hope that some of these skills and tools that we talk about on Your Anxiety Toolkit are helpful. And I hope you have a wonderful, wonderful day.

THE RISING TIDE OF TEEN DEPRESSION: UNDERSTANDING AND ADDRESSING A MODERN CRISIS In recent times, the specter of teen depression has loomed larger than ever before, casting a long shadow over the lives of young individuals across the globe. With reports indicating a significant upsurge in cases of depression among adolescents, the need to unravel the complexity of this issue and explore effective strategies for intervention has never been more urgent. At the heart of the matter is the alarming statistic that suicide rates among teenagers aged 15 to 19 have surged by 76% since 2007, with a particularly distressing increase observed in teen girls. The rates of suicide have doubled among female teens compared to their male counterparts, underscoring a gendered dimension to the crisis. Moreover, the youngest demographic, children between the ages of 10 and 14, has witnessed the highest rate of increase in suicide across all age groups, a fact that underscores the severity and early onset of mental health challenges in today's youth. This escalation in teen depression and suicidal ideation can be attributed to a myriad of factors, ranging from societal pressures and the rapid pace of cultural shifts to the unique challenges posed by the digital age. The omnipresence of social media and technology, while offering new avenues for connection, has paradoxically fostered a sense of isolation and disconnection among adolescents. The digital landscape, with its relentless comparison and instant feedback loops, has exacerbated feelings of inadequacy, anxiety, and despair among young people. Furthermore, the impact of depression is not confined to any single demographic. Contrary to previous beliefs that African-American families were less likely to experience suicidal ideation, recent research has unveiled an elevated risk among African-American boys aged five to 11. This revelation challenges preconceived notions about the protective factors supposedly inherent in certain communities and underscores the indiscriminate nature of mental health challenges. The narrative surrounding teen depression and despair is further complicated by the conflation of despair with clinical depression. While depression is a diagnosable condition characterized by a specific set of symptoms persisting over time, despair can embody similar feelings of hopelessness and sadness without necessarily meeting the criteria for a clinical diagnosis. This distinction is crucial for understanding the breadth and depth of the emotional turmoil experienced by adolescents, which may not always fit neatly into diagnostic categories. Addressing this burgeoning crisis requires a multifaceted approach, centered around the power of connection and the cultivation of resilience. Building resilience in young people involves fostering internal coping mechanisms as well as providing robust external support systems. Parents, educators, and mental health professionals play a pivotal role in modeling healthy coping strategies and offering unwavering support to adolescents navigating the tumultuous waters of mental health challenges. One of the key strategies for combatting teen depression involves nurturing meaningful connections between young people and their caregivers. The act of showing up for adolescents in both significant moments and the mundane details of daily life can have a profound impact on their sense of belonging and self-worth. Consistency in presence and support, coupled with genuine engagement in activities that resonate with the interests of young people, can fortify their emotional resilience and counteract feelings of isolation and despair. In the digital realm, it is imperative to strike a balance between leveraging technology for connectivity and mitigating its potential negative impacts on mental health. Encouraging responsible and mindful use of social media, fostering face-to-face interactions, and emphasizing the importance of digital detoxes can help alleviate the pressure and anxiety associated with online environments. As society grapples with the escalating crisis of teen depression, it becomes increasingly clear that a collective effort is required to address the underlying causes and provide a supportive framework for adolescents. By prioritizing mental health education, advocating for comprehensive support services, and fostering an environment of openness and understanding, we can begin to turn the tide against teen depression. In doing so, we not only alleviate the immediate suffering of young individuals but also lay the groundwork for a healthier, more resilient generation. TRANSCRIPTION Kimberley: Welcome, everybody. I am so delighted to have our guest on today, Dr. Chinwé Williams. Welcome, Dr. Chinwé Williams. I’m so happy to have you here. Chinwé: Oh, I’m so excited to be here. Thanks so much for having me. Kimberley: As I said to you, several months ago, I was having a massive influx of cases of teens, my teen clients and my staff’s teen clients reporting really strong waves of depression, including not just my clients, but also my pre-teen, also reporting that that’s what some of our friends are reporting. I think it’s everywhere. And I really feel that, even though we always talk about anxiety here, I really wanted to make sure we’re addressing the really high rates of depression and despair in teens. So, thank you for writing the most wonderful book. As I went to research that, I found your book, it’s called, Seen: Despair and Anxiety in Kids and Teenagers and the Power of Connection. So, thank you for writing that book.  Chinwé: Thank you so much for reading it. Yes.   Kimberley: Yes, I actually listened to it. So, I actually got to hear your voice, which I thought was really beautiful because you and Will Hutcherson, who wrote it, it was lovely. You bounced back and forward between the two of you. Chinwé: Yes, we did. We did.  Kimberley: What made you decide to write this book? Chinwé: I started my career as a high school counselor, my goodness, probably now 18 years ago, which is so weird for me to admit that, or even wrap my mind around that. And I loved working with adolescents. And in the particular high school that I was working at, we were really, really able to do the work of promoting and supporting the mental and emotional well-being of students, not just the academic well-being. And a lot of my school counselor friends at other schools, they were really focused on the schedule and post-secondary options, and SATs. So, I was really fortunate to be at a school where I saw students almost like how I’m seeing clients clinically, 10 o’clock, 11 o’clock, 11:15, 11:30. And so, that was such a great experience for me, especially early in my career.  The reason we wrote the book is because, back then, 18 years ago, I saw a little bit of self-harm. I saw anxiety. I saw depression. I certainly saw despair. I saw kids, students struggling with relationships, struggling with, what is my future going to look like? However, what we are seeing today, what I am seeing in my clinical practice, I still work with adolescents, but I do work with a great deal of adults. I work with parents and families, and I have conversations with just my friends and people that I’m doing life with. The episodes or experiences of anxiety and depression has really just increased significantly. Kimberley, I am sure that you are so aware of just the stats that are out there that really point to the shift that’s occurred in our culture, specifically as it relates to youth mental health.  Just for example, and this seems like such a long time ago, but I think it really gives us an idea of how much has changed, a good bit has changed in a relatively short period of time. But the stats are pointing to the fact that since 2007, suicide rates have increased a whopping 76% for teenagers between the ages of 15 and 19. So 76%. So the bulk of that number really is pointing to how our teen girls are struggling. Suicide rates are double in teen girls versus our boys. The highest rate of increase in suicide among all age groups—and this is where I always have to take a deep breath still—is in kids. These are kids between the ages of 10 and 14 is what the research is showing.  The alarming part of this whole thing is that we’re seeing younger and younger kids impacted by what we sometimes think of as, yes, adolescence is tough. There are hormones. There’s social pressures. There are academic pressures. Kids are worried about the future. Well, younger and younger kids are also being impacted by feelings of hopelessness and discouragement.  And the other thing—you and I talked about this before we started recording. The other thing that’s been really shocking for a lot of people to learn is when I started my career, way back in the day, we were told that families of color, specifically African-American families, were really the least likely to take their own lives. But what we have learned recently, and this is a stat that has really shocked, but also confused and confounded a lot of clinicians, as well as mental health researchers, is that there’s an elevated risk of suicidal thoughts for African-American boys between the ages of five and 11. So once again, just younger and younger kids are experiencing really hopeless feelings, but we are seeing the most anxiety, the most despair, and depression among adolescents and young adults. So that’s why we wrote the book.  Kimberley: I get teary just hearing about it. My heart aches, and I feel like it’s a crisis. It’s a crisis that they’re experiencing and parents. I think what was really also very beautiful that you talked in the book about how, I think, even as clinicians, we perceive kids who are struggling with, “Oh, they must have gone through a trauma.” But also, it’s just kids who haven’t been through a trauma. I mean, I think the COVID in and of itself and all of the unrest of our world is traumatic for everybody. But it was also very validating to see that this is also for reasons that we yet don’t really understand. Do you want to speak to that at all?  Chinwé: Yes, absolutely. So in the book, I wrote about clients that I’ve experienced throughout the years. I’ve changed factors and variables that would easily identify them. But many people will point to some of the illustrations in the book that are of kids who come from really supportive families. Many of them are high achieving. Many of them have a lot of resources that they just have access to, and yet they still experience levels of anxiety, sadness, even are self-harming, even espouse suicidal thoughts, or we call it suicidal ideation.  What that tells us, again, I think just sort of zooming out, is the bigger picture of just so many things that have shifted in our culture, so many things that have shifted from a societal perspective where young people are feeling disconnected, they’re feeling more anxious, they are more resourced. The research tells us that Gen Alpha and Gen Z are the most diverse, more resourced, tech-savvy. They’re so connected to the technological and global world, but they feel so disconnected oftentimes from themselves, from their family members, and also their friends. And so, I think it really is so interesting that it really speaks to, regardless of the walk of life or where you or your family falls from an income perspective, none of us are immune.  I try to be pretty transparent. My daughter has given me permission to share. She is 20 years old. She’s in college. She is brilliant and kind and thoughtful and highly sensitive and gifted and has a mother who’s a mental health professional. And at 13, she experienced high, high anxiety and high levels of despair. And again, she’s given me permission to share, and I do share this when I talk to parents and educators across the country, and I’m so grateful that she’s given me that permission. But just to show that she had resources. She was in private school. She’s my bonus daughter. She had support from me, her dad, and also her biological mom, and her grandparents, and she still experienced what a lot of kids across the country are experiencing.  Kimberley: I’m so grateful you share that. I think that that’s it too. We would assume that if your bonus mom is a therapist and you have all the resources, it just wouldn’t happen to you. But it doesn’t discriminate, does it? It can affect any family. As a clinician, I don’t think I was really trained to really understand that either. I was trained to think like, okay, there must be something wrong with the family, they must be fighting at home, or there must be discord at home, or so forth. So I’m so grateful that you share that. And thank you to her. How brave and wonderful that she struggled and obviously came through on the other side, absolutely.  In the book, this blew my mind, really, honestly. I’m almost embarrassed to say, but it blew my mind that you described that there is a difference between despair and depression. Can you share what that is all about?  Chinwé: Yes. As you know, depression is a clinical term. It’s a diagnosis that has a set of symptomology that’s connected to it. So, we as clinicians are looking for certain symptoms that exist more days than not over a two-week period of time, right? At that two-week mark, I’m starting to pay a lot of attention when parents are sharing what’s happening with their kids. Because when you’re an adolescent, we know that hormones will shift your mood, you’ll be high on something that you’re watching on TV. Not high literally, because we got to make that distinction. You’re not vaping or using marijuana, but you’re feeling euphoric and you’re elated about something maybe you’re seeing on television. And then you look down at your phone, or your mom asks you to clean your room or do your work. And then you can look like you have a level of despair. But that may not be the case, right? We know with adolescents, there are just normal ups and downs that are just a part of that stage of development.  So it’s important to really share that in order to get a diagnosis of depression. You want to see a number of symptoms for a period of time that really impact your child’s level of functioning in a persistent and pervasive way. Maybe they’re not functioning as well as they normally would at school or if they have an after-school job or an extracurricular activity or you’re noticing that some things at home. So those are some things that we look at from a clinical perspective.  Now, despair is something different, but not by a whole lot. There’s a whole lot of overlap, and we do go into it with pretty great in-depth in the book, but essentially, despair really has a lot of those same symptoms of depression where you’re feeling lethargic, perhaps low energy. You struggle with thoughts that tell you maybe that you’re not enough, you’re inadequate, or inferior. Sometimes you don’t feel like doing those things that you normally love to do. In clinical terms, we call it anhedonia, right? Those things that you typically enjoy that make you happy—playing with your pet, going for a walk, hanging out with your friends. If you’re not doing those things, we do start to wonder about some mood issues, some internalizing disorders. So, anxiety, mood issues such as depression, but with despair, and we make this distinction on purpose with intentionality, and here’s why.  Despair does share a lot of the symptoms as depression, but it doesn’t need to meet the criteria for major depression for us to really know that is a tough place to be. And many of us, especially young people, we may not be able to just relate or connect to having major depression or bipolar, but many of us on this earth can relate to having an experience of loss or grief or deep disappointment, or pain that we just continue to stuff and we rally and we show up for the next thing and we show up for the next thing. But that pain is still there, and it doesn’t really have a place to go because we haven’t really shared with people that we were going through this pain. We just kept going with our routine.  Despair can make you feel the exact same way, but it doesn’t necessarily rise to the level of a mental health diagnosis. And it’s important to point out because young people right now are going to social media outlets like TikTok, and they’re hearing from social media influencers—I put that in quotation marks—that are saying, “If you have this symptom, then you have this diagnosis.” And so, young people are attaching to those labels, and we did not want that in this book. This book is for anyone who has a child, a student, someone that you’re coaching, leading, guiding, that is struggling with a mental health issue, or just struggling emotionally, but it doesn’t necessarily lead to a criteria that indicates that there’s some sort of diagnosis.  Kimberley: Thank you for differentiating that, because that was really cool for me to hear from a clinician diagnostically. That was really cool to know. Let’s talk about solutions. So we know this is happening. You talk about, and I am too is going to say, like we’re sending all the love to the parents who are navigating this. We’re sending all the love to the clinicians and the teachers and the school counselors and the guidance counselors who are navigating this with their teens. What can we do for our teens, or how can we help them?  Chinwé: Excellent question. As a mental health practitioner and a parent of three kids, I know how difficult it can be to sort of see the big picture when your child is struggling. We all can relate to feeling overwhelmed, again, even as a professional. I’ve talked to my pediatrician friends and my medical doctor friends. It’s the same thing when it’s your kid. You have all the head knowledge, but sometimes it can still be difficult.  I think for all of the families that are listening right now, I want you to remember a really important word that’s actually overused. That word is resilience. We’re hearing a whole lot about resilience. We’re hearing a whole lot about emotional resilience, mental resilience. In the book Seen, we call it grit. We acknowledge because I’m talking to educators across the country that are seeing this and parents and even employers that are feeling this. We acknowledge that in a lot of ways, the younger generation, they have lost their grit. They don’t appear to be as resilient as the older generations.  But where I want to step in is by saying that we don’t shame them or blame them. And how many times have we turned on the news and we heard, “Oh, these kids are snowflakes,” or “These kids are weak,” or “They’re not tough, and they just need to pull their pants up,” and whatever the saying is. Kimberley: Pull them up by the bootstraps. Chinwé: Thank you. And your big girl panties—I’ve heard that too. And I was traveling the other day, someone said, “Yeah, my dad always said, ‘Just put some mud on it, put some dirt on it, and keep it going.’” And the older generation, we have a tendency to blame the younger generation for experiencing this mental health crisis, and that just isn’t fair.  We do want to help them to develop grit and build grit, but the way that we help them with resilience is remembering that a key element of resilience is internal coping resources with external support. That external support is key. When young people are facing any sort of mental health challenge, again, it doesn’t have to be depression; it could just be a period of high anxiety or sadness that’s just gone on for too long. They need to know that they have what it takes, but they need people to remind them and people to walk alongside them because life will be full of difficulty, of course. But we want to teach our young people that they can face this, anything that overwhelms them. They can experience that overwhelm, but also know that they have the ability to pull on those internal coping resources, assuming that they’ve been taught those resources, and also access the support of families.  The first thing that I want to tell parents is to model exactly what you want to see. And this is big, and this could be its own episode, and maybe you’ve already done an episode. But the way that we help young people when they’re having a tough time is to model good mental health even—and this is important—even when you’re struggling. Because I struggle sometimes, and I have the coping resources. Life can feel really overwhelming and can test us. But do we pretend like we don’t struggle just because we’re parents or adults or because I’m a licensed professional? Well, how’s that going to help my child?  So, it’s important for parents to know that the very first lesson around mental and emotional wellness has to come from you. When your kids are able to see how you, first of all, identify that you’re having a challenge and then respond to the challenge, that helps them. That helps them know that, okay, I can go through a tough situation or feel a level of distress, but I don’t have to sit with it and rally, or I don’t have to pretend like it hasn’t happened or whatever’s happening hasn’t affected me.  So, what a parent can do is when you get home from work or your day or a meeting with a friend that just was hard and heavy, acknowledge that. We don’t want to weigh kids down, and I get that. We don’t want to put our problems onto them, but it’s okay to say in a very general or conversational way it has been a really long day. Or, “I met with mommy’s friend, Cindy. Oh, she’s had a lot going on in her family. Oh, I just need a moment. I think what I’m going to do is before I get dinner started, I’m going to go for a walk, or I’m going to just take a couple of deep breaths, or I’m just going to have a seat. I’m going to rest.” How many of us—Kimberley, I’m guilty of this—come home, we’ve had a hard day, we heard something heavy, and we go straight to cooking and cleaning and checking homework and all the things. So, what happens to that energy? So, I feel like this is just a really good opportunity to show kids the value of acknowledging that every day isn’t going to be great and it’s not supposed to be, but what can you do about it?  Kimberley: Yeah. That is so important, I think. And I think it’s easier said than done. I think that parents are exhausted too, right? They’re struggling at high rates too, I’m assuming. I don’t know the research on that. So, I think we also need to wrap everyone in compassion in that we’re doing the best we can.  You also talked about social media before and about how much connecting to social media disconnects them from the family. And I think that as parents, sometimes we let them be on tech because parents need a break, you know what I mean? I know I’ve caught myself with that with my nine-year-old of, “I’m just going to let him have some tech time because I need a break,” but then that’s disconnecting them. Can you speak to the impact of social media for teens?  Chinwé: Yeah. I think the first thing that would really highlight this topic is to mention that just so recently, I want to say probably a couple of months ago, we learned that the federal government, along with at that time 13 separate states—I’m sure it’s more at this point—sued the social media giant, Meta, which many of your listeners will recognize Meta as the parent organization for Facebook and Instagram. Now, we use Facebook and Instagram to promote mental health. And so, there are benefits to social media 100%, and I think it’s important to highlight that for parents because some kids really are getting information about causes that they want to support. They are getting information about mental health. Sometimes it’s in the bite-size way where we want them to dig in a little bit more, right? But they’re good aspects to mental health.  But the reason for the lawsuit was because the social media giant was being accused of creating intentionality features that are causing addiction to social media, which is one of the things that has been identified as fueling this mental health crisis among youth. So, there are real stats that are -- we probably have always had a sense that being connected or over-connected to technology wasn’t good. During COVID, what the heck else were we supposed to do as parents? We were doing Zoom school. I’m sure you had your own podcasts at that point. I was doing podcasts. I was doing telehealth. So I appreciated technology, but like you said, a lot of parents really leaned on technology during that time because we didn’t have a whole lot else going on and kids still needed to stay connected, and so did we. But I think that balance is so key.   I’m going to tell you, when I travel and people ask me, what’s the thing that worries you the most about young people as a former high school counselor, someone who works with adolescent mental health? And I say very quickly, without hesitation, that I am really concerned about the fast-paced nature of our culture. We are moving, I think, at lightning speed as a culture. We’re becoming increasingly more digitally connected, which means that we’re becoming more and more less physically connected. So how does that impact our young people? And we’re so quick to point to these things (I’m holding my phone right now) and ask young people, especially teenagers, to do less of this. But if we’re honest, aren’t we just as guilty as parents?  I have a colleague, and I don’t know if you would agree with this at all. I’m still kind of wrapping my mind around it because I like to see hard stats. But I had a colleague that said that he believes that most adults have some level of digital addiction. I don’t know. I don’t know that for a fact, but I know again that we are very much so attached to our phones. And so, the younger generation sees that. And if they’re going through despair, if they’re having thoughts of self-harming, if they’re having anxious thoughts, and they see that we are super duper connected to our phones, where then do they go? Are we essentially modeling the same thing?  So again, I’m not here to say that technology doesn’t have its utility. It’s not all bad. But when our world is moving so fast that our nervous systems can’t keep up, what do we need to do? The answer is to slow down and have more face-to-face connections. Kimberley: Yeah. I think that without the research, I can say for myself, it’s interesting. I actually had a colleague of mine, we both agreed we would track how many times we picked up our phone. And when I tracked it, it was always like, “Oh, I’m overwhelmed. I’ll just watch Instagram for a minute,” or “I’m feeling sad. I’ll just watch Instagram for a second.” And it was like, that’s my first coping skill. This is not good. That’s not good. So I totally agree with what you’re saying.  I have one more question for you. So, the real word that felt so yummy to my whole body when I read your book was the word connection and how important that is for our teens but also for, I think, all humans. How might we connect better with our teens? Chinwé: Oh gosh, can I throw a stat that’s sticking in my head? Can I throw that out right now?  Kimberley: Please. Chinwé: From birth to graduation, I still get goosebumps, and I’ve been saying this for about a year now. From birth to graduation, we have 936 weeks with our kids. 936 weeks and roughly 3,000 hours in one year. So, just depending on where you are in your parenting phase, depending on just who you are and the makeup of your nervous system, that’s going to land differently for you. But I know the first time, and even today when I hear that, I’m like, “There’s not enough time. Am I doing enough? Should I not be on this podcast? Should I be with her in school?” So it’s fine.  But I think that, like, am I spending enough time? Am I connecting? And I don’t know one parent that I’ve counseled or that I do life with that doesn’t want to be a good parent. And I always remind parents that it’s not this whole connection piece that we’re seeing in the attachment research and the neuroscientific research. It’s not about being a perfect parent. It really is about being an intentional parent and showing up undistracted. So that whole conversation about before we check our kids, let’s see if we’re modeling the behavior we want them to see as it relates to technology. And again, tons of compassion. I’m a huge proponent on giving yourself the kindness that you would give someone else who might be struggling. So, that’s really important. But showing up undistracted, but also showing up when it’s not convenient.  We know through brain research that connection can help bring down all of that energy that happens on the right side of the brain when an individual is highly activated, high anxiety for far too long, a state of despair for far too long, which can actually end up feeling like just numbness, like I feel nothing.  So, what helps individuals to begin to heal, promote that healing is connection with another human being that they feel loved and cared for, that they feel respected, someone that respects them, someone that values who they are, not just what they do. “I love you just for who you are.” That’s something that I say.  I’m actually being reminded of a Valentine’s Day card that my third grader made for me. And he wrote the sweetest thing, and I’m not going to read all of it, but at the very end, he said, “Thank you for loving me even when I’m unlovable.” And I sort of chuckled, and he read it to me and we laughed at the same time because that’s something I say to him all the time. Regardless of the behavior, regardless of what we are facing right now, the correction or the challenge, or you’re not getting along with your brother, I love you no matter what.  So, even just hearing that, even just hearing that as adults that someone is going to be by our side and going to help us through a tough time, even when maybe we’re not acting lovable or “acceptable” from society’s perspective, what’s better than that?  One of the very first tools that we talk about in our book Seen, we have five connection tools. The very first tool is showing up and showing up when it’s not convenient. As mama bears and papa bears, we have that instinct to swoop in and protect our kids when they’re struggling. And we also show up during those huge milestone moments—the concerts, the graduations, the big sporting events. And by the way, kids want to look up and see us and see grandparents in the stands. That’s important. But the kids that I’ve been counseling throughout the years, they want their parents to show up in the seemingly insignificant and mundane moments of life, just to do basic things. Not to check the homework, not to talk about the boy that texted last night, but go for a coffee to just connect. Go in the front yard and play basketball. Go fishing.  The key is whatever is meaningful and valuable to your child, those are the things that we want parents to engage in. And consistency really matters. And we’re talking about teenagers. This is what I’ve learned throughout the years, especially when I was a school counselor—the tendency is to think that as our kids get older, they need us less and less. And this is what my teenagers in therapy are telling me—I find that when they hit 13, 14, and 15, ooh, they are making huge life decisions. And even though there’s sometimes that conflict that happens between parents and teenagers or parents and preteens that can cause parents to sometimes disconnect because we get our feelings hurt sometimes and disengage, that’s when our kids are making really tough life decisions, so that’s when they need us the most.  Consistency matters. So, it’s not showing up here and there. No knock on people who have busy lives and busy jobs, but the research shows that consistency builds trust. So, we show up, we show up undistracted, and we show up before they ask us to. Kimberley: So beautiful. For me, it’s been a constant reminder of like, look them in the eyes. It’s so easy to be talking while chopping vegetables or checking email. It’s like, “Kimberley, stop and look at them in the eyes. That’s what they need to be seen.” So, I love that so much.  I understand that you have a new book out. Please tell us all about where people can find you and learn about you. And you have a new book out. Tell us all the things. Chinwé: Oh, thank you so much. Yes, our first book was Seen, which is really a book for connecting with a young person, if you’re a parent, educator, coach, regardless of mental health diagnosis. However, as we were traveling and sharing about the contents of Seen, everywhere we would go, parents would say, “Oh, this is awesome. I’m going to give this to my teenager.” And Will and I would be like, “No, this is not for your teenager; this is actually for you and another caring adult.” And then they would say, “Well, where’s the book for teenagers or is there a workbook?”  And so, we wrestled with this for about a year, and we decided, looking at the stats, that’s really pointing to anxiety being super high, very rampant among all of us, including adults, 28% of adults have an anxiety disorder. We also are seeing that young people, adolescents, and young adults are struggling with anxiety. So we wrote a book that’s specifically for strategies to help with anxiety, and it’s called Beyond the Spiral: Why You Shouldn’t Believe Everything Anxiety Tells You. And it’s really going over six different lies that anxiety tells you. And here’s a sneak peek: Anxiety tells you that you have no control. Anxiety tells you that you’re going to miss out. Anxiety tells you that you should just ignore it, and anxiety tells you that you’re not safe. And there are two more. But then every single chapter, we talk about the lie, we talk about what’s happening in the brain that’s really highlighting that lie. And then we talk about psychological strategies that are tried and true, probably many of the ones that you’ve written about in your books and resources, many of the ones that I use with my clients today. And then there’s a spiritual piece for those who really have a strong faith. We bring in spiritual elements and practices that we believe are also really important to ease in anxiety. Kimberley: Amazing. Thank you so much for being here. Is there any social media handles or websites that people can find your information? Chinwé: Thank you for asking. So I am also pretty active on Instagram, and my Instagram handle is dr.chinwewilliams. So dr.chinwewilliams. And if you want to just learn a little bit more about me and my practice, I have a website, and it’s drchinwewilliams.com. Kimberley: Amazing. And we’ll link all that in the show notes. I am so grateful for this book. I’m so grateful for you. I love the work that you’re doing. So thank you for coming on. Chinwé: Thank you for your kindness. Thank you for your -- I’ll be honest with you, when I’m preparing for podcasts, I don’t have a lot of time, but I really do think it’s important to just get a flavor of the host, the content that they produce, the guests that they have on. But I don’t have a lot of time, right? So, I usually have time to listen to maybe 15 or 20 minutes of maybe one or two podcast episodes. When I tell you, I was like, “Where am I going to start?” I was looking through your title list, and I was blown away. I listened to two and a half episodes, two entire episodes, and a half of one. And I was thinking, where has she been all my life? She’s going to be an amazing resource for my clients who -- I’m a trauma therapist, and as you know, that was formerly considered an anxiety disorder. So this is something that I’m really excited to present to my clients. So thank you for the work that you do. Kimberley: Oh, thank you so much. I’m so grateful.

In the realm of mental health, the role of an anxiety therapist is often shrouded in mystery and misconceptions. To shed light on this crucial profession, Joshua Fletcher, also known as AnxietyJosh, shares insights from his latest book, "And How Does That Make You Feel?: Everything You (N)ever Wanted to Know About Therapy," in a candid conversation with Kimberley Quinlan on her podcast. Joshua's book aims to demystify the therapeutic process, offering readers an intimate look behind the therapy door. It's not just a guide for those struggling with anxiety but an engaging narrative that invites the general public into the world of therapy. The book's unique angle stems from a simple yet intriguing question: Have you ever wondered what your therapist is thinking? One of the book's key revelations is the humanity of therapists. Joshua emphasizes that therapists, like their clients, are complex individuals with their own vices, flaws, and inner dialogues. The book begins with a scene where Joshua, amidst a breakthrough session with a client, battles an array of internal voices—from the biological urge to use the restroom to the critical voice questioning his decision to drink an Americano right before the session. This honest portrayal extends to the array of voices that therapists and all humans contend with, including anxiety, criticism, and analytical thinking. Joshua's narrative skillfully normalizes the internal chatter that professionals experience, even as they maintain a composed exterior. The conversation also touches upon the diverse modalities of therapy, highlighting the importance of finding the right approach for each individual's needs. Joshua jests about "The Yunger Games," a fictional annual event where therapists from various modalities compete, underscoring the passionate debates within the therapeutic community regarding the most effective treatment methods. A significant portion of the book delves into the personal growth and challenges therapists face, including dealing with their triggers and the balance between professional detachment and personal empathy. Joshua shares an anecdote about experiencing a trigger related to grief during a session, illustrating how therapists navigate their emotional landscapes while maintaining focus on their clients' needs. The awkwardness of encountering clients outside the therapy room is another aspect Joshua candidly discusses. He humorously describes the internal turmoil therapists experience when meeting clients in public, highlighting the delicate balance of maintaining confidentiality and acknowledging the shared human experience. Joshua's book, and his conversation with Kimberley, paint a vivid picture of the life of an anxiety therapist. It's a role filled with challenges, personal growth, and the profound satisfaction of facilitating others' journeys toward mental wellness. By pulling back the curtain on the therapeutic process, Joshua hopes to demystify therapy, making it more accessible and less intimidating for those considering it. In essence, being an anxiety therapist is about embracing one's humanity, continuously learning, and engaging in the most human conversations without judgment. It's a profession that requires not only a deep understanding of mental health but also a willingness to confront one's vulnerabilities and grow alongside their clients. Through his book and the insights shared in this conversation, Joshua Fletcher invites us all to appreciate the intricate dance of therapy—a dance that, at its best, can be life-changing for both the therapist and the client. Transcript:  Kimberley: I’m very happy to have back on the show Joshua Fletcher, a dear friend of mine and quite a rock star. He has written a new book called And How Does That Make You Feel?: Everything You (N)ever Wanted to Know About Therapy. Welcome back, Josh. Joshua: It’s good to be back. Thanks, Kim. When was the last time we spoke together on a podcast? I think you were on The Disordered podcast not so long ago. That was lovely. But I remember my guest appearance on Your Anxiety Toolkit was lovely. HOW DOES THAT MAKE YOU FEEL?  Kimberley: I know. I’m so happy to actually spend some time chatting with you together. I’m very excited about your new book. It’s all about therapy and anxiety and what it’s really like to be an anxiety therapist and the process of therapy and all the things. How did this book come about? Joshua: I wanted to write a book about people who struggle with anxiety, but in the mainstream, because a lot of the literature out there is very self-help, and it’s in a certain niche. One of my biggest passions is to write something engaging with a nice plot where people are reading about something or a storyline that they’re interested in whilst inadvertently learning without realizing you’re learning. That’s my kind of entertainment—when I watch a show and I’ve learned a lot about something or when I’ve read a book and I’ve inadvertently learned loads of things because I’m taking in the plot.  With this book, I wanted to write a book about therapy. Now, that initially might not get people to pick it up, might not interest you, might not interest you about anxiety therapy, but I wanted to write something that anyone could pick up and enjoy and learn lots because I want to share our world that we work in with the general public. And so, the hook that I focused on here was, have you ever wanted to know what your therapist is thinking? And I thought, well, I’m going to tell people what I’m thinking, and I’m going to invite people behind the therapy door, and you’re going to see what I do and what’s going on in my head as I’m trying to work with people who struggle with mental health.  I wrote the pitch for it. People went bananas, and they loved it because it’s not been done before. Not necessarily a good thing if it’s not been done before. And here we are. I love it. I’m really proud of it. I want people to laugh, cry, be informed. If you go on a journey, learn more about therapy, learn more about anxiety. All in one book. THERAPISTS ARE HUMANS TOO Kimberley: Yeah. I think that one of the many cool things about it is, as a therapist, people seem to be always very curious or intrigued about therapists, about what it’s like and what it’s like to be in a room with someone who’s really struggling, or when you’re handling really difficult topics, and how to be just a normal human being and a therapist at the same time. Joshua: Yeah. What I want to write about is to remind people that therapists are humans. We have our vices and flaws. I’m not talking on behalf of you, Kim. I’m sure you’re perfect.  Kimberley: No, no. No, no. Flawed as flawed could be. Joshua: Yeah, but to a level that it’s like, even our brains have different voices in them all the time, different thought processes as part of our rationalization. And I want people to peer inside that and have a look. So, one of them is like the book opens with me and a client and it’s going really well, and this person’s talking, this character’s talking about where they’re up to, and celebrating on the brink of something great. And then there’s the voice of biology that just pops into the room, into my head. And it’s the biology of you need to go to the toilet. Why did it? And then the voice of critic comes in and says, “Why did you drink an Americano moments before this client?” Now you’re sat here, and you can leave if you want, but it would be distasteful. And you’re on this brink of this breakthrough.  And so, I’ve got this argument going on in my head, going, “You need the toilet.” “Yeah, but this person’s on a breakthrough.” And then I got empathy, like, “Yeah, but they feel so vulnerable. They want to share this.” And then you’ve got analytical and all the chaotic conversations that are happening as a therapist as I’m sat there nodding and really wanting the best for my client. THE VOICES IN OUR HEAD Kimberley: Exactly. That’s why I thought it was so brilliant. So, for those of you who haven’t read it, I encourage you to, but Josh really outlines at the beginning of the book all of these different voices that therapists and all humans have. There’s the anxiety’s voice and there’s biology, which you said, like, “I need to go to the restroom,” or there’s the critic that’s judging you, or there’s the analytical piece, which is the clinical piece that’s making sense of the client and what’s going on and the relationship and all the things. And I really resonated with that because I think that we think as clinicians, as we get better and more seasoned, that we only show up with this professional voice we’re on the whole time, but we’re so not. We’re so not on the whole time. This whole chatter is happening in the background. And I think you did a beautiful job of just normalizing that. Joshua: Thanks, Kim. It’s a book that therapists will like, but do you know what? People will identify their own voices in this, particularly the anxiety. You and I talk about anxiety all day every day, always beginning with what if—that voice of worry that sits around a big table of thoughts and tries to shout the loudest and often gets our attention. And I tried to show that this happens to a lot of people as well. It’s just the what-if is different. So, for some people, it’s, “What if this intrusive thought is true?” For some people, it’s, “What if I have a panic attack?” For some people, it’s, “What if this catastrophe I’ve been ruminating on for so long happens?” For therapists, it’s, “What if the worst thing that happens here, even in the therapy room?”  I’m an anxiety therapist that has been through anxiety, and I still get anxiety because I’m human. So, I celebrate these voices as well. Also, because I’m human, I can be critical almost always of myself in the book. So, I’m not just criticizing the people I’m working with. Absolutely not. But that voice comes in, and it’s about balancing it and showing the work and what a lot of training to be a therapist is. It’s about choosing the voice. And I didn’t realize how much training to be a therapist actually helps me live day-to-day. Actually, I’m more rational when making more life decisions because I can choose to observe each voice, which was integral to me overcoming an anxiety disorder, as well as just facing life’s challenges every day. WHAT IS IT LIKE TO BE A THERAPIST?  Kimberley: Right. Because we’re really today talking a lot about what it’s ACTUALLY like to be a therapist—and I emphasize the word ‘actually’—what is it actually like to be a therapist, if we were to be really honest? Joshua: One thing I mentioned is that I talk about the therapeutic hour, which is how long, Kimberley? Kimberley: Fifty minutes. Joshua: Yeah. The therapy took out and I explained what we do in the 10 minutes that we have between clients on a busy day. And people imagine us doing meditation or grounding ourselves or reflecting or whatever. Sometimes I do do that. Sometimes I just scroll Reddit, look at memes, eat candy, and do nothing. And it’s different each time. That’s what I’m doing. I’m not some mystic sage in my office, sitting sinisterly under the lamplight waiting for you to come in. No, I’m usually faffing around, panicking, checking that I don’t look like a scruff, putting a brush through my hair, trying to hide the stains of food I’ve got on my shirt because I overzealously consume my lunch.  And there’s obviously some funny stories in there, but also there’s dark stuff in there as well. When I trained to be a therapist, I went through grief, and I made some quite unethical decisions back when I was training. Not the ones I’m proud of, but it actually shows the serious side of mental health and that a lot of therapists become therapists because of their own journeys. And I know that that applies to a lot of therapists I know. Kimberley: For sure. I have to tell a story. A few months ago—I’m a member of lots of these therapist Facebook groups—one of the therapists asked a question and said, “Tell me a little bit what your hour looks like before you see a client. What’s your routine or your procedure pre-clients?” And all these people were saying, “I journal and I meditate and all of these things.” Some people were like, “I water the plants and I get my laptop open.” And I just posted a meme of someone who’s pushing all the crap off my table and screeching into the computer screen and being like sitting up straight. And all of these people responded like, “Thank God,” because all the therapists were beautifully saying, and I just came in here honestly, “Sometimes I literally sit down, open the laptop, and it is a mess. But I can in that moment be like, ‘Take a breath,’ and be like, ‘Tell me how you’re doing.’” Like you said, how does that end? We start the therapeutic hour. And I think that we have to normalize therapists being that kind of person. Joshua: Definitely. I think one of the barriers to people seeking therapy is that power dynamic, that age-old trope that someone stood leaning against a mahogany bookcase. You’ve probably got a mahogany bookcase. Your practice is really nice. I certainly have. I’ve got an Ikea KALLAX unit full of books I’ve never read.  Kimberley: Exactly. Your books aren’t organized by color because mine are not. Joshua: No, no. There’s just some filler books in there. Just like, why is Catcher in the Rye? Why is Catcher in the Rye? I don’t know, I just put it on there. I just want to look clever. Anyway, it’s like people are afraid of that power dynamic of some authority figure going in there about to judge them, mind-read them, shame them, or analyze them. And no, I think dispelling that myth by showing how human we are can challenge that power dynamic. It certainly did for me. I would much rather open up to someone who isn’t showing the pretense that they have all of life together. Don’t get me wrong, professionalism is essential, but someone who’s professional and human, because going to therapy is some of the most human experiences you’ll ever do. I don’t want someone who isn’t showing too scared to show that sign or certain elements of being human, but obviously professionally. And it’s a fine balance to get. But when you do find a therapist like that, for me personally, one who’s knowledgeable, compassionate, empathetic, has humility, I think beautiful things can happen. Kimberley: Yeah. I think you use the word that I exactly was thinking of, which is, it’s such a balancing act to, as a therapist, honor your own humanity from a place of compassion. Like, yeah, we’re not going to have it all together and it’s not going to be perfect, and we won’t say the right thing all the time. But at the same time, be thoughtful and have the skills and the supervision to balance it so that you are showing up really professional and from that clinical perspective.  DO THERAPISTS GET CONSULTATION?  Tell me a little bit about consultation as a clinician. I know for me, I require a lot of consultation for cases, not because I don’t know what I’m doing, but I’m always going to be honest with the fact that maybe I’m seeing it from a perspective that I hadn’t thought of yet. What are your thoughts on that kind of topic? Joshua: Therapy’s got to work for both people as well, because the therapeutic connection, I believe, is one of the drivers that promotes therapeutic growth and change. It promotes trust. I will consult with clients and my supervisor and make sure it’s right. I’m not everyone’s cup of tea, but for people, particularly with anxiety disorders, I think they like to know and come to therapy. I think I’ve used self-disclosure on my public platforms tastefully in the sense that I know what it’s like to have gone through an anxiety disorder, whether it’s OCD or panic disorder or agoraphobia, and come out the other side.  But also, it’s balancing that with, “Actually, I’m your therapist here. I will help you in a therapeutic setting and use my training.” You know I’m not someone who’s got everything worked out, but you do know that someone who can relate that can step into your frame of reference, something I talk about a lot in the book frame of reference and empathy. If you feel like a therapist has done that and is in your frame of reference and it’s like, “Ah, yeah, they get it or they’re at least trying,” and we as therapists feel like there’s a connection there too on a professional and therapeutic level, I think magic can happen. And I love therapy for that. Not all therapy is great and beautiful and wonderful. Some of it is messy, and some of it just doesn’t work sometimes. And I do talk about that too, but it’s about when you get that intricate dance and match between therapist and client, I think it’s life-changing. WHAT TYPE OF PERSON DO YOU NEED TO BE TO BECOME AN ANXIETY THERAPIST? Kimberley: Yeah. What do you think about the type of person you would have to be to be an anxiety specialist, especially if you’re doing exposure and response prevention? The reason I ask that is I have a private practice in California. I have eight clinicians that work for me. Almost every time I have a position that’s open, and when I’m interviewing people to come on to my team, I would say 60% come in, and they’re good to go. They’re like, “I want to do this. I love the idea of exposure therapy.” But there is often 40% who say, “I’m not cut out for this work. This is not how I was trained. It’s not how I think about things.” After I’ve explained to them what we do and the success rate and the science behind it, they clearly say, “This isn’t for me.” What are your thoughts about what it takes or what kind of person it takes to be an anxiety specialist? Joshua: That’s a great question. First of all, you’ve got to trust and believe in the modality that you’re trained in. You and I use the principles a lot of cognitive behavioral therapy and exposure response prevention. I’ve got first-hand experience of that. You’ve got to trust the science and what we know about human biology, which is really important. It’s about what you’re trading in that modality. What I talk about -- again, see how I’m segueing it back to the book. Brilliant. I’ve done my media training, Kim. It’s like, “Always go back to the book. Come on, Josh.” One of my favorite chapters in the book is explaining about modalities because a lot of people just think therapy is one big world where you see a therapist, they wave a magic wand, you feel better, and suddenly our parents love us again. No, that’s not how it works.  Kimberley: It’s not? DIFFERENT TYPES OF ANXIETY THERAPISTS Joshua: No, it’s not. Mental health has different presentations, and a modality is a school of thought that approaches difficulties in mental health. So, the first modality I go to is person-centered, which is counseling skills, listening, empathy, unconditional positive regard.  The Carl Rogers way of thinking—I think I love that. Is that good for OCD, intrusive thoughts, exposure therapy, and phobias? Not really. It’s nice to have a base of that because there’s more chance of a therapist being understanding, stepping in your frame of reference, and supporting you through that modality. But I wouldn’t say it’s equipped for that.  Whereas in CBT, a lot of it is psychoeducation, which I love. And that’s a different modality. Cognitive behavioral sciences, whether it’s third wave, when you’re looking at acceptance commitment, where are you looking at exposure response prevention. There’s lots of song and dance about I-CBT at the moment and things like that. They’re all different modalities and skills of thought.  Then you’ve got psychodynamic, which is the mahogany bookcase, lie on the sofa, let’s play word association. Oh yeah, you want to sleep with your mom, Josh? No, I don’t. That’s nothing to do with why I keep having panic attacks in the supermarket. Stop judging me. But that’s a different type of approach. Jungian approach can be quite insightful, but it’s got to match what the presentation is for you.  I think CBT is my favorite, but it sucks for stuff like grief. When I was grieving, I did not want CBT. I did not want my grief formulated. I did not want to see that my behaviors were perpetuating discomfort. I was like, “Yeah, that’s just part of my grieving process.” And in this chapter, I just talk about the different modalities. Therapists are very passionate about the modality of the school that they train in because you have to give part of yourself to it. You have to go through it yourself. And I’m very passionate about the modalities I’m trained in. And so, I play on this in the book. There’s a chapter called The Younger Games or The Yunger Games, a play on words. And basically, it’s once-a-year therapists from every modality, whether it’s hypnotherapy, transactional analysis, CBT, person-centered, the trauma-informed. All of these, they all meet up in a field, and we all fight to the death. And the last remaining person is crowned the one true modality. Now last year, it was hypnotherapy. And what I also say is that a betting tip for next year is the trauma-informed. So, every year, I’ll keep you updated on The Yunger Games. And basically, it’s a narrative device to explain that.  Within the world of therapy, there are different types of therapists. You and I, we love CBT. We’ll bang the drum for that. We feel that there’s not enough ERP out there that certainly isn’t, particularly with the evidence and the points towards it and mountains of evidence. But other therapists may not feel the same. So, when people come to work at CBT School and they realize that Dumbledore, aka Kim Quinlan, is like, “No, we do ERP here; we’ve got to get down and dirty and do the horrible work,” they’re like, “That’s not conducive to the softer step-back approach that I’ve trained in, in my modality.” Kimberley: Yeah. I’m always so happy that they just are honest with me. I remember as an intern at OCD Center in Los Angeles very clearly saying, “Are you okay talking about really very sexual, very, very graphic topics?” He listed off. Like, “Here is what you’re going to need to be able to talk about very clearly with a very straight face. You can’t have a wincing look on your face when you talk about intrusive, violent sexual thoughts. You’re going to have to be up for the game.” And I think that was a big thing for me. But what I think is really cool about your book, and you see now I’m bringing it back to your book, is it doesn’t mean the voice isn’t in your head sometimes questioning you. As I was reading it, I’m like, there is an imposter in therapists all the time saying, like you said, the critic that’s like, “You don’t know what you’re doing. You’re a failure. You’re a flake. You’re a complete fraud. You haven’t got it together. Maybe you haven’t even worked on the thing yourself yet.” That’s going to be there. Joshua: Yeah, and I still get that. I can’t speak for you. But I think what makes a good therapist is a therapist who self-doubts. You don’t want to go and see a therapist who thinks that they’ve got it all worked out. That’s a red flag in itself. A good therapist is one that always wants to improve and uses that doubt and anxiety to make themselves a better therapist. Don’t get me wrong, I’m pretty confident in my ability to be a therapist now, but there are challenges. In the book, the voices that come up, there’s 13 of them. One of them is escapist, which is, “I just want to get the hell out of you,” or “Maybe I want to get rid of this client. I’m not equipped for it.” And then the other voices come in and they’re like, “But maybe this is just you being critical,” or “The evidence suggests that actually you are trained for this,” and navigating that doubt, the anxiety that your therapist has. And I think it’s a beautiful thing.  A lot of therapists are very harsh on themselves, but I think it’s a gift to have that inner critic. Because if you stand there like one of these therapists, and these therapists do exist, unfortunately, I have completed all my training. I know everything inside out. My word is gospel. I worked out what the problem was with this person within 10 minutes. You don’t want to talk to that person. What a close-minded moron. And there’s a judgmental voice from a therapist. Kimberley: No, but I think that’s informed. Joshua: So, it celebrates the vulnerability. You want a therapist who’s not got everything worked out. Absolutely. I do anyway. Kimberley: Yeah, for sure. I’m wondering, how often have you had to work through your own shit in the room with a client? Meaning—I’ll give you a personal example—the very first time I ever experienced derealization for myself was with a client, and I was sitting across from them. They were just talking, and all of a sudden, I had this shift, like everything wasn’t real. Their head looked enormous and their body looked tiny. Like they were this tiny little bobbly head thing on the couch. And I knew what was happening. Thankfully, I knew what it was like. I knew what it was. Otherwise, I probably would have panicked, but I had to spend the rest of the session being as level and mindful as I could as I watched their head just bubble around in this disproportionate way. I got through it. I can say confidently I think I pulled it off really well, but it was hard. And I left the session being like, “What the heck just happened?” Has there been any experiences for you like that? Joshua: Yeah, all the time. I mean, first of all, I’d question if you did have derealization. I was your client with a giant head and a tiny body. I was like, “What’s going on here?” There wasn’t derealization. That’s my body, Kim. Kimberley: No, that’s just how I look, Kimberley.  Joshua: It’s just how I look.  Kimberley: “Stop judging.” Joshua: But in general, no, it’s true. And again, one of the voices in my book, And How Does That Make You Feel?, it’s called trigger because therapists, they have to give a lot of themselves and they’re living a life and have had stuff in their past. One of the voices is trigger. One of the things I get asked a lot is, I don’t know about you, Kim, “If you’ve had anxiety, how can you work with it all day?” I’m like, “Because I’m all right with it. It’s okay now.” Sometimes it creeps in, though, if I’m tired or have not slept well. There’s stress in my personal life that you can’t avoid. Maybe I’ve not eaten too well. Maybe it’s just ongoing things. Sometimes trigger can happen, and it can be a stress-induced trigger or it could be a literal trigger from a traumatic event.  So, in the book, I explain when people bring grief and death, that sometimes makes me feel vulnerable because of my own experiences with grief and death. No spoilers, but the book throughout, one of the themes is why I became a therapist. Not only because of my passion for anxiety disorders and to be self-righteous around other therapists, train different modalities, but also because it’s a very grief-informed decision to want to help people.  And there’s several traumatic stories. One traumatic story around grief, that trigger, the voice of trigger will come up. So, a client could be talking about their life, like, “I’ve lost this person; I’m going to talk about it.” And of all these 13 voices around the table, what your therapist is thinking, trigger then shouts loudest. It goes, “Ah, trigger.” There’s some pain that you’ve not felt for a while and I’ve got to navigate it. You navigated the derealization, the dissociation. You’ve got to navigate it somehow by pulling on the other voices. And not only do therapists do this, but people do this as well sometimes, whether you’ve got to be professional or you don’t want to turn up to your friend’s birthday and just listen to trigger and anxiety and start crying all over your friend’s birthday cake. You might do. It’s quite funny, but not funny.  Kimberley: I was going to say, what’s wrong with that?  Joshua: Have you done it again? I thought you stopped that.  Kimberley: Yeah. You haven’t done that?  Joshua: It’s part of the interview at CBT School. You need to do really hard, tricky things. Go to your best friend’s birthday and make it all about you.  Kimberley: Exactly. Joshua: But yeah, it’s one of those. It crops up. The book’s funny a lot, but it’s good. It takes some really serious turns, and it shows you a lot of stuff can creep in and how I deal with it as a therapist. And I’m sure you related to it as well, Kim, because we do the same job, but you just do it in a sunnier climate. SEEING CLIENTS IN PUBLIC  Kimberley: Right. What I can say, and this will be the last thing that I point out, is you also address the awkwardness of being a therapist, seeing your clients in public and the awkwardness of that, or the, “Oh crap, I know this person from somewhere.” Again, no trigger. I don’t want to give the fun parts of the book, but as a therapist, particularly as someone who does exposure therapy, I might go across the road and take a client to have coffee because they’ve got to do exposures. We very often do see people, our clients, our friends in our work. How much does that impact the work that you do? Joshua: If you ever bump into your therapist, just know that you have all the power there. Your therapist is squirming inside, “I don’t know what I’m doing. I don’t know. Do I completely blank this person?” But then I look like a dick. “Do I give a subtle nod? Oh, you’re breaking confidentiality. They’re out with loved ones.” It’s up to you. You can put your therapist out of their misery by just saying, “Hey, Kim.” “Hey, Josh.” And then I will say hi back because that shows that you’re okay with that.  There is a very extreme shocking version of this story, of this incident in the book where, when I’m at my lowest, I do bump into a previous client. On a night out, when I’m off my face on alcohol. Oh, if you want to find out more about that... Media training’s really paid off. Get him on the hip.  Kimberley: I didn’t want to give it all away, and you just did. Joshua: No, no, not giving any more away. A media training woman said, “Entice them, then leave it, because then they’re more likely to read it.” So, I have listened to that media woman because my previous tactic of just begging and screaming into a camera doesn’t work. It’s like... Kimberley: But going back exactly—going back, we are squirming. I think that is true that there is a squirm factor there when you see clients, and it happens quite regularly for me. But I think I’ve come to overcome that by really disclosing ahead of time. Like if I see you outside, you’re in the place of power, you decide what to do, and I’ll just follow your suit. It’s a squirm factor, though. Joshua: See, that’s clever, good therapy stuff because you do it all part of the contracting and stuff. Actually, I told all my clients this is okay. But also, when you’re a new therapist or sometimes you forget, you’re like, “Oh no.” I used to run a music night in Manchester as part thing I did on the side. Enjoy it, love music, I was the host. One week I was on holiday, so a friend organized all the lineup of people to come down. Headline Act was a band name. Went along, and when I’m there, I’m having fun. I’ve got whiskey in my hand. I’m walking around telling irreverent, horrible jokes. No one in there would guess I was a therapist because I’m having fun and I’m entitled to a life outside the therapy room.  What I didn’t know was that the Headline Act was a current client, and they’d just arrived dead late. They didn’t know, and they walked on stage, and I looked. It’s something that they’ve gone on publicly to talk about, so this is why I’m saying it now. I got permission to use it because they said it publicly on the radio and stuff like that. And we just looked at each other. It was like, “Oh my God.” And I stood there with this. I was like, “Oh my God.” And I’ve said all this bad language and cracking jokes, roasting people in the audience, my friends usually. And it’s like, yeah, I was squirming.  So, at this point, I did just pretend I didn’t know them because it was the best I could do. And they got me out of trouble. They were obviously confident in performance mode. And they got onto mic and was like, “Can you believe that guy is my therapist?” And I was like, “What?” I was like, “Wow.” And then he said some really lovely things. And it wasn’t really awkward in therapy. If anything, it was quite something we laughed about in therapy afterwards, and it contributed to it. But yeah, the horror I felt. Oh, I felt sick, and oh. I don’t want to think about it. FINAL CONCLUSIONS Kimberley: I want to be respectful of time. Of course, before you share this all about you and where people can get a hold of you and learn about your book, is there anything you want to say final point about what it’s like to actually be an anxiety therapist? Joshua: It’s the best job in the world for me. It’s the best job in the world. All my friends and family go, “I don’t care how you can do that.” I love it. I get to have the most human conversations with people without judgment. You mentioned before about intrusive thoughts. I’ve got the magic guitar in this room, and we make songs about horrible intrusive thoughts. There was one the other day about kicking babies down the stairs. You can’t say that out loud. Yes, we do in here, to the three chords of the guitar I only know, particularly postpartum mothers.  Kimberley: You told me we couldn’t sing today.  Joshua: No, I’m not singing. Kimberley: I wanted to sing today, and now you’re telling me we can’t sing. Joshua: I don’t think it’s going to be Christmas number one—a three-chord banger about harming loved ones or sexual intrusive thoughts—but you never know. Yeah, it’s the most beautiful job. Kimberley: I am known to sing intrusive thoughts to happy birthday songs. Joshua: That’s a good one. I have to close my window though in my office because I do get scared that people walk past and like, “Wow, that’s a very disturbed man.” No, he’s not. I’m confident in the powers of ERP and how it can help. Kimberley: You are. I love it. Josh, tell us where we can hear more about your book and learn more about you. Joshua: I’m Joshua Fletcher, also known as AnxietyJosh on social media and stuff. The book is called And How Does That Make You Feel?: Everything You (N)ever Wanted to Know About Therapy. It follows the stories of the four client case studies, obviously highly scrambled and anonymized, and gone through a rigorous ethical process there. So, don’t be like, “He’s talking about his clients.” No, that’s not what the book’s about. It’s about appearing in behind the therapy room door. It’s out in the US before the UK, which is here. I don’t know if anyone’s watching or whatever, but there it is. And it’s also been commissioned to be a television show for major streaming services. We don’t know which one yet, but it’s exciting.  Go get yourself a copy. It should be in your bookstore. Get it at Barnes & Noble and all the other US ones. And I think you’ll really enjoy it. So, it’s a really lovely endorsement. Kim has also said it’s really good, and Kim is harsh. So, if Kim says it’s good, then it’s going to be good. And I hope you really enjoy it and pass it on to a loved one who doesn’t have anxiety, and you’ll find that, “Oh, I actually learned quite a lot there whilst laughing and being captivated by the absolute bananas behind-the-scenes life of being a therapist.” Kimberley: Yeah, I love it. Josh, the way that you present it, if I was scared to go to therapy, I think it would make me less scared. I think it would make me feel like this is something I could do. Joshua: And that’s the best compliment I can receive, because that’s why I wrote the book. So, thank you so much. Kimberley: Yeah. So fun to have you. Thanks for being here. Joshua: Thanks, Kim.

In the realm of mental health, the significance of structured daily routines for depression cannot be overstated. Kimberley Quinlan, an anxiety specialist with a focus on mindfulness, Cognitive Behavioral Therapy (CBT), and self-compassion, emphasizes the transformative impact that Daily Routines for Depression can have on individuals grappling with this challenging condition. Depression, characterized by persistent feelings of sadness, hopelessness, and a lack of interest in once-enjoyable activities, affects every aspect of one's life. Quinlan stresses that while professional therapy and medication are fundamental in the treatment of depression, integrating specific daily routines into one's lifestyle can offer a complementary path toward recovery and mental wellness. THE POWER OF MORNING ROUTINES FOR DEPRESSION Starting the day with a purpose can set a positive tone for individuals battling depression. Quinlan recommends establishing a consistent wake-up time to combat common sleep disturbances associated with depression. Incorporating light physical activity, such as stretching or a gentle walk, can significantly boost mood. Mindfulness practices, including meditation, journaling, or gratitude exercises, can help foster a healthier relationship with one's thoughts and emotions. Additionally, a nutritious breakfast can provide the necessary energy to face the day, an essential component of "Daily Routines for Depression." DAYTIME ROUTINES FOR DEPRESSION Throughout the day, setting realistic goals and priorities can help maintain focus and motivation. Quinlan advocates for the inclusion of pleasurable activities within one's schedule to counteract the anhedonia often experienced in depression. Techniques like the Pomodoro Method can aid in managing tasks without becoming overwhelmed, breaking down activities into manageable segments with short breaks in between. Exposure to natural light and ensuring a balanced diet further contribute to improving mood and energy levels during the day. EVENING ROUTINES FOR DEPRESSION As the day draws to a close, engaging in a digital detox and indulging in relaxation techniques become crucial. Limiting screen time and investing time in hobbies or skills can provide a sense of accomplishment and fulfillment. Establishing a calming bedtime routine, including activities like reading or taking a bath, can enhance sleep quality, an essential factor in "Daily Routines for Depression." WEEKLY ACTIVITIES TO OVERCOME DEPRESSION Quinlan also highlights the importance of incorporating hobbies and community engagement into weekly routines. Finding a sense of belonging and purpose through social interactions and new skills can offer a much-needed respite from the isolating effects of depression. NAVIGATING TOUGH DAYS WITH COMPASSION Acknowledging that the journey through depression is fraught with ups and downs, Quinlan advises adopting a compassionate and simplified approach on particularly challenging days. Focusing on basic self-care and seeking support when needed can provide a foundation for resilience and recovery. In conclusion, Daily Routines for Depression are not just about managing symptoms but about rebuilding a life where mental wellness is prioritized. Through mindful planning and self-compassion, individuals can navigate the complexities of depression and move towards a more hopeful and fulfilling future. PODCAST TRANSCRIPT If you’re living with depression today, we are going to go through some daily routines for your mental wellness.  Welcome. My name is Kimberley Quinlan. I’m an anxiety specialist. I talk all about mindfulness, CBT, self-compassion, and skills that you can use to help you with your mental wellness.  Let’s talk about living with depression, specifically about daily routines that will set you up for success. My goal first is to really highlight the importance of routines. Routines are going to be the most important part of your depression recovery, besides, of course, seeing your therapist and talking with your doctor about medication.  This is the work that we do at home every day to set ourselves up for success, finding ways that we can manage our depression, overcome our depression by tweaking the way in which we live our daily life because the way we live our lives often will impact how severe our depression can get. There are some behaviors and actions that can very much exacerbate and worsen depression. And there are some behaviors and routines that can very much improve your depression. So, let’s talk about them today. DEPRESSION SYMTPOMS Let’s first just get really clear on depression and depression symptoms. Depression is a common and can be a very serious mental illness and medical condition that can completely negatively impact your life—the way you feel, the way you think, the way you act. It often includes persistent feelings of sadness, emptiness, hopelessness, worthlessness that can really impact the way you see yourself and your own identity. It often includes a lack of interest in pleasure in the activities that you once enjoyed.  Depression symptoms can vary from mild to very severe. They can include symptoms such as changes in appetite, sleep disturbances, loss of energy, excessive guilt, difficulty thinking or concentrating. Sometimes you can feel like you have this whole brain fog. And again, deep, overwhelming feelings of worthlessness and hopelessness.  Now, it is important to recognize that depression is not just a temporary bout of sadness. It’s a chronic condition. It’s one that we can actually recover from, but it does require a long-term treatment plan, a commitment to taking care of yourself, including therapy and medication. So, please do speak to your medical professional and a mental health professional if you have severe depression or think you might have severe depression.  It can also include thoughts of wanting to die and not feeling like you want to live on this earth anymore. Again, if that’s something that you’re struggling with, please go to your local emergency room or immediately seek out professional mental health or medical health care.  It is so important that you do get professional help for depression because, again, depression can come down like a heavy cloud on our shoulders, and it tells a whole bunch of lies. We actually have a whole podcast episode about how depression is a big fat liar. And sometimes when you are under the spell of those lies, it’s hard to believe that anything else might be true. So, it’s very important that we take it seriously. And as we’re here today to talk about, it’s to create routines that help really nurture you and help you towards that recovery.  TREATMENT FOR DEPRESSION Before we move into those routines, I want to quickly mention the treatment for depression. The best treatment for depression is cognitive behavioral therapy. Now there is often a heavy emphasis on mindfulness and self-compassion as well. Cognitive behavioral therapy looks at both your thoughts and your behaviors. And it’s important that we look at both because both can impact the way in which this disorder plays out.  If you don’t have access to a mental healthcare professional, we also have an online course called Overcoming Depression. Overcoming Depression is an on-demand online course where I teach you the exact steps that I use with my clients to propel them into setting up their cognition so that they’re healthy, their behaviors, so that they bring a sense of pleasure and motivation, and structure into their daily lives. And then we also very heavily emphasize self-compassion and that mindfulness piece, which is so important when it comes to managing highly depressive and hopeless thoughts. So, that’s there if you want to go to CBTSchool.com/depression, or you could go to CBTSchool.com, and we have all the links right there.  DAILY ROUTINES FOR DEPRESSION All right, so let’s talk about daily routines for depression. Research shows that, specifically for depression, finding a routine and a rhythm in your day can greatly improve the chances of your long-term recovery. And so, I really take time and slow down with my patients and talk to them about what routines are working and what routines are not. I’m not here to tell you or my patients, or my students how to live their lives and what to do specifically. I’m really interested at looking at what’s working for you and what’s not. Let’s first start with morning routines.  What often very much helps—and maybe you already have this, but if not, this is something I want you to consider—is the importance of a consistent wake-up time. When you’re depressed, as I mentioned before, a common depression symptom is sleep disturbance. Often, people lay awake all night and sleep all day, or they sleep all night and they sleep all day, and they’re heavily overwhelmed with this sleepy exhaustion. It is really important when it comes to morning routines that you set a time to wake up every morning and you get up, even if it’s for a little bit, if that’s all you can handle. Try to set that really consistent wake-up time.  What I want to emphasize as we go through these routines for depression is I don’t mind if you even do tiny baby steps. One thing you might want to start from all of the ideas I give you today, you might just want to pick one. And if that’s all you can do, that is totally okay.  What we also want to do is we want to, if possible, engage in some kind of light movement, even stretching, to boost mood. There’s a lot of routine, even just stretching or gentle walks outside. It doesn’t have to be fast. It doesn’t have to be for an hour. It could be for a quarter of a block to start with. But that light exercise has been shown to boost mood significantly. And then if you’re able, maybe even to do that multiple times throughout the day.  Another morning routine that you may want to consider is some type of mindfulness practice. Again, we cover this in overcoming depression and with my patients in CBT, but some kind of mindfulness practice. It might be journaling, it could be a gratitude practice, it could be preferably some kind of meditation. Often, what I will encourage my clients to do is just listen to a guided meditation, even if you don’t really follow along exactly. But you’re just learning about these concepts. You’re learning about the tools. You’re getting curious about them if that’s all you can do. Or if you want, you could even go more into reading a book about mindfulness, starting to learn about these ideas and concepts because they will, again, help you to have a better relationship with your thoughts and your feelings.  Another morning routine I want you to maybe consider here is to have some type of nutritious breakfast, something that supports your mental health. We want to keep an eye out for excessive sugar, not that there’s anything wrong with sugar, but it can cause us to have another energy dump, and we want to have something that will improve our energy. With depression, usually, we don’t have much energy at all. So, whatever tastes yummy, even if nothing feels yummy, but there’s something that maybe slightly sounds good, have that. If it’s something that you enjoy or have good memories about, or if it’s anything at all, I’m happy just for you to eat anything at all if it’s not something that you’ve been doing.  Let’s now move over to work-day or daytime strategies or routines. The first thing I want you to consider here throughout the day is setting realistic daily goals and priorities. We have a course at CBT School called Optimum Time Management, and one of the core concepts of that course, which teaches people how to manage their time better, is we talk about first prioritizing what’s most important.  If you have depression, believe it or not, one of the most important things you can do to prioritize in your daily schedule is pleasure. And I know when you have depression, sometimes nothing feels pleasurable. But it’s so important that you prioritize and schedule your pleasure first. Where in the day can you make sure that you do something enjoyable, even if it’s this enjoyable, even if nothing is enjoyable, but you used to find it enjoyable? We want to prioritize your self-care, prioritize your eating, having a shower, brushing your teeth. If nothing else gets done that day, that’s okay. But we want to prioritize them depending on what’s important to you.  Now, if you’re someone who’s depressed because you’re so overwhelmed with everything that you have to do—again, we talk about this in the time management course—we want to really look at the day and look at the schedule and say, “Is this schedule nurturing a mental health benefit to me? Is it maybe time for me to reprioritize and take things off my schedule so I can get my mental health back up to the optimum level?”  I have had to do this so many times in the last few years, especially as I have suffered a chronic illness, really separate like an hour to really look at the calendar and say, “Are these things I’m doing actually helping me?” Sometimes I found I was doing things for the sake of doing them to check them off the list, but I was getting no mental benefit from them. No real value benefit from them either.  Another daytime strategy you can use is a technique or a tool called the Pomodoro Technique or the Pomodoro Method. This is where we set a timer for a very short period of time and we go and we do the goal and we focus on the thing for a short period of time. So, an example might be I might set a timer for 15 minutes, and all I’m going to do during that 15 minutes is write email. If 15 minutes is too much for you, let’s say maybe you need to tidy up your dishes, you might set a timer for 45 seconds and just get done with what you can for 45 seconds and then take a short break. Then you set the timer again. All I have to do is 45 seconds or a minute and a half or three minutes or five minutes, whatever is right for you, and put your attention on just getting that short Pomodoro little bout done.  This can be very helpful to maintain focus. It can be very helpful to maintain the stress of that activity, especially if it’s an activity that you’re dreading. And so, do consider the Pomodoro technique. You can download free apps that have a Pomodoro timer that will set you in little increments. It was actually, first, I think, created for exercise. So, it sets it like 45 minutes on, 20 seconds off, 45 seconds on. And so, you can do that with whatever task you’re trying to get done as well.  Another daytime routine I want you to consider is getting some kind of natural light or going outdoors. There is so much research to show that going outside, even if it’s for three minutes, and taking in the green of the earth or the dirt under your feet, really getting in touch and grounding with some kind of nature, or being in the sunlight, can significantly improve mood. So, consider that as well. And again, I’m going to mention, make sure you eat lunch. Eat something that boosts your mood and boosts your energy levels.  Now let’s talk about evening or wind-down routines for depression or practices. Now, number one, one of the things that we often do the most, which we really need to be better about, and this is me too, is doing some kind of digital detox in the evenings. Try your hardest to limit screen time before bed because we know screens before bed actually disturb our sleep. We also know that often we spend hours, hours of our day scrolling on social media. And even though that might feel pleasurable, it actually removes us from engaging in hobbies and things that actually make us feel good about ourselves.  One of the best ways to feel good about who you are and to feel accomplished is to be learning something or mastering something. I don’t care if it’s something that you’re starting and you’re terrible at. We have a lot of research that even moving and practicing a skill will improve and boost your mood so much more than an hour of sitting and watching funny TikTok videos.  Now, again, if all you want to do is that for right now, that’s fine. Maybe spend five minutes doing some hobby or task—something that you enjoy or used to enjoy—that you feel like you’re getting better at. Maybe you learn Spanish, you learn to crochet, you learn to knit, you do paint by number. It doesn’t matter what it is. Just pick something and work at something besides looking at a screen, especially in the evenings.  Another evening routine I want you to consider is some kind of relaxation technique for depression—reading, take a bath, maybe do again some stretching or some light yoga, maybe dance to one song. Anything you can do to, again, move your body. Again, we have so much research to show that moving your body gently, especially in the evening, can help with mood.  Another thing here is to find a comfortable sleep routine and bedtime routine. So, if you can, again, go back to your scheduling, and if you’re not good at this—we do have that online course for time management—create a nighttime routine that feels yummy in your bones. Maybe it’s reading a book, a lovely warm blanket, the pillow you love, a scent—sometimes an oil diffuser would be lovely for you. Dim the lights, close the blinds, create a nice, warm, cozy nook where you can then ease into your sleep.  Overall, weekly activities and routines that you may want to consider for your mental wellness include again finding hobbies. It doesn’t have to be grand. You don’t have to sign up for a marathon. You don’t have to become an amazing artist. You can just pick something that you suck at. That’s okay.  I always tell my patients to do paint by number. It requires very little mental energy, but you do have this cool thing that you did at the end that you can gift somebody, or you can even scrap it at the end, it doesn’t matter. Put it up on your wall—anything to get you out of your head and out of the mood piece—and really get into your body, moving your hands and thinking about focusing on other things.  One of the most important things that you can do to help boost mood and decrease depression is to find a community of like-minded people. The social interaction and improving and maintaining connections between people are going to be so important. In fact, in some countries, the treatment per se for depression, no matter how depressed somebody is, the community go and get them, bring them out, they have a party for them, they cook for them, they surround them, they dance with them. And that’s how those communities and tribes help people get through depression. And we in our Western world have forgotten this beautiful, important piece of community and being a part of a big community family.  Now, if you have struggled with this and it’s been difficult, I encourage you to reach out to support groups. There are so many ways—meet-up groups, local charities, volunteering, maybe finding again a hobby, but a place where you go and you’re with other people, even just doing that. You don’t have to spend a lot of time, but being around people. Even though when you’re depressed, I know it doesn’t feel like that’s a helpful thing. We do know that it does connect those neural pathways in our brain and does help with the management and maintenance of depression recovery.  Now, what do we do, and how can we maintain these routines on the really tough days? When it comes to handling the tough days, I understand it can feel overwhelming. All of this can feel like so, so much. But what I’m going to encourage you to do is keep it really simple. Just doing your basic functioning is all that’s required on those really tough days. It doesn’t matter if you don’t get all the things done on your list. Be compassionate, be gentle, encourage yourself, look at the things you did do instead of the things you didn’t get to do, and also seek support. Reach out to your mental health professional or a support group or your medical doctor or family or a friend or a neighbor if you’re really needing support.  There will be hard days. Depression is not linear. Recovery for depression is not linear. It’s up and down. There will be hard days. So, be as gentle as you can. Keep it as simple and as basic as you can. Do one thing at a time. Try not to focus at the whole day and all the things you have to do. That’s going to help you feel less overwhelmed and, again, help you get through one thing a day.  Let me do a quick recap. The importance of routine is huge. Routines are going to be probably one of the most important parts of your long-term recovery, besides, of course, treatment and medication. It will help you to get through the hard and stressful days and will also allow you to slowly make steps into the life that you want, and often, because we have depression, depression can take away the life that we want. So, that routine can help you slowly build up to the things that you want to do and get back to the life that you do really value.  I encourage you all to play around with this. Remember, look at the routine you have already, and maybe add one thing for now. Take what works for you, but if some of the things I mentioned today, don’t leave them. Please don’t feel judged or embarrassed if some of these aren’t really working for you. We have to look at what works for us and be very gentle with ourselves with that as well. I hope this has been helpful. The routines have really saved me in my mental health. And so, I hope it helps you just as much as it’s helped me.  Have a great day, and I’ll see you guys next week.

In the insightful podcast episode featuring Joanna Hardis, author of "Just Do Nothing: A Paradoxical Guide to Getting Out of Your Way," listeners are treated to a deep dive into the concept of distress tolerance and its pivotal role in mental health and personal growth. Joanna Hardis, with her extensive background in treating anxiety disorders such as panic disorder, OCD, and Generalized Anxiety Disorder, shares her professional and personal journey toward understanding and teaching the art of effectively managing internal discomfort without resorting to avoidance or escape tactics. The discussion begins with an exploration of the title of Joanna's book, "Just Do Nothing," which encapsulates the essence of her therapeutic approach: the intentional practice of stepping back and allowing thoughts, feelings, and sensations to exist without interference. This practice, though seemingly simple, challenges the common impulse to engage with and control our internal experiences, which often exacerbates suffering. A significant portion of the conversation is dedicated to "distress intolerance," a term that describes the perceived inability to endure negative emotional states. This perception leads individuals to avoid or escape these feelings, thereby increasing vulnerability to a range of mental health issues including anxiety, depression, and substance abuse. Joanna emphasizes the importance of recognizing and altering the self-limiting beliefs and thoughts that fuel distress intolerance. Practical strategies for enhancing distress tolerance are discussed, starting with simple exercises like resisting the urge to scratch an itch and gradually progressing to more challenging scenarios. This gradual approach helps individuals build confidence in their ability to manage discomfort and makes the concept of distress tolerance applicable to various aspects of life, from parenting to personal goals. Mindfulness is highlighted as a crucial component of distress tolerance, fostering an awareness of our reactions to discomfort and enabling us to respond with intention rather than impulsivity. The podcast delves into the importance of connecting with our values and reasons for enduring discomfort, which can provide the motivation needed to face challenging situations. Joanna and Kimberley also touch on the common traps of negative self-talk and judgment that can arise during distressing moments, advocating for a more compassionate and accepting stance towards oneself. The idea of "choice points" from Acceptance and Commitment Therapy (ACT) is introduced, encouraging listeners to make decisions that align with their values and move them forward, even in the face of discomfort. The episode concludes with a message of hope and empowerment: everyone has the capacity to work on expanding their distress tolerance. By starting with small, manageable steps and gradually confronting more significant challenges, individuals can cultivate a robust ability to navigate life's inevitable discomforts with grace and resilience. EPISODE HIGHLIGHTS:  The Concept of "Just Do Nothing": This core idea revolves around the practice of intentionally not engaging with every thought, feeling, or sensation, especially when they're distressing. It's about learning to observe without action, which can reduce the amplification of discomfort and suffering. Understanding Distress Intolerance: Distress intolerance refers to the belief or perception that one cannot handle negative internal states, leading to avoidance or escape behaviors. This concept highlights the importance of recognizing and challenging these beliefs to improve our ability to cope with discomfort. Building Distress Tolerance: The podcast discusses practical strategies to enhance distress tolerance, starting with simple exercises like resisting the urge to scratch an itch. The idea is to gradually expose oneself to discomfort in a controlled manner, thereby building resilience and confidence in handling distressing situations. Mindfulness and Awareness: Mindfulness plays a crucial role in distress tolerance by fostering an awareness of our reactions to discomfort. This awareness allows us to respond intentionally rather than react impulsively. The practice of mindfulness helps in recognizing when we're "gripping" distressing thoughts or sensations and learning to gently release that grip. Aligning Actions with Values: The podcast emphasizes the significance of connecting actions with personal values, even in the face of discomfort. This alignment can motivate us to face challenges and make choices that lead to personal growth and fulfillment, rather than making decisions based on the urge to avoid discomfort. These concepts together form a comprehensive approach to managing distress and enhancing personal well-being, as discussed by Joanna Hardis in the podcast episode. TRANSCRIPTION:  Kimberley: Welcome, everybody, today. We have Joanna Hardis. Joanna wrote an amazing book called Just Do Nothing: A Paradoxical Guide to Getting Out of Your Way. It was a solid gold read. Welcome, Joanna. Joanna: Thank you. Thank you for having me. Thank you for reading it, too. I appreciate it. Kimberley: It was a wonderful read and so on point, like science-backed. It was so good, so you should be so proud. Joanna: Thank you. Kimberley: Why did you choose the title Just Do Nothing? Joanna: I mean, it’s super catchy, but more importantly than that, it is really what my work involves on a personal level and on a professional level—learning how to get out of my own way or our own way by leaving our thoughts alone, learning how to leave uncomfortable feelings alone, uncomfortable sensations alone, uncomfortable thoughts alone. Because that’s what creates the suffering—when we get so engaged in them. Kimberley: Yeah. It’s such a hard lesson. I talk about this with patients all the time. But as I mentioned to you, even my therapist is constantly saying, “You’re going to have to just feel this one.” And my instinct is to go, “Nope. No thanks. There has to be another way.” Joanna: A hundred percent. Yes. I mean, it really is something on a daily basis. I have to remind myself and work really hard to do. Kimberley: It is. But it is such powerful work when you do it.  Joanna: Mm-hmm.  Kimberley: Early in the book, you talk about this term or this concept called ‘distress intolerance.’ Can you tell us what both of those are and give us some ideas on why this is an important topic? Joanna: Sure, and this is what got me interested in the book and everything. Distress tolerance is a perception that you can handle negative internal states. And those internal states can be that you feel anxious, that you feel worried, you feel bored, vulnerable, ashamed, angry, sad, mad, off. There’s an A to Z alphabet of those unpleasant and uncomfortable emotional states. And when we have that perception that we can handle it, our behavior aligns, so we tend to do things.  When we are distress-intolerant, we have a perception—often incorrect—that we cannot handle negative internal states. So then we will either avoid them or escape them or try to figure them out or neutralize them or try to get rid of them, make them stop—all the things that we see in our work every day.  Before I had my practice in anxiety disorders, I worked over a decade in an eating disorder treatment center, and we know that when someone has really low distress tolerance, they are more vulnerable to developing eating disorders, anxiety disorders, depressive disorders, substance use disorders. So, it’s a really important concept. Kimberley: It’s such an important concept. And you talk about how the thoughts we have which can determine that. Do you want to share a little bit about that? Because there was a whole chapter in the book about the thoughts you have about your ability to tolerate distress. Joanna: Sure, and I didn’t answer the second part of your question., I just realized, which will tie into that, which is how it sounds. How it sounds is, “I can’t bear to feel this way, so I’m going to avoid that party,” or “I’m having too good of a day, so I can’t do my homework,” or “I can’t bear if my kids see me anxious, so we’re not going to go to the playground.” And so, what drives someone’s perception are their thoughts and these thoughts and these self-limiting stories that we all have, and that oftentimes we just buy into as either true, or perhaps at one point, they may have been true, but we’ve outlived them. Kimberley: Yeah. We’re talking about distress tolerance, and I’m always on the hunt to widen my distress tolerance to be able to tolerate higher levels of distress. And I think what’s interesting is, first, this is more of a question that I don’t know the science behind it, but do you think some people have higher levels of distress which makes them more intolerant, or do you think the intolerance which is what makes the distress feel so painful? Joanna: I don’t know the research well enough to answer it. Because I think it’s rare that you see -- I mean, this is just one construct. So it’s very hard to isolate it from something like emotional sensitivity or anxiety sensitivity or intolerance for uncertainty, or something else that may be contributing to it. Kimberley: Yeah. No, I know. It’s just a question I often think about, particularly when I’m with patients. And this is something that I think doesn’t really matter at the end of the day. What matters is—and maybe this will be a question for you—if our goal is to increase our distress tolerance, how might somebody even begin to navigate that? Joanna: Sure. I love that question. I mean, in the book, I take it down to such a micro level, which is learning how—and I think you’ve talked about it on podcasts—itch serve. So, one of the exercises in the book is learning how you set your timer for five minutes and you get itchy, which of course is going to happen. And it’s learning how to ride out that urge to scratch the itch. So, paying attention to. If you zoom in on the itch, what happens?  What happens when you zoom out? What else can you pay attention to?  And so when someone learns that process, that is on such a micro level. I often tell patients it’s like a one-pound weight. Kimberley: Yes. Joanna: And then what are some two-pound weights that people can use? So then, for many people, it’s their phone. So, it’s perhaps not checking notifications that come in right away. They begin to practice in low-distress situations because I want people to get confident that they know how to zoom in, they know how to zoom out. They know if they’re feeling a sensation, the more that they pay attention to it, the worse it’s going to feel. And so, where else can they put their awareness? What else can they be doing?  And once they get the hang of it, we introduce more and more distress. So then, it might be their phone, then it might be them intentionally calling up a thought. And we work up that way with adding in, very gradually, more distress or more discomfort. Exercise is a great way, especially if it’s not married to anxiety, to get people interacting with it differently. Kimberley: Yeah. We use this all the time with anxiety disorders. It’s a different language because we talk about an ERP hierarchy, or your exposure menu, and so forth. But I love that in the book, it’s not just specific to that. It could be like you talked about. It’s for those who have depression. It’s those who have grief. It’s those who have eating disorders. It’s those who have anger. I will even say the concept of distress tolerance to me is so interesting because there’s so many areas of my life where I can practice it. Like my urgency to nag my kids another time to get out the door in time, and I have to catch like, “You don’t need to say it the third time.” Can you tolerate your own discomfort about the time it’s taking them to get out the door? And I think that when we have that attitudinal shift, it’s so helpful. Joanna: Yes. I find parenting as one of the hardest places for me, but it was also a reminder like the more I keep my mouth shut, the better. Kimberley: Yeah. And I think that’s really where I was talking before. I found parenting to be quite a triggering process as my kids have gotten older, but so many opportunities for my own personal growth using this exact scenario. Like your fear might come up, and instead of engaging in that fear, I’m actually just going to let it be there and feel it and parent according to my values or act according to my values. And I’ve truly found this to be such a valuable tool. Joanna: Yes. And I have found what’s been really interesting, when my kids were at home, that was where my distress was. Now that the two of the three are out of the house, my distress is when we’re all together and everyone have a good time. And so, it morphs, because what I tell myself and my perception and the urgency, it changes. It’s still so difficult with them, but it changes based on what’s happening. Kimberley: Yeah. And I think this is an opportunity for everyone, too. How much do you feel that awareness piece is important in being aware that you are triggered? For the folks listening, of course, you’re on the Your Anxiety Toolkit podcast. Most are listening because they have anxiety. Do you encourage them to be aware of other areas? They can be practicing this.  Joanna: Yes. Kimberley: Can you talk to me about that? Joanna: 100%, because I feel like -- what is that metaphor about the onion? It’s like the layers of an onion. So, people will come, and they’ll think it’s about their anxiety. But this is really about any uncomfortable feeling or uncomfortable sensation. And so. It may be that they’re bored or vulnerable or embarrassed or something else. So, once someone learns how to allow those feelings and do what is important to them or what they need to do while they feel it, then yes, I want them to go and notice where else in their life this is showing up. Kimberley: Talk to me specifically about how in real-time, because I know that’s what listeners are going to ask.  Joanna: Of course. Kimberley: I have this scary thing I want to be able to do, but I don’t want to do it because I’m scared, and I don’t want to feel scared. How might someone practice tolerating their distress in real-time? Joanna: I’m going to answer two ways. One, I would say that might be something to scale. Sometimes people want to do the thing because doing the thing is like the goal or the sexy thing, but if it’s outside of their window of tolerance, they may not be able to do it. So, it depends on what they want to do. So, I might say, as just a preface, this might be something that people should consider scaling.  Kimberley: Gradual, you mean? Joanna: Yes. So, for instance, they want to go to the gym, but they’re scared of fainting on the treadmill or something. Pretty common for what we see. It would be like, scale it back. So it might be going to the parking lot. It might be taking a tour. It might be going and standing on the treadmill. It might be walking on the treadmill. But we have to put it in smaller pieces.  In the moment that we’re doing something that is difficult, first, we have to notice if we’re starting to grip. I use this “if we’re starting to grip” something. If we’re starting to zoom in on what we don’t like, if we’re starting to zoom in on a sensation we don’t like, a thought we don’t like, a feeling we don’t like, I want people to notice that and you get better at noticing it faster.  The first thing is you got to notice it, that it’s happening, because that’s going to make it worse. So, you want to be able to notice it. You want to be able to loosen your grip on it. So, that might be finding out what else is going on in my surroundings. So, I’m on the treadmill, I’m walking maybe at a faster pace, and I’m noticing that my heart rate is going up, and I’m starting to zoom into that. What else am I noticing, or what else am I hearing? What else do I see? What else is going on around me? Can we make something else a louder voice? And so, every time that my brain wants to go back to heart focus, it’s like, no, no. It’s taking it back to something else that’s going on. And it helps to connect with why is this important to do? So, as I’m continuing to say, “I’m okay. I am safe. I’m listening. I’m focusing on my music, and I’m looking out the window," This is really important to do because my health is important. My recovery is important. It becomes that you’re connecting to something that’s important, and the focus is not on what we don’t like because that’s going to make it bigger and stronger. Kimberley: Right. As you’re doing that, as we’ve already mentioned, someone might be having those can’t thoughts, like I can’t handle it, even if it’s within their window of tolerance, right? It’s reasonable, and it’s an appropriate exposure. How might they manage this ongoing “You can’t do this, this is too hard, it’s too much, you can’t handle it” kind of thinking? Joanna: I like “This may suck, and I can do it.” Kimberley: It’s funny. I will tell you, it’s hilarious. In the very beginning of the book, you make some comments about the catchphrases and how you hate them, and so forth. I always laugh because we have a catchphrase over here, but it’s so similar to that in that we always talk about, like it’s a beautiful day to do hard things. And that seems to be so hopeful for people, but I do think sometimes we do get fed, like over positive ways. You have a negative thought, so we respond very positively, right? And so, I like “This is going to suck, and I’m going to do it anyway.” Joanna: Yes. So you’re acknowledging this may suck, especially if you’re deconditioned, especially if you’re scared. It may suck AND—I always tell people not the BUT—AND I can do it. Even in 30-second increments. So, if someone is like, “I can’t, I cant,” I’ll say, “You can do anything for 30 seconds.” So then we pile on 30 seconds. Kimberley: Yeah. And that’s such an important piece of it too, which is just taking a temporary mindset of we can just do this for a little tiny bit and then a little tiny bit and then a little tiny bit.  Joanna: Yes, I love that. I love that. Kimberley: Why do we do this? What’s the draw? Sell me on why someone wants to do this work. Joanna: To do...? Kimberley: Distress tolerance. We talk about this all the time. Why do we want to widen our distress tolerance? Joanna: Oh my goodness. Oh my gosh. I think once you realize all the little areas that may be impacting one’s life, it just blows your mind. But in a practical sense, people can stay stuck. When people are stuck. This is often a piece. It’s absolutely not the whole reason people are stuck, but this is such a piece of why people get stuck. And so I think for anyone that might feel stuck, perhaps they want a different job or they want to show up differently as a parent or they feel like they are people-pleasers, or they’re having trouble dating because they get super controlling. It can show up in any area of one’s life. Kimberley: Yeah. For me, the selling point on why I want to do it is because it’s like a muscle—if I don’t continue to grow this muscle, everything feels more and more scary. Joanna: Oh, sure. Yeah, hundred percent. Kimberley: The more I go into this mindset of “You can’t handle it and it’s too much, it’s too scary” things start to feel more scary. The world starts to feel more unsafe, whereas that attitude shift, there’s a self-trust that comes with it for me. I trust that I can handle things. Whereas if I’m in the mindset of “I can’t,” I have no self-trust. I don’t trust that I can handle scary things, and then I’m constantly hypervigilant, thinking when the next scary thing's going to happen. Joanna: Right. Another reason to also practice doing it, if you never challenge it, you don’t get the learning that you can do it. Kimberley: Yeah. There’s such empowerment with this work. Joanna: Yes. And you don’t have to do big, scary things. You don’t have to jump out of an airplane to do it or pose naked, because I see that on Instagram now, people who are conquering their fears by doing these. Very Instagram-worthy tasks, which could be very scary. We can do it, just like you say, with not nagging our kids, by choosing what I want to make for dinner versus making so many dinners because I am so scared that I can’t handle it if my kids are upset with me. Kimberley: Right. And for those who have anxiety, I think from the work I do with my patients is this idea of being uncertain feels intolerable. That feeling. You’re talking about these real-life examples. And for those who are listening with anxiety, I get it. That feeling of uncertainty feels intolerable, but again, that idea of widening your tolerance or increasing your ability to tolerate it in 10-second increments can stop you from engaging in compulsions that can make your disorder worse or avoiding which can make your disorder worse. Do you have any thoughts on that? Joanna: I 100% agree with you. I always say, let’s demote intolerable to uncomfortable. Because I feel sometimes like I have to know I can’t stand it, I’m crawling out of my skin. But if I’m then able to get some distance from it, that’s the urgency of anxiety. Kimberley: Yeah. It’s such beautiful work. Joanna: Yes, and especially the more people do, they’re able to say, “You know what? I can do things.” It may feel intolerable. That diffusion, it may feel intolerable. It’s probably uncomfortable. So, what is the smallest next step I can take in this situation to do what I need to do and not make it worse? That’s a big thing of mine—not making a situation worse. Kimberley: Yes. And that’s where the do-nothing comes in. Joanna: Yes. That’s the paradoxical part.  Kimberley: Yeah. Is there any area of this that you feel like we haven’t covered that’s important to you, that would be an important piece of this work that someone may consider as they’re doing this work on their own? Joanna: I think and I know that you are a big proponent of this too. I think it’s very hard to do this work without some mindful awareness practice. And I talk about it in the book. It’s just such an enhancer. It enhances treatment, but it also enhances our daily life. So, I can’t say strongly enough that it is so important for us to be able to notice this pattern when we are saying, “Oh my gosh, I can’t take this,” or “I can’t do this.” And then the behavior and to think about what’s the function of me avoiding. But if we’re going so fast and our gas pedal is always to the floor, we don’t have the opportunity to notice. Kimberley: Yeah, the mindfulness piece is so huge. And even, like you’re saying, the mindfulness piece of the awareness but also the non-judgment in mindfulness. As you’re doing the hard thing, as you’re tolerating distress, you’re not sitting there going, “This sucks and I hate it.” I mean, you’re saying like it will suck, and that's, I think, validating. It validates you, but not staying in “This is the worst, and I hate it, and I shouldn’t be here.” That’s when that suffering does really show up.  Joanna: Yes. The situation may suck. It doesn’t mean I suck. That was a hard lesson to learn. The situation may, but I don’t have to pour gas on it by saying, “How long is it going to last? Oh my gosh, this feeling’s never going to end. Do I still feel it? Oh my gosh, do I still feel it as much?” All the things that I’m prone to do or my clients are prone to do that extend the suffering. Kimberley: Make it worse. Joanna: Yeah, exactly. Kimberley: It’s a great question, actually. And I often will talk with my patients about it, in the moment, when they’re in distress. Sometimes writing it down, like what can we do that would make this worse? What can we do that will make this better? And sometimes that is doing nothing at all. And you do talk about that in the book. Joanna: Yeah. Kimberley: The forward and the backward.  Joanna: The choice points. Yes. Kimberley: Can you share just a little bit about that? Joanna: It’s a concept from ACT (Acceptance and Commitment Therapy) that says, when we have a behavior, a behavior can either move us toward or forward what’s meaningful in our values or can move us away from it. And so, as we’re thinking about doing whatever the hard thing maybe or it may not even be a hard thing; it just may be something you don’t want to do. Thinking about what your why is, what’s the forward move? Why is it meaningful to you? What do you stand to get? What’s on the other side? Because most of us are well versed, and if we give in, that’s an away move. And we have to be able to do this non-judgmentally because some days it’s just not in us, and that’s totally fine. But I want people to be honest with themselves and non-judgmental about whatever decisions they make. But it does help to have a reason that moves us forward. Kimberley: Absolutely. I think that’s such an important piece of the work. Again, that’s the selling point of why we would want to be uncomfortable. There’s a goal or a why that gets us there. Joanna: Yeah. And it’s amazing how much pain we will put up with. I mean, think about all the things people like—waxing and some of these exercise classes. It’s amazing because it’s important to someone. Kimberley: Exactly. And I think that’s a great point too, which is we do tolerate distress every day when we really are clear on what we want. And I think sometimes we have these things like I can’t handle it, but you might even ask like, what are some harder things that I’ve actually tolerated in my lifetime? Joanna: Yes, exactly because there’s a lot of things you’re so right that we do that are uncomfortable, but it’s worth it because, for whatever reason, it’s worth it. Kimberley: Yeah, I love this. I have loved chatting with you. I know I’ve asked you this already, but is there any final words you want to share before we learn more about you and where people can get in touch with you? Joanna: I just want people to know that anybody can do this. It may be that it’s just creating the right scale—a small enough step forward—but anybody can work on this. There are so many areas and ways in which we can strengthen this muscle. And so there is hope. No one is broken. It may be that people just don’t know the next best move. Kimberley: I love that. Thank you. Where can people hear more about you and get in touch with you? Joanna: My website is JoannaHardis.com and my Instagram is the same thing, @JoannaHardis. And excitingly, the book just came out in audio yesterday.  Kimberley: Congratulations.  Joanna: Thank you. Thank you.  Kimberley: That’s wonderful. And we can get the book wherever books are sold.  Joanna: Wherever books are sold, yes. Kimberley: I really do encourage people to buy it. I think it’s a book you could pick up and read once a year, and I think that there’s messages. You know what I’m saying? There are some books where you could just revisit and take something from, so I would really encourage people to buy the book and just dabble in the many concepts that you share. Joanna: Wonderful. Thank you. Kimberley: Yeah. Thank you so much for being on the show. This is such a concept and a topic that I’m really passionate about, and for myself too. I think it’s something I’ll be working on until I’m 99, I think. Joanna: Me too. I’m with you right there. Kimberley: There’s always an opportunity where I’m like, “Oh okay. There’s another opportunity for me to grow. All right, let’s get on board. Let’s go back to the school.” So, I think it’s really wonderful. Thank you so much for being here. Joanna: Thank you so much for having me.

Visual Staring OCD (also known as Visual Tourrettic OCD), a complex and often misunderstood form of Obsessive-Compulsive Disorder, involves an uncontrollable urge to stare at certain objects or body parts, leading to significant distress and impairment. In an enlightening conversation with Kimberley, Matt Bannister shares his journey of overcoming this challenging condition, offering hope and practical advice to those grappling with similar issues. Matt's story begins in 2009, marked by a sense of depersonalization and dissociation, which he describes as an out-of-body experience and likened to looking at a stranger when viewing himself in the mirror. His narrative is a testament to the often-overlooked complexity of OCD, where symptoms can extend beyond the stereotypical cleanliness and orderliness. Kimberley's insightful probing into the nuances of Matt's experiences highlights the profound impact of Visual Staring OCD on daily life. The disorder manifested in Matt as an overwhelming need to maintain eye contact, initially with female colleagues, out of fear of being perceived as disrespectful. This compulsion expanded over time to include men and intensified to such a degree that Matt felt his mind couldn't function normally. The social implications of Visual Staring OCD are starkly evident in Matt's recount of workplace experiences. Misinterpretation of his behavior led to stigmatization and gossip, deeply affecting his mental well-being and leading to self-isolation. Matt's story is a poignant illustration of the societal misunderstandings surrounding OCD and its variants. Treatment and recovery form a significant part of the conversation. Matt emphasizes the role of Cognitive Behavioral Therapy (CBT) and Exposure and Response Prevention (ERP) in his healing process. However, he notes the initial challenges in applying these techniques, underscoring the necessity of a tailored approach to therapy. Kimberley and Matt delve into the power of community support in managing OCD. Matt's involvement with the IOCDF (International OCD Foundation) community and his interactions with others who have overcome OCD, like Chris Trondsen, provide him with valuable insights and strategies. He speaks passionately about the importance of self-compassion, a concept introduced to him by Katie O'Dunne, and how it transformed his approach to recovery. A critical aspect of Matt's journey is the realization and acceptance of his condition. His story underscores the importance of proper diagnosis and understanding of OCD's various manifestations, which can be as unique as the individuals experiencing them. Matt's narrative is not just about overcoming a mental health challenge; it's a story of empowerment and advocacy. His transition from a struggling individual to a professional peer support worker is inspiring. He is now dedicated to helping others navigate their paths to recovery, using his experiences and insights to offer hope and practical advice. In conclusion, Matt Bannister's journey through the complexities of Visual Staring OCD is a powerful testament to the resilience of the human spirit. His story offers valuable insights into the disorder, challenges misconceptions, and highlights the importance of tailored therapy, community support, and self-compassion in overcoming OCD. For anyone struggling with OCD, Matt's story is a beacon of hope and a reminder that recovery, though challenging, is within reach. Instagram - matt bannister27 Facebook - matthew.bannister.92 Facebook group - OCD Warrior Badass Tribe Email :[email protected] Kimberley: Welcome back, everybody. Every now and then, there is a special person that comes in and supports me in this way that blows me away. And today we have Matt Bannister, who is one of those people. Thank you, Matt, for being here today. This is an honor on many fronts, so thank you for being here. Matthew: No, thank you for bringing me on, Kim. This is a huge honor. I’m so grateful to be on this. It’s just amazing. Thank you so, so much. It’s great to be here. Kimberley: Number one, you have been such a support to me in CBT School and all the things that I’m doing, and I’ve loved hearing your updates and so forth around that. But today, I really want you to come on and tell your story from start to end, whatever you want to share. Tell us about you and your recovery story. Matthew: Sure. I mean, I would like to start as well saying that your CBT School is amazing. It is so awesome. It’s helped me big time in my recovery, so I recommend that to everyone. I’m an IOCDF grassroots advocate. I am super passionate about it. I love being involved with the community, connecting with the community. It’s like a big family. I’m so honored to be a part of this amazing community. My recovery story and my journey started back in 2009, when—this is going to show how old I am right now—I remember talking on MSN. I remember I was talking; my mind went blank in a conversation, and I was like, “Ooh, that’s weird. It’s like my mind’s gone blank.” But that’s like a normal thing. I can just pass it off and then keep going forward. But the thing is with me. It didn’t. It latched on with that. I didn’t know what was going on with me. It was very frightening. I believe that was a start for me with depersonalization and dissociation. I just had no idea of what it was. Super scary. It was like I started to forget part of my social life and how to communicate with people. I really did start to dissociate a lot when I was getting nervous. And that went on for about three or four years, but it gradually faded naturally. Kimberley: So you had depersonalization and derealization, and if so, can you explain to listeners what the differences were and how you could tell the differences? Matthew: Yeah. I think maybe, if I’m right with this, with the depersonalization, it felt like I knew how it was, but I didn’t at the same time. It was like when I was looking in a mirror. It was like looking at a stranger. That’s how it felt. It just felt like I became a shell of myself. Again, I just didn’t know what was happening. It was really, really scary. I think it made it worse. With my former friends at that time, we’d make fun of that, like, “Oh, come on, you’re not used to yourself anymore. You’re not as confident anymore. What’s going on? You used to try and take the [03:19 inaudible] a lot with that.” With the dissociation, I felt like I was having an out-of-body experience. For me, if I sat in a room and it was really hitting me hard, as if I were anxious, it would feel like I was floating around that room. I couldn’t concentrate. It was very difficult to focus on things, especially if it was at work. It’d be very hard to do so. That came on and off. Kimberley: Yeah, it’s such a scary feeling. I’ve had it a lot in my life too, and I get it. It makes you start to question reality, question even your mental health. It’s such a scary experience, especially the first time you have it. I remember the first time I was actually with a client when it started. Matthew: Yeah, it is. Again, it is just a frightening experience. It felt like even when I was walking through places, it was just fog all the time. That’s how it felt. I felt like someone had placed a curse on me. I really believe that with those feelings, and how else can I explain it? But that did eventually fade, luckily, in about, like I said, three to four years, just naturally on its own. When I had those sensations, I got used to that, so I didn’t put as much emphasis on those situations. Then I carried on naturally through that. Then, well, with going through actually depersonalization, unfortunately, that’s when my OCD did hit. For me, it was with, I believe, relationship OCD because I was with someone at the time. I was constantly always checking on them, seeing if they loved me. Like, am I boring you? Because I thought of depersonalization. I thought I wasn’t being my full authentic self and that you didn’t want to be within me anymore. I would constantly check my messages. If they didn’t put enough kisses on the end of a message, I think, “Oh, they don’t love me as much anymore. Oh no, I have to check.” All the time, even in phone calls, I always made sure to hear that my partner would say, “Oh, I love you back,” or “I love you.” Or as I thought, I did something wrong. Like they’re going off me. I had a spiral, thinking this person was going to cheat on me. It went on and on and on and on with that. But eventually, again, the relationship did fade in a natural way. It wasn’t because of the OCD; it was just how it went. And then, with relationship OCD, with that, I faded with that. A search with my friends didn’t really affect me with that. Then what I can recall, what I have maybe experienced with OCD, I’ve had sexual orientation OCD. Again, I was questioning my sexuality. I’m heterosexual, and I was in another warehouse, a computer warehouse, and it was all males there. I was getting what I describe as intrusive thoughts of images of doing sexual acts or kissing and stuff like that. I’m thinking, “Why am I getting these thoughts? I know where my sexuality is.” There’s nothing wrong, obviously, with being homosexual or queer. Nothing wrong with that at all. It’s just like I said, that’s how it fades with me. I mean, it could happen again with someone who’s queer, and it could be getting heterosexual thoughts. They don’t want that because they know they’re comfortable with their sexuality. But OCD is trying to doubt that. But then again, for me, that did actually fade again after about five or six months, just on its own. And then, fast forward two years later is when the most severe theme of OCD I’ve ever had hit me hard like a ton of bricks. And that for me was Visual Tourettic OCD, known as Staring OCD, known as Ocular Tourettic OCD. And that was horrendous. The stigma I received with this theme was awful. I remembered the day when it hit me, when I was talking to a female colleague. Like we all do, we all look around the room and we try and think of something to say, but my eyes just landed on the chest, like just an innocent look. I’m like, “Oh my God, why did I do that? I don’t want to disrespect this person in front of me. I treat her as an equal. I treat everyone the same way. I don’t want to feel like she’s being disrespected.” So I heavily maintained eye contact after that. Throughout that conversation, it was fine. It was normal, nothing different. But after that, it really latched onto me big time. The rumination was massive. It was like, you’ve got to make sure you’re giving every single female colleague now eye contact. You have to do it because you know otherwise what stigma you could get. And that went on for months and years, and it progressed to men as well a couple of years later. It felt like my mind can’t function anymore. I remember again I was sitting next to my friend, who was having a game on the PlayStation. And then I just looked at his lap, just for no reason, just looked at his lap, and he said, “Ooh, I feel cold and want to go and change.” I instantly thought, “Oh my God, is it because he thought I might have stared that I creeped him out?” And then it just seriously latched onto me big time. As we all know, with this as well, when we think of the pink elephant allergy, it’s like when we don’t think of the pink elephant, what do we do? And that’s what it was very much like with this. I remember when it started to get really bad, my eyes would die and embarrass somebody part places. It was like the more anxious I felt about not wanting to do it, the more it happened, where me and my good friend, Carol Edwards, call it a tick with the eye movement. So like Tourette, let’s say, when you get really nervous, I don’t know if this is all true. When someone’s really nervous, maybe they might laugh involuntarily, like from the Joker movie, or like someone swearing out loud. This is the same thing with eye movement. Every time I was talking to a colleague face-to-face to face, I was giving them eye contact, my mind would be saying to me, “Don’t look there, don’t look there, don’t look there,” and unfortunately think it would happen. That tick would happen. It would land where I wouldn’t want it to land. It was very embarrassing because eventually it did get noticed. I remember seeing female colleagues covering their hi vis tops, like across their arms. Men would cover their crotches. They would literally cross their legs very blatantly in front of me. Then I could start to hear gossip. This is when it got really bad, because I really heard the stigma from this. No one confronted me by the way of this face-to-face, but I could hear it crystal clear. They were calling me all sorts, like deviant or creep or a perv. “Have you seen his eyes? Have you seen him looking and does that weird things with his eyes? He checks everyone out.” It was really soul-destroying because my compulsion was to get away from everyone. I would literally hide across a room. Where no one else was around, I would hide in the cubicles because it was the only place where I wasn’t triggered. It got bad again. It went to my family, my friends, everyone around me. It didn’t happen with children, but it happened with every adult. It was horrendous. I reached out to therapy. Luckily, I did get in contact with a CBT therapist, but it was talk therapy. But it’s better than nothing. I will absolutely take that. She was amazing. I can’t credit my therapist enough. She was awesome. If this person, maybe this is like grace, you’re amazing, so thank you for that. She was really there for me. It was someone I could really talk to, and it can help me and understand as best as she could. She did, I believe, further research into what I had. And then that’s when I finally got diagnosed that I had OCD. I never knew this was OCD, and everything else made sense, like, “Oh, this is why I was going through all those things before. It all now makes concrete sense what I was going through.” Then I looked up the Facebook group called Peripheral Vision/Visual Tourettic OCD. That was a game-changer for me. I finally knew that I wasn’t alone because, with this, you really think you’re alone, and you are not. There are thousands of people with this, or even more. That was truly validating. I was like, “Thank God I’m not the only one.” But the problem is, I didn’t really talk in that group at first because I thought if other people saw me writing in that group, it’s going to really kill my reputation big time. That would be like the final nail in the coffin. Even though it was a private group, no one could do that. But I didn’t still trust it that much at that time. I was doing ERP, and I thought great because I’ve researched ERP. I knew that it’s effective. Obviously, it’s the gold standard. But for me, unfortunately, I think I was doing it where I was white-knuckling through exposures. Also, when I was hearing at work, still going back to my most triggering place, ERP, unfortunately, wasn’t working for me because I wasn’t healing. It was like I was going through the trigger constantly. My mind was just so overwhelmed. I didn’t have time to heal. I remember I eventually self-isolated in my room. I didn’t go anywhere. I locked myself away because I thought I just couldn’t cope anymore. It was a really dark moment. I remember crying. It was just like despair. I was like, “What’s happening to me? Why is all this happening to me?” Later on, I did have the choice at work. I thought, I can either go through the stillest, hellacious process or I can choose to go on sick leave and give my chance to heal and recover. That’s why I did. And that was the best decision I ever made. I recommend that to anyone who’s going through OCD severely. You always have a choice. You always have a choice. Never pressure yourself or think you’re weak or anything like that, because that’s not the case. You are a warrior. When you’re going through things like this, you are the most strongest person in the world. It takes a lot of courage to confront those demons every single day to never ever doubt yourself with that. You are a strong, amazing individual. When I did that, again, I could heal. It took me two weeks. Unfortunately, my therapy ended. I only had 10 sessions, but I had to wait another three months for further therapy in person, so I thought, “Oh, at least I do eventually get therapy in person. That’s amazing.” And then the best thing happened to me. I found the IOCDF community. Everything changed. The IOCDF is amazing. The best community, in my opinion, the world for OCD. My god, I remember when I first went on Ethan’s livestream with Community Conversations. I reached out to Ethan, and he sent me links for OCD-UK. I think OCD Action as well. That was really cool of him and great, and I super appreciate that, and you knew straight away because I remember watching this video with Jonathan Grayson, who is also an amazing guy and therapist, talking about this. I was like, again, this is all that I have. And then after that, I reached out to Chris Trondsen as the expert. What Chris said was so game-changing to me because he’s gone through this as well and has overcome it. He’s overcome so many severe themes of OCD. I’m like, “This guy is amazing. He is an absolute rock star. Literally like a true champion.” For someone to go through as much as he has and to be where he is today, I can’t ask for any more inspirement from that. It’s just incredible. He gave some advice as well in that livestream when we were talking because I reached out and said, how did you overcome this? He said, “With the staring OCD, well, I basically told myself, while I’m staring, well, I might as well stare anyway.” And that clicked with me because I’m thinking he’s basically saying that he just didn’t give it value anymore. I’m like, “That’s what I’ve been doing all this time. I’ve given so much value, so much importance. That’s why it keeps happening to me.” I’m like, “Okay, I can maybe try and work with this.” Then I started connecting with Katie O'Dunne, who is also amazing. She was the first person I actually did hear about self-compassion. I’m like, “Yes, why didn’t I learn about this early in my life? Self-compassion is amazing. I need to know all about this.” It makes so much sense. Why’d I keep beating myself up when I treat a friend, like when I talked to myself about this? No, I wouldn’t. I just watched Katie’s streams and watched her videos and Instagram. It was just an eye-opener for me. I was like, “Wow, she’s talking about, like, bring it on mindset as well with this.” When you’re about to face the brave thing, just say, “Bring it on. Just bring on," like The Rock says. "Just bring it. I just love that. That’s what I did. That’s what I started doing. I connected as well with my friend, Carol Edwards, who is also a former therapist and is the author of many books. One of them was Address Staring OCD. If anyone’s going through this as well, I really recommend that book. Carol is an amazing, amazing person. Such an intelligent woman. When I met Carol, it was like the first time in my life. I was like, “Wow, I’m actually talking to someone who’s got the same theme as me, and a lot of other themes I’ve gone through, she has as well.” We just totally got each other. I was like, “Finally, I’m validated. I can talk to someone who gets it truly.” And that really helped, let’s say, when I started to learn about value-based exposures. I remember, again, Katie, Elizabeth McIngvale, Ethan, and Chris. I was like, “Yeah, I mean, I’m going to do it that way,” because I just did ERP before I was white-knuckling. I never thought of doing it in a value-based way. So I thought, okay, well, what is OCD taking away that I enjoy most doing? That’s what I did. I created a hierarchy, or like even in my mind. I thought, well, the cinema, restaurants, coffee shops, going to concerts, eventually going on holiday again, seeing my friends, family is most probably most important. I started doing baby steps. I remember as well, I asked Chris and Liz, how do I open up to this to my family? Because I’ve got to a point where I just can’t hide behind a mask anymore. I need someone else to know who’s really close to me. Chris gave me some amazing advice, and Liz, and they said that if you show documents, articles, videos about this, long as they have a great understanding of mental health and OCD, you should be okay. And that’s what I did. They know I had OCD. I’ve told them I had OCD, but not the theme I had. When I showed them documents and videos, it was so nerve-racking, I won’t lie. But it was the best thing I ever did because then, when they watched that, they came to me and said, “Why didn’t you tell us about this before? I thought you wouldn’t understand or grasp this.” I know OCD awareness in the UK is not the best, especially with this theme. But they said, “No, after watching that, we’re on your team; we will support you. We are here for you. We will do exposures with you.” And they gave me a massive hug afterwards. I was like, “Oh my God, this is the best scenario for me ever,” because then I can really amplify my recovery. This is where it started really kicking on for me now. Everything I’ve learned, again, from those videos, watching with the streams from IOCDF, I’ve incorporated. Basically, when I was going to go to the cinema at first, I know that the cinema is basically darkness. When you walk through there, no one’s really going to notice you. Yeah, they might see you in their peripheral vision, but they’re going to be more like concentrating on that movie than me. That was my mindset. I was like, “Well, if I was like the other person and I didn’t have VTO and the other person did, would I be more concentrated on them or the movie?” And for me, it would be obviously the movie. Why would I else? Unless they were doing something really vigorous or dancing in front of me, I’m not going to look. And that’s my mindset. The deep anxiety was there, I will be honest. It was about 80 percent. But I had my value because I was going to watch a film that I really wanted to watch. I’m a big Marvel fan. It was Black Panther Wakanda, and I really enjoyed that. It was a long movie as well. I went with my friend. We got on very, very well. For me as well, with this trigger, I get triggered when people can move as well next to me. I’m very hyper-vigilant with this. That can include me with the peripheral as well. But even though my eyes say they died, it was, okay, instead of beating myself up, I can tell myself this is OCD. I know what this is. It doesn’t define me. I’m going to enjoy watching this movie as much as I can and give myself that compassion to do so. After that moment, I was like, “Wow, even though I was still triggered, I enjoyed it. I wasn’t just wanting to get out of there. I enjoyed being there.” And that was starting to be a turning point for me because then I went to places like KFC. I miss KFC. I love my chicken bucket. I won’t lie with that. That was a big value. You got to love the chicken bucket folks. Oh, it was great. Well, I had my parents around me so that they know I was pretty anxious still. But I was there. I was enjoying my chicken again. I was like, “I miss this so much.” And then the best thing is, as far as I remember, when I left that restaurant, they said to me, “We’re so proud of you.” And that helps so much because when you’re hearing feedback like that, it just gives you a huge pat on the back. It’s like, yeah, I’ve just done a big, scary thing. I could have been caught. I could have been ridiculed. I could have been made fun of. People may have gossiped about me, but I took that leap of faith because I knew it’s better than keep isolating, where in my room, being in prison, not living a life. I deserve to live a life. I deserve to do that. I’m a human being. I deserve to be a part of human society. After that, my recovery started to progress. I went to my friend Carol to more coffee shops. We started talking about advocacy, powerful stuff, because when you have another reason on a why to recover, that’s a huge one. When you can inspire and empower others to recover, it gives you so much more of a purpose to do it because you want to be like that role model, that champion for the people. It really gives you a great motive to keep going forward with that and that motivation. And then I went to restaurants with my family for the first time in years, instead of making excuses, instead of compulsion. People would still walk by me in my peripheral, but I had the mindset, like Kate said, “You know what? Just bring it on. Just bring it.” I went in there. I know I was still pretty anxious, and I sat on my phone, and I’m going to tell myself using mindfulness this time that I’m going to enjoy the smell of the food coming in. I’m going to enjoy the conversation with my family instead of thinking of, let’s say, the worst-case scenario. The same with a waiter or waitress coming by. I’m just going to have my order. And again, yeah, my eyes die, they spit in my food—who knows? But I’m going to take that leap of faith because, again, it’s worth it to do this. It is my why to get my life back. That’s why I did it. Again, I enjoyed that meal, and I enjoyed talking to my family. It was probably the first time in years where I wasn’t proper triggered. I was like, that was my aha moment right there. The first time in years where my eyes didn’t die or anything. I just enjoyed being in a normal situation. It was so great to feel that. So validating. Kimberley: So the more triggered you were, the harder it was to not stare? Is that how it was? Matthew: Yes. The more triggered I was going down that rabbit hole, the more, let’s say, it would happen because my eyes would die, like up and down. It would be quite frantic, up and down, up and down. Everyone’s not the same. Everyone’s different with this. But that’s what mine would be like. That’s why I would call it a tick in that sense. But when we feel calm, obviously, and the rumination is not there, or let’s say, the trigger, then it’s got no reason to happen or be very rare when it does. It’s like retraining. I learned to retrain my mind in that sense to incorporate that into doing these exposures. Again, that’s what was great about opening up to my family. I could practice that at home because then, when I’m sitting with my family, I’d still be triggered to a degree, but they know what I have. They’re not going to judge me or reject me, or anything like that. So my brain healed naturally. The more I sat next to my family, I could bring that with, say, the public again and not feel that trigger. I could feel at ease instead of feeling constantly on edge. Again, going to coffee shops late, looking around the room, like you say so amazingly, Kim, using your five senses. I did that, like looking around, looking at billboards, smelling the coffee again, enjoying the taste of it, enjoying the conversation, enjoying the surroundings where I am instead of focusing on the prime fear. And that’s what really helped brought me back to the present. Being in the here and the now. And that was monumental. Such a huge tool, and I recommend that to everyone. Mindfulness is very, very powerful for doing, let’s say, your exposures and to maintain recovery. It’s just a game-changer. I can’t recommend that enough. One of my biggest milestones with recovery when I hit it, the first time again in years, I went to a live rock concert full of 10,000 people. There would be no way a year prior that would I go. Kimberley: What rock concert? I have to know. Matthew: Oh, I went to Hollywood Vampires. Kimberley: Oh, how wonderful! That must have been such an efficient, like, it felt like you crossed a massive marathon finish line to get that thing done. Matthew: Oh, yeah, it was. It was huge to see, like I say, Alice Cooper, Johnny Depp, and I think—I can’t remember this—Joe Perry from Aerosmith. I can’t remember the drummer’s name, I apologize, but it was great. You know what? I rocked out. I told myself, “I’ve come this far in my journey, I’m going to rock out. I’m going to enjoy myself. I don’t care, let’s say, where my eyes may go, and that’s telling OCD, though. I’m just going to be there in the moment and enjoy rocking out.” And that’s exactly what I did. I rocked out big time. I remember even the lead singer from the prior band pointing at me and waving. I would have been so triggered by that before, but now we’re back in the game, the rock on sign, and it was great. Kimberley: There’s so much joy in that too, right? You were so willing to be triggered that you rocked out. That’s how willing we were to do that work. It’s so cool, this story. Matthew: Yeah. The funny part is, well, the guy next to me actually spilled beer all over himself. That would have been so triggering against me before, like somebody’s embarrassing body part places. Whereas this time I just laughed it off and I had a joke with him, and he got the beer. It was like a normal situation—nothing weird or anything. His wife, I remember looking at my peripheral, was just cross-legged. But hey, that’s just a relaxing position like anyone else would do. That’s what I told myself. It’s not because of me thinking, “Oh, he’s a weirdo or a creep.” It’s because she’s just being relaxed and comfortable. That’s just retraining my mind out, and again, refocusing back to the concert and again, rocking out to Alice Cooper, which was amazing. I really enjoyed it. I just thought it’s just incredible from where I was a year ago without seeing-- got to a point where I set myself, I heard the worst stigma imaginable to go to the other aspect, the whole end of the other tunnel, the light of the tunnel, and enjoy myself and being free. I love what Elizabeth McIngvale says about that, freedom over function. And that’s exactly at that point where that’s where I was. I’m very lucky to this day. That’s why I’ve maintained it. Sometimes I still do get triggered, but it’s okay because I know it’s OCD. We all know there’s no cure, but we can keep it in remission. We can live a happy life regardless. We just use the tools that we’ve learned. Again, for me, values-based exposure in that way was game-changing. Self-compassion was game-changing. I forgot to mention my intrusive thoughts with sexual images as well with this, which was very stressing. But when I had those images more and more, it’s basically what I learned again from Katie. I was like, “Yeah, you know what? Bring it on. Bring it on. Let’s see. Turn it up. Turn it up. Crank it up.” Eventually, the images stopped because I wasn’t giving fear factor to it. I was going to put the opposite of basically giving it the talk-to-the-hand analogy, and that worked so well. I see OCD as well from Harry Potter. I see OCD as the boggart, where when you come from the boggart, it’s going to come to your most scariest thing. But you have that power of choice right there and then to cast the spell and say ridiculous, as it says in the Harry Potter movies, and it will transform into something silly or something that you can transform yourself with compassion and love. An OCD can’t touch you with that. It can’t. It becomes powerless. That’s why I love that scene from that film. Patrick McGrath says it so well with the Pennywise analogy. The more fear we feed the beast or the monster, the more stronger it becomes. But when we learn to give ourselves self-compassion and love and, again, using mindfulness and value and knowing who we authentically are, truly, it can do nothing. It becomes powerless. It can stay in the backseat, it might try and rear its ugly head again, but you have the more and the power in the world to bring it back, and you can be firmly in that driver’s wheel. Kimberley: So good. How long did it take you, this process? Was it a short period of time, or did these value-based exposures take some time? Matthew: Yeah, at first, it took some time to master it, if that makes sense. Again, I was going to start going to more coffee shops with my friend Carol or my family. It did take time. I was still feeling it to a degree, but probably about after a month, it started to really click. And then overall, it took me about-- I started really doing this in December, January time. I went to that concert in July. So about, yeah, six, seven months. Kimberley: Amazing. Were there any stages where there were blips in the road, bumps on the road? What were they like for you? Matthew: Yeah. I mean, my eyes did that sometimes. Also, like I said, when I started to do exposures, where I’d walk by myself around town places, it could be very nerve-wracking. I could think I’m walking behind someone that all the might think I’m a stalker and things like that because of the staring. That was hard. Again, I gave myself the compassion and told myself that it’s just OCD. It doesn’t define who I am. I know what this monster is, even though it’s trying its very best to put me down that rabbit hole. Yeah, that person might turn around and say something, or even look. I have the choice again to smile back, or I can even wave at them if I wanted to do so. It just shows that you really have all the power or choice to just throw some back into OCD space every single time. Self-compassion was a huge thing that helped smooth out those bumps. Same with mindfulness. When I was getting dissociated, even when I was still getting dissociated, getting really triggered, I would use the mindfulness approach. For example, when I was sitting in pubs, and that was a value to me as well, sometimes that would happen. But I would then use the tools of mindfulness. And that really, really helped collect myself being present back in the here and the now and enjoying what’s in front of me, like having a beer, having something to eat, talking to my friend, instead of thinking like, are they going to see me staring at them weirdly? Or my eyes met out someone, and I don’t know, the waitress might kick me out or something like that. Instead of thinking all those thoughts, I just stay present. The thing is with this as well, it’s like when you walk down places, people don’t even look at you really anyway. They just go about their business, like we all do. It’s just remembering that and keeping that mindfulness aspect. You can look around where you are, like buildings, trees, the ocean, whatever you like, and you can take that in and relearn. Feel the wind around you. If it’s an ice wind, obviously, that’s freezing right now. The smells—anything, anything if it’s a nice smell, or even if it’s a bad smell. Anything that use your senses that can just bring you back and feel again that peace, something you enjoy, surround yourself with. Again, when I was seeing my friend Carol, the town I went to called Beverley, it’s a beautiful town, very English. It is just a nice place. That’s what I was doing—looking at the scenery around where I was instead of focusing on my worst worries. Kimberley: This is so cool. It’s all the tools that we talk about, right? And you’ve put them into practice. Maybe you can tell me if I’m wrong or right about this, but it sounds like you were all in with these skills too. You weren’t messing around. You were ready for recovery. Is that true? Or did you have times where you weren’t all in? Matthew: Yeah, there were times where I wasn’t all in. I suppose when I was-- I also like to ask yourself with me if I feel unworthy. That is still, I know it’s different to staring OCD and I’m still trying to tackle that sometimes, and that can be difficult. But again, I use the same tools. But with, like I say, doing exposures with VTO, I would say I was all in because I know that if I didn’t, it’s going to be hard to reclaim my life back. I have a choice to act and use the tools that I know that’s going to work because I’ve seen Chris do it. It’s like, “Well, I can do it. I’ve seen Carol do it. That means I can do it. So I’m going to do it.” That’s what gave me the belief and inspiration to go all in. Because again, reach out to the community with the support. If it was a hard time, I’d reach out. The community are massive. The connection they have and, again, the empowerment and the belief they can give you and the encouragement is just, oh, it’s amazing. It’s game-changing. It can just light you up straight off the bar when you need it most, and then you can go out and face that big scary thing. You can do it. You can overcome it because other people have. That means you can do it. It’s absolutely possible. Having that warrior mindset, as some of my groups—the warrior badass mindset—like to call it, you absolutely go in there with that and you can do it. You can absolutely do it. Kimberley: I know you’ve shared with me a little bit privately, but can you tell us now what your big agenda is, what your big goal is right now, and the work you’re doing? Because it’s really exciting. Matthew: Sure, I’d be glad to do it. I am now officially a professional peer support worker. If anyone would love to reach out to me, I am here. It’s my biggest passion. I love it. It’s like the ultimate reward in a career. When you can help someone in their journey and recovery and even empower each other, inspire, motivate, and help with strategies that’s worked for you, you can pass on them tools to someone else who really needs it or is still going through the process where it’s quite sticky with OCD. There’s nothing more rewarding than that. Because for me, when I was at my most severe, when I was in my darkest, darkest place, it felt like a void. I felt like just walking through a blizzard of nothing. Having someone there to speak to who gets it, who truly gets it, and who can be really authentically there for you to really say, “You can do this. I’m going to do it with you. Let’s do it. Like really, let’s do it. Bring it on, let’s do it. Let’s kick this thing’s butt,” it’s huge. You really lay the smackdown on OCD. It’s just massive. For me, if I had that when I was going through it, again, I had a great therapist, but if I had a peer support worker, if I was aware that they were around—I wasn’t, unfortunately, at that time—I probably would have reached out because it’s a huge tool. It’s amazing. Even if you’re just to connect with someone in general and just have a talk, it can make all the difference. One conversation, I believe, can change everything in that moment of what that person’s darkness may be. So I’m super, super excited with that. Kimberley: Very, very exciting. Of course, at the end, I’ll have everyone and you give us links on how to get to you. Just so people know what peer support counseling is or peer support is, do they need to have a therapist? Who’s on the team? What is it that they need in order to start peer support? Matthew: Yeah. I mean, you could have a therapist. I mean, I know peer support workers do work with therapists. I know Chrissie Hodges. I’ve listened to her podcast, and she does that. I think it may be the same with Shannon Shy as well. I’m not too sure. I think as well to the person, what they’re going through, if they would want to at first reach out to a peer support worker that they know truly understands them, that can be great. That peer support like myself can then help them find a therapist. That’s going to really help them with their theme—or not just their theme—an OCD specialist who gets it, who’s going to give them the right treatment. That can be really, really beneficial. Kimberley: I know that we’ve worked with a lot of peer support, well, some peer support providers, and it was really good because for the people, let’s say, we have set them up with exposures and they’re struggling to do it in their own time, the peer support counselor has been so helpful at encouraging them and reminding them of the tools that they had already learned in therapy. I think you’re right. I think knowing you’re not alone and knowing someone’s done it, and I think it’s also just nice to have someone who’s just a few steps ahead of you, that can be very, very inspiring for somebody. Matthew: Absolutely. Again, having a peer support work with a therapist, that’s amazing. Because again, for recovery, that’s just going to amplify massively. It’s like having an infinite gauntlet on your hand against OCD. It’s got no chance down the long run. It’s incredibly powerful. I love that. Again, like you said, Kim, it’s like when someone, let’s say, they know that has reached that mountain top of recovery, and that they look at that and thinking, “Well, I want to do the same thing. I know it would be great to connect with that person,” even learn from them, or again, just to have that connection can make a huge, huge difference to know that they can open up to other people. Again, for me, it’s climbing up that other mountain top with someone else from the start, but to know I’ve got the experience, I get to climb that mountain top with them. Kimberley: Yeah, so powerful. Before we finish up, will you tell us where people can get ahold of you if they want to learn more? And also, if there’s anything that you feel we could have covered today that we didn’t, like a main last point that you want to make. Matthew: Sure. People can reach out to me, and I’m going to try and remember my tags. My Instagram tag is matt_bannister27. I think my Facebook is Matthew.Bannister.92, if you just type in Matthew Bannister. It would be in the show notes as well. You can reach out to me on there. I am at the moment going to create a website, so I will fill more onto that later as well. My email is [email protected], which is probably the best way to reach out to me. Kimberley: Amazing. Anything else you want to mention before we finish up? Matthew: Everyone listening, no matter what darkness you’re going through, no matter what OCD is putting in your way, you can overcome it. You can do it. As you say brilliantly as well, Kim, it’s a beautiful day to do hard things. You can make that as every day because you can do the hard things. You can do it. You can overcome it, even though sometimes you might think it’s impossible or that it’s too much. You can do it, you can get there. Even if it takes baby steps, you’re allowed to give yourself that compassion and grace to do so. It doesn’t matter how long it takes. Like Keith Smith says so well: “It’s not a sprint; it’s a marathon.” When you reach that finish line, and you will, it’s the most premium feeling. You will all get there. You will all absolutely get there if you’re going through it. Oh, Kim, I think you’re on mute. Kimberley: I’m sorry. Thank you so much for being on. For the listeners, I actually haven’t heard your story until right now too, so this is exciting for me to hear it, and I feel so inspired. I love the most that you’ve taken little bits of advice and encouragement from some of the people I love the most on this planet. Ethan Smith, Liz McIngvale, Chris Trondsen, Katie O’Dunne. These are people who I learn from because they’re doing the work as well. I love that you’ve somehow bottled all of their wisdom in one thing and brought it today, which I’m just so grateful for. Thank you so much. Matthew: You’re welcome. Again, they’re just heroes to me, and yourself as well. Thank you for everything you do as well for the community. You’re amazing. Kimberley: Thank you. Thank you so much for being here. Matthew: Anytime.

If you want to know the 5 Most Common Recovery Roadblocks with Chris Tronsdon (an incredible anxiety and OCD therapist), you are in the right place. Today Chris and I will go over the 5 Most common anxiety, depression, & OCD roadblocks and give you 6 highly effective treatment strategies you can use today.  Kimberley: Welcome everybody. We have the amazing Chris Trondsen here with us today. Thank you for coming, Chris. Chris: Yes, Kim, thanks for having me. I’m super excited about being here today and just about this topic. Kimberley: Yes. So, for those of you who haven’t attended one of the IOCDF Southern California conferences, we had them in Southern California. We have presented on this exact topic, and it was so well received that we wanted to make sure that we were spreading it out to all the folks that couldn’t come.  You and I spoke about the five most common anxiety & OCD treatment roadblocks, and then we gave six strategic solutions. But today, we’re actually broadening it because it applies to so many people. We’re talking about the five most common anxiety treatment roadblocks, with still six solutions and six strategies they can use. Thank you for coming on because it was such a powerful presentation. Chris: No, I agree. I mean, we had standing room only, and people really came up to us afterwards and just said how impactful it was. And then we actually redid it at the International OCD Foundation, and it was one of the best-attended talks at the event. And then we got a lot of good feedback, and people kept messaging me like, “I want to hear it. I couldn’t go to the conference.” I’d play clips for my group, and they’re like, “When is it going to be a podcast?” I was like, “I’ll ask Kim.” I’m glad you said yes because I do believe for anybody going through any mental health condition, this list is bound, and I think the solutions will really be something that can be a game changer in their recovery. Kimberley: Absolutely, absolutely. I love it mostly because, and we’re going to get straight into these five roadblocks, they’re really about mindset and going into recovery. I think it’s something we’re not talking about a lot. We’re talking about a lot of treatment, a lot of skills, and tools, but the strategies and understanding those roadblocks can be so important. Chris: Yeah. I did a talk for a support group. They had asked me to come and speak, and I just got this idea to talk about mindset. I did this presentation on mindset, and people were like, “Nobody’s talking about it.” In the back of my head, I’m like, “Kim and I did.” But we’re the only ones. Because I do think so many people get the tools, right? The CBT tools, they get the ERP tools, the mindfulness edition, and people really find the tools that work for them. But when I really think of my own personal recovery with multiple mental health diagnoses, it was always about mindset. And that’s what I like about our talk today. It’s universal for anyone going through any mental health condition, anxiety base, and it’s that mindset that I think leads to recovery. It shouldn’t be the other way around. The tools are great, but the mindset needs to be there. Kimberley: Yeah. We are specifically speaking to the folks who are burnt out, feeling overwhelmed, feeling a lack of hope of recovery. They really need a kickstart, because that was actually the big title of the presentation. It was really addressing those who are just exhausted with the process and need a little bit of a strategy and mindset shift. Chris: Yeah. I don’t want to compare, but I broke my ankle when I was hiking in Hawaii, and I have two autoimmune diseases. Although those ailments have caused problems, especially the autoimmune, when I think back to my mental health journey, that always wore me out more because it’s with you all the time, 24/7. It’s your mental health. When my autoimmune diseases act up, I’m exhausted, I’m burnt out, but it’s temporary. Or my ankle, when it acts up, I have heating pads, I have things I can do, but your brain is with you 24/7. I do believe that’s why a lot of people resonate with this messaging—they are exhausted. They’re busting their butt in treatment, but they’re tired and hitting roadblocks. And that’s why this talk really came about. Kimberley: Yeah, exactly. All right, let’s get into it here in a second. I just want to give one metaphor with that. I once had a client many years ago give the metaphor. She said, “I feel like I’m running a marathon and my whole family are standing on the out, like on the sidelines, and they’re all clapping, but I’m just like faceplant down in the middle of the road.” She’s like, “I’m trying to get up, I’m trying to get up, and everyone’s telling me, ‘Come on, you can do it.’ It’s so hard because you’re so exhausted and you’ve already run a whole bunch of miles.” And so I really think about that kind of metaphor for today. If people are feeling that way, hopefully they can take away some amazing nuggets of information.  Chris: Absolutely. That’s a good visual. Faceplant. Kimberley: It was such a great and powerful visual because then I understood this client’s experience. Like, “Oh, okay. You’re really tired. You’re really exhausted.” ROADBLOCK #1: YOU BEAT YOURSELF UP! Okay, let’s get into it. So, I’m going to go first because the number one roadblock we talked about, not that these are in any particular order, but the one we came up first was that you beat yourself up. This is a major roadblock to recovery for so many disorders. You beat yourself up for having the disorder. You beat yourself up for not coping with it as well as you could. You beat yourself up if you have OCD for having these intrusive thoughts that you would never want to have. Or you’re beating yourself up because you don’t have motivation because you have, let’s say, some coexisting depression.  The important thing to know there is, while beating yourself up feels productive, it might feel like you’re motivating yourself, or you may feel like you deserve it. It actually only makes it harder. It only makes it feel like you’ve got this additional thing. Again, a lot of my patients—let's use the marathon example—might yell at themselves the whole way through the marathon, but it’s not a really great experience if you’re doing that, and it takes a lot of energy.  SOLUTION #1: SELF-COMPASSION So what we offered here as a strategic solution is self-compassion—trying to motivate and encourage yourself using kindness. If you’re going through a hard day, maybe, just if you’ve never tried this before, trial what it would be like to encourage yourself with kind words or asking for support, asking for help so that you’re not burning all that extra energy, making it so much harder on yourself, increasing your suffering. Because I often say to patients, the more you suffer, the more you actually deserve self-compassion. It’s not the other way around. It’s not that the more you suffer, the less you deserve it. Do you have any thoughts on that, Chris? Chris: Oh yeah. I would say I see that across the board with my clients, this harshness, and there’s this good intention behind it, this idea that if I can just bully myself into recovery. I always try to remind clients that anxiety-based disorders, it’s a part of our bodies as well. Our brain is a part of our body, just like our arm, our tibia, our leg, all these other bones, but there’s a lack of self-empathy that we have for ourselves, as if it’s something that we’re choosing to do. Someone with a broken leg doesn’t wake up in the morning and get mad at themselves that their leg is still broken. They have understanding, and they’re working on their exercises to heal. It’s the same with these disorders.  So, the reason I love self-compassion is when we go and step in to help one of our friends, we use a certain tone, we use certain words, we tap into their strengths, we use encouragement because we know that method is going to be what boosts them up and helps them get through that rough patch. But for some reason, when it’s ourselves, we completely abandon everything we know that’s supportive, and we talk to ourselves in a way that I almost picture like a really negative boot camp instructor, like in the military, just yelling and screaming into submission. The other thing is when we’re beating ourselves up like that, we’re more likely to tap into our unhelpful habits. We’re more likely to shut down and isolate, which we see a lot in BDD, social anxiety, et cetera. But that self-compassion isn’t like a fake pop culture support. It’s really tapping into meeting yourself where you’re at, giving yourself some understanding, and tapping into the strategies that have worked in the past when you’re in a low moment.  I know sometimes people are like, “I don’t know how to do that,” but you’re doing it to everybody else in your life. Now it’s time to give yourself that same self-compassion that you’ve been giving to everybody important to you. Kimberley: Yeah, and we actually have a few episodes on Your Anxiety Toolkit on exactly how to embrace self-compassion, like how that might actually look. So, if people are really needing more information there, I can add in the show notes some links to some resources there as well.  ROADBLOCK #2: THERE WILL BE HARD DAYS  Okay. Now, Chris, can you tell us about the second most common or another common anxiety roadblock around this idea that there will be hard days? Chris: There’s always these great images if you Google about what people think recovery will look like versus what recovery looks like. I love those images because there is this idea. We see a lot of perfectionism in anxiety disorders. In OCD, we see perfectionism. So, this idea of, like, I should be here and I should easily scoot to the end. It’s not going to be like that; it’s bumpy, it’s ups and downs. We know so much factors into or impact how our mental health disorder shows up. We can’t always control our triggers. Sometimes if we haven’t slept well or there’s a lot of change in our life, we could have more anxiety. So, it’s going to ebb and flow.  So, when we have this fixed mindset of like, it has to be perfect, there has to be absolutely no bumps on the road, no turbulence, we’re going to set ourselves up for failure because the day we have a hard day, we want to completely shut down. So I really believe, in this case, the solution is thinking bigger. If you’re thinking day to day, sometimes if you’re too in it, you’re dealing with depression, you’re really feeling bad, you skipped school because you have a presentation, social anxiety is acting up. You think bigger picture. Why am I here? Why am I doing this? Why have I sought out treatment? Listen to this podcast. What am I trying to accomplish?  SOLUTION #2: KNOW YOUR WHY I know for me in my own recovery, knowing my why was so important. There were certain things in my life that I found important to achieve, and I kept that as the figurative carrot in front of the mule to get me to go. So, that way, if I had a rough day, I thought bigger picture. What do I need to do today to make sure that I meet my goals? And so, I believe everybody needs to know their why.  Now, it doesn’t have to be grandiose. Some people want to build a school and teach kids in underprivileged countries. Amazing why. But other people are sometimes like, “I just want to be able to make my own choices today and not feel like I base them out of anxiety.” There’s no right or wrong why, but if you can know what beacon you’re going to, it really helps you get through those hard days.  What about for you? When we talk about this, what comes up for you? Kimberley: Well, I think that for me personally, the why is a really important mindset shift because often I can get to this sort of, like you said, perfectionistic why. Like, the goal is to have no anxiety, or the goal is to have no bad days. We see on social media these very relaxed people who just seem to go with the flow, and that’s your goal. But I have to often with myself do a little reality check and go, “Okay, are you doing recovery to get there? Because that goal might be setting you up for constant disappointment and failure. That mightn’t be your genetic makeup.”  I’m never going to be like the go-with-the-flow Kimberley. That’s just not who I am. But if I can instead shift it to the why of like, what do I value? What are the things I want to be able to do despite having anxiety in my life? Or, despite having a hard day, like you said, how do I want that to look? And once I can get to that imagery, then I have a really clear picture. So, when I do have a bad day, it doesn’t feel so defeating, like what’s the point I give up, because the goal was realistic. Chris: For me, a big part of my why in recovery, once I started getting into a place where I was managing the disorders I was dealing with—OCD, body dysmorphic disorder, I had a lot of generalized anxiety, and major depressive disorder—I was like, “I need to give back. There’s not people my age talking about this. There’s not enough treatment providers.” There was somewhere, like in the middle of my treatment, that I was like, “I don’t know how I’m going to advocate. I don’t know what that’s going to look like, but I have to give back.” And so, on those hard days when I would normally want to just like, “Well, I don’t care that it’s noon, I’m shutting it down, I’m going into my bed, I’m just going to sleep the rest of the day,” reminding myself like there’s people out there suffering that can’t find providers, that can’t find treatment, may not even know they have these disorders. I have to be one of the voices in the community that really advocates and gets people education and resources. And so, I didn’t let myself get in bed. I looked at the day as quarters. Okay, the morning and the afternoon’s a little rough, but I still have evening and night. Let me turn it around. I have to go because I have this big goal, this ambitious dream. I really want to do it. So that bigger why kept me just on track to push through hard days. ROADBLOCK #3: YOU RUN OUT OF STAMINA Kimberley: Amazing. I love that so much. All right. The third roadblock that we see is that people run out of stamina. I actually think this is one that really ties into what we were just talking about. Imagine we’re running a marathon. If you’re sprinting for the first 20 miles, you probably won’t finish the race. Or even if you sprint the first two miles, you probably won’t finish the marathon.  One of the things is—and actually, I’ll go straight to the strategy and the thing we want you to practice—we have to learn to pace ourselves throughout recovery. As I said, if you sprint the first few miles, you will fall flat on your face. You’re already dealing with so much. As you said, having a mental health struggle is the most exhausting thing that I’ve ever been through. It requires such of your attention. It requires such restraint from not engaging in it and doing the treatment and using the tools. It’s a lot of work, and I encourage and congratulate anyone who’s trying. The fact that you’re trying and you’re experimenting with what works and what doesn't, and you’re following your homework of your clinician or the workbook that you’ve used—that's huge. But pacing yourself is so important. So, what might that look like? Often, people, students of mine from CBT School, will say, “I go all out. I do a whole day of exposures and I practice response prevention, and I just go so hard that the next day I am wiped. I can’t get out of bed. I don’t want to do it anymore. It was way too much. I flooded myself with anxiety.” So, that’s one way I think that it shows up. I’ll often say, “Okay, let’s not beat yourself up for that.” We’ll just use that as data that that pace didn’t work. We want to find a rhythm and a pace that allow you to recover. It’s sort of like this teeter-totter. We call it in Australia a seesaw. You want to do the work, but not to the degree where you faceplant down on the concrete. We want to find that balance.  I know for me, when I was recovering from postural orthostatic tachycardic syndrome, which is a chronic illness that I had, it was so hard because the steps to recovery was exercise, but it was like literally walking to the corner and back first, and then walking half a block, and then walking three-quarters of a block, and then having my husband pick me up, then walking one block. And that’s all I was able to do without completely faceplanting the next day, literally and figuratively.  My mind kept saying to me, “You should be able to go faster. Everybody else is going faster. Everyone else can walk a mile or a block. So you should be able to.” And so, I would push myself too hard, and then I’d have to start all over again because I was comparing myself to someone who was not in my position.  SOLUTION #3: PACE YOURSELF So, try to find a pace that works for you, and do not compare your pace with me or Chris or someone in your support group, or someone you see on social media. You have to find and test a pace that works for you. Do you have any thoughts, Chris? Chris: Yeah. I would say in this one, and you alluded to it, that comparison, that is going to get you in this roadblock because you’re going to be looking to your left and your right. Why is that person my age working and I’m not? It’s not always comparing yourself. Sometimes, like you said, it is people in your support group. It’s people that you see advocating for the disorder you may have. But sometimes people even look at celebrities or they’ll look at friends from college, and can I do that? The comparison never motivates you, it never boosts you; it just makes you feel less than. That’s why one of my favorite quotes is, “Chase the dream, not the competition.” It’s really finding a timeline that works best for you.  I get why people have this roadblock. As somebody who’s lived through multiple mental health disorder diagnoses, it’s like, once we find the treatment, we want to escalate to the finish line, and we’ll push ourselves in treatment sometimes too much. And then we have one of those days where we can’t even get out of bed because we’re just beat up, we’re exhausted, and it’s counterproductive.  I wanted to add one thing too. The recovery part may not even be what you’re doing with your clinician in a session that you are not pacing yourself with. My biggest pacing problem was after recovery, not that the disorders magically went away, they were in remission, I was working on doing great, but it was like, I went to martial arts, tennis, learned Spanish, started volunteering at an animal shelter, went back to school, got a job, started dating. It was so much. Because I felt like I was behind, I needed to push myself.  The problem that started to happen was I was focusing less on the enjoyable process of dating or getting a job, or going back to school. I was so fixated on the finish line. “I need to be there, I need to be there. What’s next? What’s next?” I got burnt out from that, and I was not enjoying anything I was doing.  So, I would say even after you’re managing your disorder, be careful about not pacing yourself, even in that recovery process of getting back into the lifestyle that you want. Kimberley: Yeah, absolutely. I would add too, just as a side point, anyone who is managing a mental health issue or an anxiety disorder, we do also have to fill our cup with the things that fill our hearts. I know that sounds very cliche and silly, but in order to pace ourselves and to have the motivation and to use the skills, we do have to find a balance of not just doing all the hard things, but making sure you schedule time to rest and eat and drink and see friends if that fills your cup, or read if that fills your cup. So, I think it’s also finding a rhythm and a balance of the things that fill your cup and identifying that, yes, recovery is hard. It will deplete your stores of energy. So, finding things that fill that cup for you is important.   Chris: Well, you just made a good point too. In my recovery, all those things you mentioned, I thought of those as like weakness, like I just wasted an hour reading. Sometimes even with friends. That one, not as much, because I saw value in friendship. But if I just watched a movie or relaxed, or even just hung out with friends, it felt like a waste. I’m like, “How dare I am behind everybody else? I should be working. I should be this. I should move up.” A lot of should statements, a lot of perfectionist expectations of myself.  So, the goal for me or the treatment for me wasn’t to then go to the other extreme and just give up everything; it was really to ask myself, like you said, how can I fill my cup in ways that are important and see value and getting a breakfast burrito with a friend and talking for three hours and not thinking like, “Oh, I should have been this because I got to get my degree.” I’m glad that you brought that up. I always think of like we’re overflowing our cup with mental health conditions. We have to be able to have those offsets that drain the cup so we have a healthy balance. So, a great point. ROADBLOCK #4: NOT OWNING YOUR RECOVERY Kimberley: I agree. So important. Would you tell us about owning your recovery? Because you have a really great story with this. Chris: Yeah. People ask me all the time how I got better. A lot of people with body dysmorphic disorder struggle to get better. Obviously, we know that with obsessive-compulsive disorder, major depressive disorder, et cetera. So, a lot of people will ask sometimes, and I always say to them, if I had to come up with one thing, it was because I made my mental health recovery number one. I felt that it was like the platform that I was building my whole life on. I’m so bad with the-- what is it? The house, the-- I’m not a builder.  Kimberley: Like the foundation. Chris: Thank you. Clearly, I’m not going to be making tools tomorrow or making things with tools. But yeah, like a house has to have a nice foundation. You would never build a house on a rocky side of the mountain. And so, I had to give up a lot, like most of us do, as we start to get worse. I became housebound and I dropped out of college, and I gave up a job. I was working in the entertainment industry, and I really enjoyed it. I was going to film school, and I was happy. I had to give all that up because I couldn’t even leave my house because of the disorder.  SOLUTION #5: MAKE YOUR RECOVERY THE MOST IMPORTANT THING So, when I was going to treatment and I was really starting to see it work, I was clear to that finish line of what I needed to do. So I made it the most important thing. It wasn’t just me; it was my support system. My treatment was about a four-hour round trip from my house, so my mom and I would meet up every day. We drive up to LA. I go to my OCD therapist, and I’d go to my psychiatrist and then my BDD therapist and support group, and then come home. There’s times I was exhausted, I wanted to give up, I was over it, but I never ever, ever put it to number two or three. I almost had this top three list in my head, and number one was always my recovery. My mom too, I mean, when she talks, she’ll always say it's the most important thing. If my job was going to fire me because I couldn’t come in because I had to take my kid on Wednesdays to treatment, I was going to get fired and find a new job. We just had to make this important.   As I was getting better, there were certain opportunities that came back to me from my jobs or from school. My therapist and I and my mom just decided, “Let’s hold off on this. Let’s really, really put effort into the treatment. You’re doing so well.” One of the things that I see all the time, my mom and I run a very successful family and loved ones group. A lot of times, the parents aren’t really making it the priority for their kids or the kids, or the people with the disorders aren’t really making it a priority. It’s totally understandable if there’s things like finances and things, barriers. But that’s not what I’m talking about. I’m talking about when people have access to those things, they’re just not owning it. Sometimes they’re not owning it because they’re not taking it seriously or not making it important. Or other times, people are expecting someone else to get them better.  I loved having a team. I didn’t have a big team. I came from nothing. It was a very small team. I probably needed residential or something bigger. I only really had my mom’s support, but we all leaned on each other. But I always knew it was me in the driver’s seat. At the end of the day, my therapist couldn’t save me, my mom couldn’t save me, they couldn’t come to my house and pull me out of bed or do an exposure for me, or have me go out in public during the daytime because of BDD. I had to be the one to do it. I could lean on them as support systems and therapists are there for, but at the end of the day, it was my choice. I had to do it. When my head hit the pillow, I had to make sure that I did everything I possibly could that day to recover.  When I took ownership, it actually gave me freedom. I wasn’t waiting for someone to come along. I wasn’t focusing on other things. I made it priority number one. I truly believe that that was the thing that got me better. Once again, didn’t have a lot of resources, leaned a lot on self-help books and stuff because I needed a higher level of care, but there was none and we couldn’t afford it. I don’t want anyone to hear this podcast and think, “Well, I can’t find treatment in my area.” That’s not what I’m saying. I’m just saying, whatever you have access to, own it, make it a priority, and definitely be in that leader’s seat because that’s going to be what’s going to get you better. Kimberley: Yeah, for sure. I think too when I used to work as a personal trainer, I would say to them, “You can come to training once a week, but that once a week isn’t going to be what crosses you across that finish line.” You know what I mean? It is the work you do in the other 23 hours of that day and the other seven days of the week. I think that is true. If you’re doing and you’re dabbling in treatment, but it’s not the main priority, that is a big reason that can hold you back. I think it’s hard because it’s not fair that you have to make it priority number one, but it’s so necessary that you do.  I really want to be compassionate and empathize with how unfair it is that you have to make this thing a priority when you see other people, again, making their social life their priority or their hobby their priority. It sucks. But this mindset shift, this recalibration of this has to be at the top. When it gets to being at the top, I do notice, as a clinician, that’s when people really soar in their recovery. Chris: Yeah. We had a very honest conversation with my BDD therapist, my OCD therapist, and my psychiatrist, and they’re like, “You need a higher level of care. We understand you can’t afford it. There’s also a lot of waiting lists.” They’re like, “You’re really going to have to put in the work in between sessions. You’re supposed to be in therapy every day.” We just couldn’t. All we can afford is once a week. They said, “Look, when you’re not in our session, you need to be the one.”  So, for instance, with depression, my psychiatrist is like, “Okay, you’re obviously taking the medication, but you need to get up at the same time every day. Open up all your blinds, go upstairs, eat breakfast on the balcony, get ready, leave the house from nine to five.” I didn’t have a job. “But you need to be out of the house. You need to be in nature. You need to do all these things.” I never wanted to, but I did it. Or with my OCD and BDD recovery, I didn’t want to go out in public. I felt like it looked horrendous. I felt like people were judging me, but I did. Instead of going to the grocery store at 2:00 in the morning, I was going at noon. When everyone’s there for OCD, it was like, I didn’t want to sit in public places. I didn’t want to be around people that I felt I could potentially harm.  My point is like every single day, I was doing work, I was tracking it, I was keeping track, and I had to do that because I needed to do that in order to get better based on the setup that I had.  I do want to also say a caveat. I always have the biggest empathy for people or sympathy for people that are a CEO of a company or like a parent and have a lot of children, or it’s like you’re busy working all day and you’re trying to balance stuff. I mean, the only good thing that came from being housebound is I didn’t have a lot of responsibilities. I didn’t have a family. I wasn’t running a company. I wasn’t working. So, I did have the free time to do the treatment. So, I have such sympathy for people that are parents or working at a company, or trying to start their own small business and trying to do treatment too. But I promise you, you don’t have to put your recovery first forever. Really dive into it, get to that place where you’re really, really stable. It’ll still be a priority, but then you will be a better parent, a better employee, a better friend once you’ve really got your mental health to a level that you can start to support others. You may need to support yourself first, like the analogy with a mask on the plane. ROADBLOCK #5: YOU HAVE A FIXED MINDSET Kimberley: Agreed. That’s such an important point. All right, we’re moving on to roadblock number five. This is yours again, Chris. Tell us about the importance of specific mindsets, particularly a fixed mindset being the biggest roadblock. Chris: One of the things that makes me the most sad about people having a mental health condition because of how insidious they are is it starts to have people lose their sense of identity. It has them start to almost re-identify who they are, and it becomes a very fixed mindset. So, if you have social anxiety or social phobia, it’s like, “Oh, I’m somebody that’s not good around people. I say embarrassing things. I never know what kind of conversation to lead with. I should probably just not be around people.” Or, let’s say generalized anxiety. “Deadlines really caused me too much strain. I can’t really go back to school.” BDD. “I’m an unattractive person. Nobody wants to date me. I’m unlovable.”   We get into these fixed mindsets and we start to identify with them, and inevitably, that person’s life becomes smaller and smaller and smaller. So, the more they identify with it, the more that they become isolated from others, and they have this very fixed mindset. I think of like OCD, for instance, isn’t really about guidelines; it’s all about rules. This is how things are supposed to be. What happens is when I work with a client specifically, somebody that’s pretty severe, it’s trying to get them to see the value in treatment and to even tap into their own personal values is really difficult. It’s like, “Treatment doesn’t work. I’ve tried all the medications. I don’t know what I’m going to do. I’m just not somebody that can get better.” SOLUTION #5: GROWTH MINDSET What I tell clients instead is, “Let’s be open. Let’s be curious. Let’s move into a growth mindset. Let’s focus on learning, obtaining education, being open to new concepts. Look, when you were younger and the OCD didn’t really attack you, or when you were younger and you didn’t deal with social anxiety, you were having friends, you had birthday parties, you were going to school, and everything. Maybe that’s the real you, and it’s not that you lost it. You just have this disorder that’s blocked you from it.” And so, when clients become open and curious and willing to learn, willing to try new things, and to get out of their comfort zone, that’s where the growth really happens.  If you’re listening to this podcast or watching it right now and you’re determined like, “This isn’t working; nothing can help me,” that fixed mindset is never something that’s going to get you from where you are to where you want to be. You have to have that growth, that learning, that trying new things, expanding.  I always tell clients, “If you try something with your therapist and it doesn’t work, awesome. That’s one other thing that doesn’t work. Move on to something else.” That openness. What I always love after treatment is people are like, “I am social. I do love to be around people. I am somebody who likes animals. I just was avoiding animals because of harm thoughts.” People start to get back into who they really are as soon as they start to be more open to recovery. Kimberley: Yeah, for sure. The biggest fixed mindset thought that I hear is, “I can’t handle it.” That thought alone gets in the way of recovery so many times. We go to do an exposure, “I can’t handle this.” Or, “What if I have a panic attack? I cannot handle panic attacks.” It’s so fixed. So I often agree with you. I will often say, this work, this mental health work, or this human work that we do is shifting the way we see ourselves and life as an experiment. We always have these black-and-white beliefs like “I can’t handle this” or “I can’t do this. I can’t get in an elevator. I can’t speak public speaking,” or whatever it might be. But let’s be curious. Like you said, let’s use it as an experiment. Let’s try, and we’ll see. Maybe it doesn’t go great. That’s okay, like you said, but then we know we have data, and then we have information on what got in the way, and we have some information.  I think that even just being able to identify when you’re in a fixed mindset can be all you need just to be like, “Oh, okay, I’m having a very black-and-white fixed mindset.” Learning how to laugh and giggle at the way our brain just gets so determined and black-and-white, like you can’t do this, as you said, I think is so important because, like you said, once you get to recovery, then you go on to live your life and actually do the things that you dream, the dream that you’re talking about. It might be you want to get a master’s degree or you might want to go for a job, or you want to go on a date. You’re going to be able to use that strong mindset for any situation in life. It applies to anything that you’re going to conquer.  I always say to clients, if you’ve done treatment for mental health, you are so much more prepared than every student in college because they haven’t gone through, they haven’t had to learn those skills. Chris: Yeah, no, exactly. I remember like my open mindset was one of the assets I had in recovery. I remember going to therapy and being like, “I’m just going to listen. These people clearly know what they’re doing. They’ve helped people like me. Why would it be any different?” And I was open. I can see the difference with clients that have a more growth mindset. They come in, they’re scared. They’re worried. They’ve been doing something for 10, 15, 16 years, and they’re like, “Why is this guy going to tell me to try to do different things or to think different or have different thinking patterns?” But they’re open. I always see those people hit that finish line first. It’s the clients that come and shut down. The family system has been supporting this like learned helplessness. Nobody really wants to rock the boat. Everything shut down and closed. It’s like prying it open, as most of the work. And then we finally get to the work, but we could have gotten there quicker. Everybody’s at their own pace, but I really hope that people hear this, though, are focused on that openness. You were talking about like people thinking they can’t handle it. The other thing I hear sometimes is people just don’t think they deserve it. “I just don’t even deserve to get better.” You do. You do. That’s what I love about my job the most. Everybody that comes into my office, and I’m like, “You deserve a better life than you’re living. Whatever it is you want to do. You want to be a vet. How many animals are you going to save just by getting into being a vet? You got to do it.” My heart breaks a little bit when people have been dealing with mental health for long enough that they start to believe they don’t even deserve to get better.  SOLUTION #6: IT’S A BEAUTIFUL DAY TO DO HARD THINGS Kimberley: I love that. So, we had five roadblocks, and we’ve covered it, but we promised six strategies. I want to be the one to deliver the last one, which everyone who listens already knows what I’m going to say, but I’m going to say it for the sake that it’s so important for your recovery, which is, it’s a beautiful day to do hard things. It is so important that you shift, as we talked about in the roadblock number one, you shift your mindset away from “I can’t do hard things” to “It’s okay to do hard things.” It doesn’t mean you’ve failed. Life can be hard.  I say to all my patients, life is 50/50 for everybody. It’s 50% easy and 50% hard. I think some people have it harder than others. But the ones who seem to do really well and have that grit and that survivor’s mindset are the ones who aren’t destroyed by the day when it is hard. They’re willing to do the hard thing. They’re okay to march into uncertainty. They’re willing to do the hard thing for the payoff. They’re willing to take a short-term discomfort for the long-term relief or the long-term payout. I think that mindset can change the game for people, particularly if you think of it like a marathon. Like, I just have to be able to finish this marathon, I’m going to do the hard thing, and think of it that way. There’ll be hills, there’ll be valleys, there’ll be times where you want to give up, but can I just do one hard thing and then the next hard thing, and then the next hard thing? Do you have any thoughts on that? Chris: I’m glad that this is the message that you put out there. I’d say, obviously, when I think of Kim Quinlan as a friend, I think of other things and all the fun we’ve had together. But as a colleague, I always think of both. Obviously, self-compassion. But this idea of it’s a beautiful day to do hard things, I like it because we’ve always talked about doing hard things as this negative thing before you came along, and by adding this idea of it’s a beautiful day. When I look at all the hard things I did in my own recovery, or I see clients do hard things, there’s this feeling of accomplishment, there’s this feeling of growth, there’s this feeling of greatness that we get. Just like you were saying, beyond the mental health conditions that I dealt with, when I start getting into real life after the mental health conditions now are more in recovery, every time I choose to do hard things, there’s always such a good payoff. I was convinced I would never be able to get through school and get a degree and become a licensed therapist because I struggled with school with my perfectionism. It was difficult for me to get back in there and to humble myself and say, “Hey, you may flop and fail.” But now I’m a licensed therapist because of that willingness to do hard things.  I could give a plethora of examples, but I want people to hear that doing hard things is your way of saying, “I believe in myself. I trust myself that I can accomplish things, and I’m going to tap into my support system if I need to, but I am determined, determined, determined to push myself to a level that I may not think I can.” I love when clients do that, and they always come in, they’re like, “I’m so proud of myself, I can’t wait to tell you what I did this weekend.” I love that. So, always remember hard things come with beautiful, beautiful, beautiful outcomes and accomplishments. Kimberley: Yeah. I think the empowerment piece, when clients do scary, hard things, or they feel their hard feelings, or they do an exposure, they’ll often come in and be like, “I felt like I could do anything. I had no idea about the empowerment that comes from doing hard things.” I think we’ve been trained to think that if we just avoid it, we then will feel confident and strong, but it’s actually the opposite. The most empowered you’ll ever feel is right after you’ve done a really, really hard thing, even if it doesn’t go perfectly. Chris: Yeah, and so much learning comes out of it. That’s why I always tell clients too, going back to one of our first roadblocks, beating yourself up prevents the learning. Let’s say you try something and it doesn’t go well. I was talking to a colleague of ours who I really, really like. She was telling me how her first treatment center failed. Now she’s doing really well for herself down in San Diego. She’s like, “I just didn’t know things, and I just did things wrong, and I learned from it, and now I’m doing well.”  It’s like, whenever we look at something not going the way we’d like as an opportunity to learn and collect data, it just makes us that much better when we try it the other time. A lot of times these anxiety disorders were originally before treatment, hopefully trying to find ways to avoid our way through life—tough words—and trying to figure out, like, how can I always be small and avoid and still get to where I want to be? When people hear this from your podcast—it’s a beautiful day to do hard things—I hope that they recognize that you don’t have to live an avoidant lifestyle, an isolated lifestyle anymore. Really challenging yourself and doing hard things is actually going to be so rewarding. It’s incredible what outcomes come with it. Kimberley: Amazing. Well, Chris, thank you so much for doing this with me again. We finally stamped it into the podcast, which makes me so happy. Tell us where people can hear about you, get in contact with you, and learn more about what you do. Chris: I am really active in the International OCD Foundation. I’m one of their board members. I also am one of their lead advocates, just meeting as somebody with the disorder. I speak on it. Then I lead some of their special interest groups. The Body Dysmorphic Disorder Special Interest Group is one of them, but I lead about four of them. One of their affiliates, OCD Southern California, I am Vice President of OCD SoCal and a board member. We do a lot of events here locally that Kim is part of, but also some virtual events that you could be a part of. And then, as a clinician, I’m a licensed clinician in Costa Mesa, California. I currently work at The Gateway Institute. You can find me either by email at my name, which is never easy to spell. So, [email protected], or the best thing is on social media, whether it’s Instagram, Facebook, or X, I guess we’re calling it now. Just @christrondsen. You could DM me. I always like to hear from people and get people’s support, and anything I can do to support people. I always love it. Kimberley: Oh my gosh, you’re such a light in the community, truly. A light of hope and a light of wisdom and knowledge. I want to say, because I don’t tell you this enough as your friend and as your colleague, thank you, thank you for the hope that you put out there and the information you put out there. It is so incredibly helpful for people. So, thank you. Chris: I appreciate that. I forgot to say one thing real quick. Every first, third, and fourth Wednesday of the month at 9 a.m. Pacific Standard Time on the IOCDF, all of their platforms, including iocdf.org/live, I do a free live stream with Dr. Liz McIngvale from Texas, and we have great guests like Kim Quinlan on, so please listen. But thank you for saying that. I always try to put as much of myself in the community, and you never know if people are receiving it well. I want to throw the same thing to you. I mean, this podcast has been incredible for so many. I always play some of this stuff for my clients. A lot of clients are looking for podcasts. So, thanks for all that you do. I’m really excited about this episode because I think it’s something that we touch so many people. So, now to share it on a bigger scale, I’m excited about it. But thank you for your kind words. You’re amazing. It’s all mutual. Kimberley: Thank you. You’re welcome back anytime. Chris: And we’re going to get Greek food soon. It’s funny [inaudible] I’m telling you. It’s life-changing. Thanks, Kim. Listen to other episodes. Kimberley: Thank you.

Welcome back, everybody. This is Part 2 of Your 2024 Mental Health Plan, and today we are going to talk about the specific tools that you need to supercharge your recovery. This podcast is called Your Anxiety Toolkit. Today, we are going to discuss all the tools that you are going to have in your tool belt to use and practice so that you can get to the recovery goals that you have. Let’s go. For those of you who are here and you’re ready to get your toolkit, what I encourage you to do first is go back to last week and listen to Part 1 of this two-part series, which is where we do a mental health recovery audit. We go through line by line and look at a bunch of questions that you can ask yourself, journal them down, and find specifically what areas of recovery you want to work on this year.  Now, even if you’re listening to this as a replay and it’s many years later, that’s fine. You can pick this up at any point. This episode and last week’s episode actually came from me sitting down a few weeks ago and actually going, “Okay, Kimberley, you need to catch up and get some things under control here.” You can do this at any time in a month from now or a year from now. We’re here today to talk about tools, so let’s get going.  First, we looked at, when we did our audit, the general category. The general question was, how much distress are you under? How much time is it taking up, and how do you feel or what are your thoughts about that distress? That is a very important question. Let’s just start there. That is an incredibly important question because how you respond to your distress is a huge indicator of how much you will suffer.  If you have anxiety and your response is to treat it like it’s important, try to get it to go away, and spend your time ruminating and wrestling, you’re going to double, triple, quadruple your suffering. You’re already suffering by having the anxiety, but we don’t want to make it worse.  If you’re having intrusive thoughts and you respond to them as if they’re important and need to be solved, again, we’re going to add to our suffering. If you have grief, shame, or depression and you’re responding to that by adding fuel to the fire, by adding negative thoughts, or by saying unkind things to yourself, you’re going to feel worse. How do you respond?  WILLINGNESS Tool #1 you’re going to need in this category is willingness. When you identify that you’re having an emotion, how willing are you to make space for that emotion? I’m not saying give it your attention; I’m saying, are you willing to just allow it to be there without wrestling it, trying to make it go away? Are you willing to normalize the emotion? Yeah, it makes complete sense that I’m having a hard time, or that all humans have these emotions. How willing can you be?  Often, what I will ask my patients is, out of 10, if 10 being the highest, how willing are you? We’re looking for eights, nines, and tens here. If you’re at like a six, seven, that’s okay. Let’s see if we can get it up to the eights, nines, and tens.  VALUES OVER FEAR Another tool (Tool #2) is respond with values, not fear or emotion. We want to work at being very clear on what our values are, what is important to us. Because if we don’t, emotions will show up. They will feel very, very real. When they feel very, very real, you’re likely to respond to them as if they’re real. Again, adding fuel to the fire, adding to the suffering. Instead, we want to respond with values.  If you have fear, you’re going to ask yourself, do I want to respond based on what fear is telling me, or my values, my beliefs, the principles, the things that are important to me? If you’re depressed, do you want to respond based on what depression is telling you to do? Like, "Give up, it’s hopeless, there’s no point." Or do you want to get back in touch with what matters to you? What would you do if depression wasn’t here? What would you do if anxiety was not here?  The third tool I’m going to give you, and this is a huge one—I’m going to break it down into different categories—is mindfulness. Now, if you’ve been here on Your Anxiety Toolkit, you already know that I think mindfulness is the most important tool, one of the most important tools you will have in your tool belt. You should be using it in your tool belt every day. It’s like if you actually had a tool belt, it’d be like the hammer, the thing you probably use the most.  Mindfulness involves four things, and this is the way I want you to think about it.  MINDFULNESS Number one, it’s awareness. Mindfulness is being present and aware of what is happening to you internally. Being able to identify, I feel sad, I feel anxious, I notice uncertainty, I’m noticing I’m having thoughts about A, B, and C. That awareness can help you stay in line with your values, but stay present enough to respond wisely.  Mindfulness is also presence. I’ve already given you that word. It’s being in the here and now. Fear always wants us to look into the future; mindfulness is being in the here and now. Depression often always wants us to look at the past and ruminate on the past and what went wrong or what will potentially go wrong in the future; mindfulness is only tending to the here and now, what’s actually happening.  When I’m anxious and I become present in my body, I realize that the thing that I’m afraid of hasn’t happened yet. If it is happening, if the thing that I’m afraid of is happening, then I can still go, “Okay, what’s happening in the present? How can I relate to it?” As we’ve discussed in earlier tools, how can I relate to it in a way that doesn’t add to my suffering? Can I make some space for it? Can I be willing to have it? Can I respond with values? Really getting present in this moment will give you some space to act very skillfully.  NON-JUDGMENT The next mindfulness tool is non-judgment. We have to be non-judgmental. Often, when I’m with my patients or with my students, they will often say, “I’m having anxiety, and it is bad and wrong, and I’m wrong for having it, and it shouldn’t be here.” All of that is a judgment.  I often bring them back to the fact that anxiety, while yes, it is uncomfortable, it is neutral. Let me say that again. Anxiety, while it is uncomfortable—it’s not fun—it is neutral. It is neither good nor bad. It just is your present experience. This work becomes how willing are you to feel discomfort. How willing are you to widen your distress tolerance for this thing that you’re experiencing, and how can you practice not judging it as bad?  The thing to remember is, if you have an emotion, a sensation, or a thought, and you appraise it as bad, your brain will remember that for next time. So next time you have it, it will more likely send out a bunch of cortisol and adrenaline and a bunch of stress hormones when you have that emotion, that sensation, or that thought. And that’s how we can break this cycle by practicing non-judgment.  WISDOM AND INSIGHT The fourth piece of mindfulness that I want you to consider is wisdom and insight. This is not a typical mindfulness tool, I would say, but it’s an important piece of our work. When we have mental struggles, when we have emotional struggles, it’s very easy to fall into the trap of believing our thoughts and our feelings, going into that narrative, and getting into that story. When we do that, again, we make things worse. We tend to act on those emotions and that distress instead of our values. A lot of mindfulness, if you can practice being present, if you can practice being aware, if you can practice being non-judgmental, you then get to be steady in wisdom. You get to check the facts and respond according to the facts and the reality. You get to be level in how you respond. It doesn’t mean your anxiety will go away. It just means that you’re thinking in a way where you can make decisions. You’re connected to your prefrontal cortex, where you can make good decisions for yourself, not just respond to the emotions that you’re having. That’s sort of like a bigger picture, but that’s sort of more like the result of practicing mindfulness.  When we last week went through the audit of your mental health recovery, we also addressed safety behaviors. Now these were avoidance, reassurance seeking, mental compulsions, physical compulsions, and there is a fifth one, but we’ll talk about that later. We really went through and thoroughly investigated, did an audit, did an inventory of how many of these behaviors and what specific behaviors you do. Again, if you didn’t listen to that episode, go back and look at that because it will help you put together a really good inventory of what’s going on for you. Now, I want to address a couple of things when it comes to these. If you’re someone who does a lot of avoidance, I’m going to strongly encourage you to use Tool #4, which is find ways to face your fear. Identify all the things that you are afraid of and you’re avoiding, and find creative ways to face your fear and make it fun. If you’re afraid of something, try to find ways to make it fun that line up with your values. If you’re afraid of airplanes but love to travel, pick a place when you first start this that you’re interested in going to. Have it be something that you have been wanting to go to for a long time. Do it with someone you enjoy doing it with. If it’s something miscellaneous around the house, include the people around you, make it fun, put the music on that you want. You’re not doing that to take the discomfort away; you’re doing it so that it’s so deeply based on your values, so deeply based on what’s important to you, and purposely every day, find ways to face your fears.  Now, if you have OCD specifically and you want help with this, we have a full, comprehensive course called ERP School. If you go to CBTSchool.com, you can get access to that, and it will take you step by step on how to do that for OCD.  If you have generalized anxiety or panic disorder, we have a step-by-step process for how you can do that. It’s called overcoming anxiety and panic.  If you have depression, we actually have a whole comprehensive course for depression as well on how you can face the depression, how you can undo the way that depression has you avoiding things and procrastinating, and how it’s demotivating you. That course is there for you as well at CBT School.  If you’re someone who struggles with mental compulsions, we actually have a free six-part mental compulsion series here on Your Anxiety Toolkit. It’s completely free. I’ll leave the links for that in the show notes below. But that will help you walk through it with six amazing clinicians from around the world, like the best ones that we can get, talking specifically about different ways to manage mental compulsions. But it does involve a lot of the tools we’ve already talked about—a lot of mindfulness, a lot of facing your fear, a lot of willingness, a lot of awareness. These are things that you can be using specifically to interrupt those safety behaviors. Now, another tool (Tool #5) is distress tolerance, because as you face your fear, you’re going to have some uncomfortable feelings. Distress tolerance is an opportunity for you to lean into that discomfort a little more. It’s very skill-based. Let me give you a couple of ideas.  BEGINNERS MIND Number one would be this idea of a beginner’s mind. Usually, when we’re uncomfortable, our natural human instinct is to get out of here. Like, “Let’s go. I don’t want to be here. I don’t want to feel it. Let’s run away.” Another instinct is to fight. Like, “Oh, I want to wrestle with it.”  Beginner’s mind is the opposite of that. It’s the practice of being curious. We actually have a whole podcast episode on beginner’s mind. Think of it like you’re a baby. I always say, imagine you’re like one or two and you hand the baby a set of keys. Now, if you handed a set of keys to an adult, they’d be like, “Yeah, that’s keys.” They wouldn’t really stop to look at the keys. But if you give it to the baby, they’re so curious, they’re so open-minded, and they look at the keys like I’ve never seen these. They’re shiny, but they’re hard, but they’re bumpy. They have these round things. What do you do with them? I’ll put them in my mouth. What do they taste like? What do they feel like? They’re so willing to see these keys as if it’s the first time they’ve ever seen them because it's the first time they’ve ever seen them.  As adults, we have to practice being curious, just like that. When we’re uncomfortable, we can be curious instead of nonjudgmental and go, “Okay, let’s be curious about this. What does it feel like? I wonder what it’s like if I’m willing to feel it. How long does it last? Can I let it be there? I wonder what will happen if I let it be there and go and do this or face the fear.” Let’s be curious instead of having a fixed mindset of, “I can’t feel this. I can’t handle it. I don’t want to,” and so forth. Beginner’s mind is very important in helping you relearn the perceived stress or the perceived danger of a certain thing.  Another really important distress tolerance skill is radical acceptance. Radical acceptance is a sort of badass response to fear and emotions by going, “Bring it. Let’s have it. It’s here. There’s nothing I can do. Trying to stop it only makes things worse. And so I’m committed to radically accepting it being here.” Then you can go on to use other tools like your values and willingness, ERP, CBT, and any of those. You can use any of those skills. But you’re coming from a place of just radically accepting that it’s there.  UNCERTAINTY Another distress tolerance skill is to be uncertain on purpose. “Bring it on.” If you have anxiety, you’re going to have uncertainty anyway. Bring it on. Let’s let it be there. Let’s make another relationship with uncertainty—one that’s not stressful and one where it’s like, I’m allowing it to be there. I actually have some mastery over it because I’ve practiced letting it be there before, and I tolerated it then, and I’m sure I’ll tolerate it again.  Remember here, you have gotten through 100% of the hard things in your life. You can do it again, and each time we can make this 1% improvement in how skillful we are in response to it. SELF-KINDNESS AND SELF-COMPASSION The next category that we had in the audit was kindness. We talked about questions such as, how do you treat yourself throughout the day? How kind are you? Do you punish yourself for having emotional struggles? And of course, you guys know this is number six, which is self-compassion. We know that self-punishment doesn’t work. In fact, it makes us feel worse.  Self-compassion is the practice of making you a safe place to have any emotion, any discomfort, have any thought, have any anxiety. You’re willing to have them all, and you’re going to promise yourself and commit to yourself that you’ll be gentle with yourself no matter what. That’s the work.  Truly, so many of you have said that you’ve been working on that, and you’ve actually made huge strides in that area. We have so much content on Your Anxiety Toolkit on self-compassion. I’d encourage you to go back and listen to any of those. This year I’m going to really heavily emphasize this work, but I really want you to really consider creating a safe place for you to have any emotion, any intrusive thought, any feeling, any discomfort at all, any pain, so that you know that you’re always in a safe place to have those feelings.  MINDSET  The last category of the audit that we did last week was on mindset. We asked questions like, how willing are you to experience these emotional struggles? When you wake up, what’s the thing you think? Do you think, “Oh no, I can’t handle it, this is going to be terrible, I hope I don’t have any anxiety today, I hope my emotions don’t come or I hope I don’t have any thoughts”? Or do you have a more positive outlook of the day?  Now, we already talked about willingness. It was one of the first tools that we used. But here, I want you to consider the idea of being positive. Now, I’m not saying positive like, “Oh no, my bad things won’t happen,” or “No, I’m not a bad person, and my fears won’t come true.” That’s not what I’m talking about being positive. I’m talking about remind yourself of your strengths. That is a tool.  Being complementary and positive is a tool that we don’t use enough. We spend all the time thinking about the worst-case scenario, and we very rarely take time to really think, “I’m actually pretty strong. I’ve actually handled a lot. I’m actually very, very resilient.” Is it possible that you do that too? What can we do to get you to see yourself the way I see you?  Often, I’ll say to clients, “Oh my gosh, you’re doing so well.” And they’ll be like, “Oh, I kind of am, you’re right.” Or I’ll say, “Wow, look at how you got through that really hard thing.” And they’re like, “No, it’s not a big deal; everyone can do it.” But I’m like, “No, you did that.”  CELEBRATE YOUR WINS  Please practice being positive towards yourself, having positive regard for yourself, celebrating your wins, thinking positive about your strengths, not just focusing on your weaknesses.  Now Tool #8, we all know. I say it every single week, which is it’s a beautiful day to do hard things. When we wake up and we think, “Oh no, I don’t want bad things to happen,” we become a victim. What we want to do is we want to stand up and say, “Today is a really beautiful day to do really freaking hard things, and I’m going to practice doing those.” I want you to think of #8 as a motto, a mantra that you can take with you everywhere. “It is a beautiful day to do hard things.” We don’t need perfect conditions to do hard things either. We don’t need motivation to do hard things. Sometimes we just have to do them, whether we’re motivated or not. And then we see the benefit. We don’t have to wait until you have the right thought, the right feeling, or the right situation.  Often, I’ll catch myself like, “Oh, I had a little bit of an argument with my husband. No, I’m not going to do hard things today.” No, that’s the day to go do the hard thing. Do it because it’s what brings you closest to your recovery. It brings you closest to the goals that you have.  TIME MANAGEMENT Now, Tool #9 is time management. When you wake up in the morning, if dread is the first thing on your mind, time management will help. We have a whole course on CBTSchool.com on time management, and what it is about is teaching you a few core things. Number one, schedule your recovery homework first because it has to be the priority. It has to be. Secondly, schedule fun time first. Don’t schedule work. Don’t schedule your chores. Make sure you’re prioritizing these things because recovery requires rest, it requires fun, it requires lightness and brightness, and fulfillment. Doing these hard things takes up a lot of energy, so any way you can, even if it’s for two minutes, manage your time so that you have set in your calendar, set a reminder, the time where you’re going to do the things that you need to do to get your recovery on its way. Prioritize it.  We have a whole course called Time Management for Optimum Mental Health. You can get it at CBTSchool.com, and it really outlines how you can do this and how you can practice prioritizing these things, which brings us to Tool #10, which is find a community of people who are doing the same things as you.  I get it, everyone on Instagram looks like they’re having a jolly time and their life is easy. The truth is, no, they’re not. Find the people who are also struggling with similar adversity. You could go to CBT School Campus, which is a Facebook group we have. On social media, there are so many amazing advocates sharing what it’s like to be doing this work. Come on over and follow me on Instagram at Your Anxiety Toolkit, where I talk a lot about this all the time. There is a community of people who make the most gorgeous comments and are so supportive and encouraging. FIND COMMUNITY Find a community, because if you feel like you’re the only one who’s struggling, it makes it really, really hard. Just know that you’re not alone and that other people are going through hard things. They might not be going through exactly what you’re going through, but this community is filled with millions of listeners. There are other people who are struggling too, so try to find them. Use them as accountability buddies. Touch base with them.  My best friend and I meet once a week, fire the phone, and check in. How are you doing? What are you doing well with? How are you doing with the goals you set for last week? Try to find someone, if you can, who can be your accountability buddy. If not, maybe ask a loved one or a friend who might be willing to do that.  There are the 10 tools that I want you to have in your toolkit. You’re not going to use them all the time. You’re not even going to be good at them. I’m even willing to say you’re going to suck at using them, and that is okay. I suck at using these sometimes too. This is not about perfection; this is about pausing, looking at the problem, asking yourself, which of these tools would be most helpful right now? And be curious. Again, use your beginner’s mind. Be curious about trying them, experimenting, giving yourself a lot of celebration in the fact that you tried.  Again, this doesn’t have to be perfect. We make 1% improvements over here. That’s all I’m looking for—a 1% improvement. Is there something you can do today that will get you 1% closer to your recovery goal? If that is possible, go for it. Give it your best. You will not regret it. I’ve never once had someone regret moving towards their recovery. In fact, I’ve only seen people say, “I’m so grateful I did it.” Even though it might have been late, it’s never too late.  All right. Have a wonderful day. I know you can do this. I cannot wait for this year. I have so many things I want to talk to you about.  Have a wonderful day, and I’ll see you next week.

f you need a mental health plan for 2024, you are in the right place. This is a two-part series where we will do a full recovery audit. And then next week, we’re going to take a look at the key tools that you need for Your Anxiety Toolkit. We call it an anxiety toolkit here, so that's exactly what you’re here to get. The first step of this mental health plan for 2024 is to look at what is working and what isn’t working and do an inventory of the things that you’re doing, the safety behaviors, the behaviors you’re engaging in, and all the actions that you’re engaging in that are getting in the way of your recovery. Now what we want to do here is, once we identify them, we can break the cycle. And then we can actually start to have you act and respond in a very effective way so that you can get back to your life and start doing the things that you really, really wanted to do in 2023 but didn’t get to. If you’re listening to this in many years to come, same thing. Every year, we have an opportunity to do an audit—maybe even every month—to look at what’s working and what’s not. Let’s do it. Now, one thing I want you to also know here is this is mostly an episode for myself. A couple of weeks ago, I was not coping well. I consider myself as someone who has all the skills and all the tools, and I know what to do, and I’m usually very, very skilled at doing it. However, I was noticing that I was engaging in some behaviors that were very ineffective, that had not the best outcomes, and were creating more suffering for myself.  Doing what I do, being an anxiety specialist, and knowing what I know as a therapist, I sat down and I just wrote it all out. What am I engaging in? What’s the problem? Where am I getting stuck? And from there, naturally, I did a mental health audit. And I thought, to be honest with you, you guys probably need such a thing as well, so let’s do it together. Here is what I did. Let’s get started with this mental health audit that we’re going to do today.  FOUR RECOVERY AUDIT CATEGORIES  General Perspective  Safety Behaviors  Safety  Mindset  What we’re going to do is we’re going to break it down into four main categories. The first category is your general perspective of your mental health, your recovery, and your internal emotional experience.  The second category is the safety behaviors you’re engaging in. A safety behavior is a behavior that you do to reduce or remove your discomfort, to get a sense of safety, or to get a sense of control. Sometimes they’re effective, sometimes they’re not, and we’re going to go through that today.  The third category is actually just safety—looking at how safe you are inside your body with your internal experience. And I’ll explain a lot more of that here in a little bit, so let’s just move on to section number four, which is mindset. What is your mindset about recovery? And we’re going to go through this together.  LET’S PROMISE TO DO THIS KINDLY  As we move forward, I want you to promise me and vow to me as we do this. We are only doing it through the lens of being curious and non-judgmental. This audit should not be a disciplinary action where you wrap yourself over the knuckles and you beat yourself up, and you just criticize yourself for the fact that you’re not coping well. That is not what we’re doing here. WE ARE JUST GATHERING DATA We are ultimately just taking data. We’re just looking at the data of what’s working and what’s not. And then we get to decide what we do differently. And we get to be honest with ourselves about what’s actually happening from a place of compassion, from a place of understanding, knowing that we’re doing the best we can with what we’ve got. Again, I could beat myself up and be like, “You’re a therapist. You do this for a living. What is wrong with you?” But instead, I just recognize. Of course, you fell off the wagon. Things don’t always work out perfectly when you’re under a high amount of stress or when it’s the holidays, when things feel out of your control. We naturally gravitate to safety behaviors that often aren’t the most effective. That’s just the facts.  BE NON-JUDGMENTAL Let’s do this from a non-judgmental standpoint. We are literally just gathering data. How we handle this is a big part of recovery. Okay? Let’s do it.  YOUR RECOVERY AUDIT  Let’s first look at the first section of your recovery audit. This is a general category. We’re going to ask some questions. You can get a pen and notepad, or you could just listen and think about this, pause it, take some stock of what’s been going on for you. But I do strongly encourage you to pause, sit down, write your answers on a piece of paper, on a Google Doc, or whatever you love to do. All right, here we go.  GENERAL   Number one, generally, how much of the day do you experience anxiety, hopelessness, or some kind of emotional distress, whatever it is that you experience? You could give a percentage, a grade, or an amount of hours. How much of the day do you experience emotions that are out of your control? We’re only here to get data on how much this thing is impacting your life. You might say all day, every day. That’s okay. You might say, “A couple of hours every day that I experience panic,” or “A couple of hours every day I’m having intrusive thoughts.” It doesn't matter; just put it down. If you’re someone who has more depressive symptoms, you might say, “For six hours of the day, I experience pretty severe depression.” Whatever you’re experiencing, you can write it down.  The second question in this category is, what are your thoughts about the emotional distress that you just documented? What are your thoughts about them? If you have anxiety, are your thoughts “I shouldn’t have anxiety”? Because what we gather there is if for, let’s say, two hours a day, you’re having anxiety, but for four hours a day, you’re saying, “I shouldn’t have it. I’m bad for having it. What’s wrong with me? Something is wrong. I’m terrible,” and so forth, we want to understand, what are the specific thoughts you’re having about the emotional distress?  If you have OCD and you’re having a lot of intrusive thoughts, what are your thoughts about that? “Oh, my thoughts make me a bad person. Oh, my intrusive thoughts mean I must want to do the thing that I’m having thoughts about.” If you’re having depression, what are your thoughts about that? “Oh, I’ll never get better, that I’m weak for having this struggle, that I should be able to handle it better. I should be able to get out of bed and function normally.” We want to really understand your general mindset and perspective of what you’re going through.  Often, we spend a lot of time thinking about why we have the problem. Why do I have this? What’s wrong with me? What did I do wrong? Why is this happening? Was it my past? Was it something that happened to me? Spending a lot of time trying to figure out why. That’s the general category.  SAFETY BEHAVIORS The second category, safety behaviors, is probably one of the most important, but there is a good chance I’m going to say that about every category, so let’s just go through them.  The first question in safety behaviors is, how much of the day do you spend ruminating, thinking, going over and over the problem, trying to solve it? How many minutes, how many hours, or what percent of the day do you spend ruminating?  We’ve already identified how much of the day you spend with the original, initial problem. But how much of the time do you actually spend engaging in the behavior of mental compulsions, mental rumination, sort of that real stressful solving practice? Write it down. Again, we’re not judging here. Even if you wrote 100% of the day, all day, every day for a year or 10 years, it doesn’t matter, okay?  The next question in safety behaviors is, if you zoomed out and looked at your entire life, what is it that you are avoiding because of this internal emotional experience, whether it be anxiety, uncertainty, depression, grief, whatever it might be, panic? Whatever it is, what is it specifically that you’re avoiding?  Some people say, “I’m avoiding a certain street. I’m avoiding a certain person. I’m avoiding a certain event. I’m avoiding an emotion. I’m avoiding a feeling. I’m avoiding a thought. I’m avoiding a specific book on a specific bookshelf. I’m avoiding a specific movie on the internet or on TV. I’m avoiding a specific topic in every area of my life.” Be as specific as you can. What is it that you are avoiding to try and reduce or remove your distress inside your body? Document all of it.  I tell my patients, it doesn’t matter if this takes 17 pages; just document it down. Don’t judge yourself. Once we have the data, we can next week meet and work on a solution here. Or as you go through this, if you’ve already clearly identified that you have, let’s say, OCD, generalized anxiety, panic, or depression, we have specific courses on CBTSchool.com that will walk you through these and give you specific solutions to specific problems. That is there for you as well.  We will next week go through the main tools you’re going to need. But if you really want to target a specific issue, we may have a course specifically in that area that will help you. If not, there are other areas where you can get resources and therapy as well. But this is going to help you get really clear on what specifically is going on for you. What is it that you’re engaging in that’s getting in the way? The next safety behavior category is, how do you carry your body throughout the day? Are you hypervigilant? Are you tense? Are you rushing around? That was me. That’s when I was like, “Oh, Kimberley, you are going down the wrong channel.” Because I noticed in many areas of my day, I was rushing, trying to avoid some emotions, trying to check boxes, rushing around, hypervigilant, looking around, what bad thing is going to happen next. How are you carrying this in your body?  If you had an eating disorder, it might be, “I’m tensing my stomach and pulling it in and trying to not eat and trying to suppress hunger and thirst.” If that’s happening, okay, let’s document. If you’re having panic, are you squinting, pushing away thoughts, trying to avoid a sensation in your body? We want to get to know what is happening with our bodies. A patient of mine a couple of weeks ago said, “I just hold my breath all day. I really do. I probably take half the breath that someone without anxiety takes.” Write it down if you notice that’s what you’re doing in your body. Again, not your fault; we’re just here to look at the data.  The next category of safety behaviors is, how often do you seek reassurance per day? How often do you consult with Google to reduce your anxiety? How often do you ask family and friends questions about your fear to get a sense of certainty or to reduce your anxiety?  Sometimes this can be tricky. You might even just mention a topic to notice their facial expression to see how they respond, or you might report to them something that happened to see if they’re alarmed so that you then know whether you should be alarmed and engage in some behavior, worrying, ruminating, and so forth.  How often are you trying to get to the bottom of anxiety and you’re noticing that it’s repetitive, and over and over again, you’re getting stuck in these rabbit holes of Googling or asking friends and families, often asking them questions they don’t even know the answer to?  Often, our family members, because they love us, will give us an answer based on probability, but they actually don’t know. And therefore, your brain-- you’re very smart. I know this because all my clients with anxiety often in depression are. You’re very smart. You know they don’t know the answer, so your brain doesn’t compute it as a real certainty anyway. Your brain is going to immediately go, “Well, how do they know? They probably don’t know any better than I do,” and it’s going to want more and more questions to be asked. How often do you seek reassurance per day, or how much of the day do you spend seeking reassurance?  And then the last safety behavior here is physical behaviors. This is more common for folks with OCD, phobias, or health anxiety. What physical behaviors do you engage in? Meaning, do you rearrange things? Do you move things? Do you check things? Do you turn things on and off? Lock doors, unlock doors, lock them again. How much are you engaging in physical behaviors to reduce your anxiety?  Again, I will also say this is very true for generalized anxiety. Often, people with generalized anxiety disorder spend a lot of time just engaging in this high-level functioning of checking boxes, getting things done, always being the busiest person in the room. And while yes, that does get rewarded by our society because, “Oh, look at them go, they’re getting all the things done,” they’re doing it to avoid or remove discomfort or uncertainty. So we want to get a thorough documentation of all of those things. Again, do not beat yourself up if it’s a long list. Those will help us next week when we talk about tools.  KINDNESS AND SAFETY  We move on now to the third category, which is kindness and safety. And now we’re talking about how do you respond to yourself and your experience of anxiety. We also talked about this through the lens of safety. Safety is when you’re feeling uncomfortable, you’re having an emotion such as anxiety, grief, sadness, dread, anger. When you have those emotions, is your brain and body a safe place to allow those emotions to exist, or is it an unsafe place in that you push it away, judge yourself, tell it shouldn’t be there, rid it out, get rid of it, banish it, avoid it, abandon it, all the things?  Question #1: How do you treat yourself throughout the day? Out of 10, how kind are you to yourself? Really think about it. How do you treat yourself?  If you thought objectively about yourself as a friend, would you want yourself as a friend around? Probably not. Maybe you’ve been listening to Your Anxiety Toolkit for some time and you’ve already really developed these skills, but really, really honestly, how kind are you to yourself? If you were another friend, would you invite yourself over? Probably not because you wouldn’t invite a friend over who’s like, “What is wrong with you? You’re crazy. You shouldn’t be doing that. You’re so silly. Why are you spending all this time? You’re lazy. You’re dumb. You’re stupid for asking these questions.” So really think about that.  The second question is, do you punish yourself for having these emotional struggles? And if so, how? Do you blame yourself? Do you shame yourself? Do you engage in a lot of guilt behavior, guilting yourself for these behaviors? Do you withhold pleasure from yourself?  I’ve had so many clients tell me that they will not allow themselves to have the nice toilet paper, and they get themselves the scratchy, one-ply toilet paper because of their intrusive thoughts or because they’re depressed and they don’t check the boxes that their friends on Instagram have checked. Therefore, they don’t deserve the nice shampoo, or they don’t deserve nice sheets, or they don’t deserve to rest. They basically punish themselves for their emotional struggles, and we don’t want to do that.  I know you know this already, but we want to know specifically. Do an inventory. Give yourself some days here to really do a thorough audit of what’s going on in your life. You might find that you don’t eat or you eat foods that aren’t delicious. One thing in my eating disorder recovery was, let’s really try to eat foods that are genuinely delicious. And if it’s not delicious, don’t eat it. Well, of course, if you need to eat and you need to function and you don’t have great options, that’s fine. Just eat for the sake of nourishment. But if you’re at a restaurant, eat the thing that’s delicious. Are you engaging in not allowing yourself to have those pleasurable things? The last question in the area of kindness and safety is, what specifically do you say to yourself when things get hard? What specifically do you say to yourself?  Often, people say, “No, I’m really kind to myself. I’m really good. I work out.” But then, when things get hard, everything goes down the drain. They start beating themselves up. When they don’t win at work or they don’t get a good grade or when they’re having a bad anxiety or depression day, that’s when they start beating themselves up. What do you say to yourself specifically when things get hard or when things get painful? Write it down.  MINDSET All right. We’re moving into the last section, which is mindset, because remember, we’re looking at 2024. We’re looking at the next six months, three months, or one month, and we’re really looking at how can we supercharge your recovery.  Here’s the question: How willing are you to experience these emotional struggles in your body? Out of 10, how willing are you?  Most of my patients report like a four, five, and a six, which is still great. I’m happy with that. It’s better than one, two, and three. And if you’re at a one, two, and three, it’s okay. We can start somewhere. Okay? What I’m looking for when I’m with my patients or when I’m with myself is a solid eight, nine, and 10 of willingness.  Of all the things that I push the most, how willing are you to actually have your emotional discomfort? Often, people are like, “I don’t want it. I’m in too much pain. I’ve had too much pain, Kimberley. Don’t even ask me to. You don’t even understand. I’ve been in pain for years,” and I get it. What we do resist persists. So we want to first ask ourselves, how willing are we to allow this discomfort to be in our body, this emotion to be in our body, or this thought to be present in our awareness?  The last question here is, when you wake up, what is your mindset about tackling the day? Do you wake up and go, “Oh no, God, I don’t want this,” or do you wake up and go, “No, no, no, no. Please, no anxiety today. Please, no thoughts today. Please, no depression today. Please, let this be a good day,” or do you wake up and say, “This will be a bad day”? Just take note of it. You’re not wrong for any of them, but we want to get a little bit of a temperature check on how you start the day.  Now, one thing to know, often these thoughts are automatic. You don’t have control of them. Again, I’m not here to say they’re wrong, but what we will talk about next week is ways in which you can change how you respond to some of those automatic negative thoughts, or even your intrusive thoughts, and really look at how we can create a mindset for you.  Let me give you just a quick rundown before we move forward.  Number one, we will be doing tools next week, and I’ll be going deep into that. And that will be the focus of mine for 2024. My biggest focus for 2024 is really doubling down on making sure you guys know what the tools are in your toolkit and which ones work for you, and you get to work from that.  Then I’m actually recording another podcast with Chris Trondsen, where we talk about common mindset roadblocks when it comes to recovery, and we will be giving you strategies there as well. Stick around for that. If you are listening to playbacks here, make sure you listen to all three episodes of this, because I think it will be so important now that you’ve done an inventory and you know what’s going on.  All right. That’s that. That is your mental health audit. Write it all down. Give yourself plenty of love. Congratulate and celebrate the fact that you did this hard thing, and I will see you next week to talk about the tools you need—the specific tools in your anxiety toolbelt—to help you go and live a life where anxiety is not in charge, not in the driver’s seat, and where you live according to your values, what is important to you. Anxiety and emotions do not get to make your decisions, and that’s my goal for you.  Have a great day. As always, I always say it’s a beautiful day to do hard things. You did a hard thing today. Thank you for sticking with me. This is not fun work. I get it. But it is important work, and you do deserve to get this really out on paper so that we can get you going in the direction that you want to go.  As always too, take what you need, leave the rest. If some of these questions don’t really fly for you or they’re very triggering, just do the best you can. I don’t ever want people to feel like what I’m saying is the rule and you have to do it.  Take what you need. Leave the rest, and I’ll see you next week. Have a good one, everyone.

Kimberley: Could I have PTSD or trauma? This is a question that came up a lot following a recent episode we had with Caitlin Pinciotti, and I’m so happy to have her back to talk about it deeper. Let’s go deeper into PTSD, trauma, what it means, who has it, and why we develop it. I’m so happy to have you here, Caitlin. Caitlin: Yes, thank you for having me back. INTRODUCING CAITLIN PINCIOTTI Kimberley: Can you tell us a little bit about you and all the amazing things you do? Caitlin: Of course. I’m an assistant professor in the Psychiatry and Behavioral Sciences Department at Baylor College of Medicine. I also serve as the co-chair for the IOCDF Trauma and PTSD in OCD Special Interest Group. Generally speaking, a lot of my research and clinical work has specifically focused on OCD, PTSD, and trauma, in particular when those things intersect, what that can look like, and how that can impact treatment. I’m happy to be here to talk more specifically about PTSD. WHAT IS PTST VS TRAUMA? Kimberley: Absolutely. What is PTSD? If you want to give us an understanding of what that means, and then also, would you share the contrast of—now you hear more in social media—what PTSD is versus trauma? Caitlin: Yeah, that’s a great question. A lot of people use these words interchangeably in casual conversation, but they are actually referring to two different things. Trauma refers to the experience that someone has that can potentially lead to the development of a disorder called post-traumatic stress disorder. When we talk about these and the definitions we use, trauma can be sort of a controversial word, that depending on who you ask, they might use a different definition. It might be a little bit more liberal or more conservative.  I’ll just share with you the definition that we use clinically according to the DSM. Trauma would be any sort of experience that involves threatened or actual death, serious injury, or sexual violence, and there are a number of ways that people can experience it. We oftentimes think of directly experiencing trauma. Maybe I was the one who was in the car accident. But there are other ways that people can experience trauma that can have profound effects on them as well, such as witnessing the experience happening to someone else, learning that it happened to a really close loved one, or being exposed to the details of trauma through one’s work, such as being a therapist, being a 911 telecommunicator, or anyone who works on the front lines.  That’s what we mean diagnostically when we talk about trauma. It’s an event that fits that criteria. It can include motor vehicle accidents, serious injuries, sexual violence, physical violence, natural disasters, explosions, war, so on and so forth—anytime when the person feels as though their bodily integrity or safety is at risk or harmed in some way.  Conversely, PTSD is a mental health condition. That’s just one way that people might respond to experiencing trauma. In order to be diagnosed with trauma, the very first criterion is that you have to have experienced trauma. If a person hasn’t experienced an event like what I described, then we would look into some other potential diagnoses that might explain what’s going on for them, because there are lots of different ways that people can be impacted by trauma beyond just PTSD. PTSD SYMPTOMS AND PTSD DIAGNOSIS  Kimberley: Right. What are some of the specific criteria for being diagnosed with PTSD? Caitlin: PTSD is comprised of 20 potential PTSD symptoms, which sounds like a lot, and it is. It can look really different from one person to the next. We break these symptoms down into different clusters to help us understand them a little bit better. There are four overarching clusters of PTSD symptoms. There’s re-experiencing, which is the different ways that we might re-experience the trauma in the present moment, such as through really intrusive and vivid memories, flashbacks, nightmares, or feeling really emotionally upset by reminders of the trauma.  The second cluster is avoidance. This includes both what we would call internal avoidance and external avoidance. Internal avoidance would be avoiding thinking about the trauma, but also avoiding any of the emotions that might remind someone of the trauma. If I felt extremely powerless at the time of my trauma, then I might go to extreme lengths to avoid ever feeling powerless again in my life. In terms of external avoidance, that’s avoiding any cue in our environment that might remind us of the trauma. It could be people, places, different situations, smells, or anything involving the senses. That’s avoidance.  The third cluster of PTSD symptoms is called negative alterations, cognitions, and mood, which is such a mouthful, but it’s basically a long way of saying that after we experience trauma, it’s not uncommon for that experience to impact our mood and how we think about ourselves or other people in the world. You’ll see some symptoms that can actually feel a little bit like depression, maybe feeling low mood, or an inability to experience positive emotions. But there’s also this kind of impact on cognition—an impact on how I view myself and my capabilities, maybe to the extent that I can trust other people or feel that the world is dangerous. Blame is really big here as well. And then the last cluster of symptoms is called hyperarousal. This is basically a scientific word for your body—sort of kicking into that overdrive feeling of that fight, flight, freeze response. These include symptoms where your body is constantly in a state of feeling like there’s danger or threat. This can impact our concentration. It can impact our sleep. We might have angry outbursts because we’re feeling really on edge. We may feel as though we have to constantly watch our backs, survey the situation, and make sure that we are definitely going to be prepared and aware if another trauma were to happen.  Those are the four overarching symptom clusters. But somebody only actually needs to have at least six of those symptoms to a clinically significant and impairing way. Kimberley: Right. Now, I remember early in my own treatment, a clinician using terms like little T trauma and big T trauma. The example that I was discussing is I grew up on a ranch, a very large ranch. My dad is and was a very successful rancher. Every eight to 10 years, we would have this massive drought where we would completely run out of water and we’d have to have trucks bring in water, and there were dead livestock everywhere. It was very financially stressful. I remember her bringing up this idea of what is a little T trauma and what is a big T trauma—not to say that that’s what was assigned to me, but that was the beginning of when I heard this term. WHAT IS BIG T TRAUMA VS LITTLE T TRAUMA?  What does it actually mean for someone to say big T trauma versus small T trauma? Caitlin: Yeah, this is another common term that people are using. I’m glad that there is language to describe this because a lot of times, when I provide the definition that I gave a few minutes ago about what trauma is according to the DSM, people will hear that and think, “Wait a minute, my experience doesn’t really fit into that criteria, but I still feel like I’ve been really impacted by something. Maybe it’s even making me experience symptoms that really look and feel a lot like PTSD.” Some people can find that really invalidating, like, “Wait a minute, you’re saying that what I experienced wasn’t traumatizing and it feels like it was traumatizing.”  Those terms can be used to separate out big T trauma, meaning something that meets the DSM definition that I provided—that really more strict definition of trauma. Whereas little T trauma is a word that we can use to describe these other experiences that don’t quite fit that strict criteria but still subjectively felt traumatizing to us and have impacted us in some way.  What’s interesting is that there’s some research that suggests that the extent to which somebody subjectively feels like something was traumatic is actually more predictive of their mental health outcomes than whether or not it meets this strict definition because we see people all the time who experience big T traumas and they might be totally fine afterwards. And then there are people who experience little T traumas and are really struggling.  We can use little T trauma to describe things like racial trauma, discrimination, minority stress, the experiences that you described, and even just significant interpersonal losses and things like that. Kimberley: Yeah. Maybe even COVID. For some, it was a capital T trauma, would you say, because they did almost lose their lives or witness someone? Is that correct? Would you say that some others would have interpreted it as a smaller T and then some wouldn’t have experienced it as a trauma at all? Caitlin: Yes, I think that’s a great example because there are definitely a lot of folks who don’t necessarily know someone who became really ill, lost their life, or didn’t have that personally happen to them. But there was this looming stress, maybe even related to quarantine and isolation and things like that. WHO GETS PTSD AND TRAUMA? Kimberley: This is really fascinating. I wonder if you could share a little, like, of all the people, what are the factors that you mentioned that increase someone’s chances of going on to have PTSD? Who goes on to get PTSD, and who doesn’t? How can we predict that? What do we know from the research? Caitlin: This is an interesting question because I think that some people might intuitively think, “Well, somebody experienced this really horrible trauma. Of course, they’re going to go on to develop PTSD.” We actually know that people on the whole can be pretty resilient even in the face of experiencing pretty horrible tragedies.  Our estimates of exposure to what we would call potentially traumatic experiences range from 70% to 90% of the population, and most of us will experience something at some point in our lives that would need that definition—that strict definition of a trauma. Yet, only about 6 to 7% of people will be diagnosed with PTSD at some point in their lives. So there’s this huge discrepancy here.  There are lots of factors, and of course, we don’t have this perfectly nailed down where we can exactly predict, “Okay, this person is going to be fine. This person is going to have PTSD.” It’s really an interaction of lots of factors. But we know that there are some things that can either provide a buffering effect against PTSD or have the opposite effect, where they might put somebody at greater risk.  One of the biggest things that’s come up in research is social support or the lack thereof, so that when people have really great social support after their trauma, whether it’s after a sexual assault or they’ve come home from combat, that can really buffer against the likelihood of developing PTSD. The reverse is true as well when people don’t have social support. We saw this, for example, after the Vietnam War, where a lot of veterans came home and really were mistreated by a lot of people. Unfortunately, that’s a risk factor for developing PTSD.  But there are other things too, like coping. Not necessarily using one particular coping skill, but rather having a variety of coping strategies that somebody can use flexibly, even something like humor. We see this as a resilience factor. Obviously, there are times when using humor can serve as a distraction or avoidance, and there are times when it can be really adaptive too. Obviously, of course, genetics that people may have a predisposition in general towards having mental health concerns. Sex, we know that people assigned female at birth have a higher likelihood of developing PTSD after trauma.  And then there are things that may be specific to the experience itself, so the type of trauma. Sexual assault is unfortunately a really big risk factor for developing PTSD, whereas there are other trauma types where fewer people go on to develop PTSD from those.  And then there’s something that we call peritraumatic fear, and that just means the fear that you were experiencing at the time that the event was happening. In the moment that the trauma was happening to me, how scared was I? How much did I feel like I might lose my life? People who experience more of that fear at the time of the event are more likely to go on and develop PTSD.  But it’s pretty interesting too, because, as with everything, there isn’t just this binary, like you either have it or you don’t have it. I want to normalize this too for anyone who might be listening and maybe has recently experienced something really horrible and is struggling with some of these symptoms that we talked about. It doesn’t necessarily mean that you have PTSD or that you’re going to continue to have PTSD.  Most people, about 50 to 65%, will experience mild to moderate post-traumatic stress symptoms after the event that will just gradually go away on their own. We call that a resilience trajectory. We also have about 10 to 15% of people who have what we call a recovery trajectory, where maybe right away they did have a spike in post-traumatic stress symptoms, right away in that first month or so. But after a year, again, it’s resolved itself.  And then we have two trajectories that go on to describe people who will have PTSD. That would be a chronic trajectory where somebody would have this elevation in symptoms after the trauma that persists. That’s usually about 15 to 20% of people. And then less likely is what we call a delayed trajectory. This is about only 5 to 10% of people who may have had really mild symptoms right away or perhaps no symptoms at all. And then, after about six to 12 months, it might just all of a sudden skyrocket for whatever reason. IT IS OCD OR AM I IN DENIAL?  Kimberley: Right. So interesting. I was actually wondering what you often hear about people who, especially as someone who treats OCD and anxiety disorders, often questioning whether there was a trauma they had forgotten. Like, did I repress or am I in denial of a trauma? What can you share statistically about that? Caitlin: Yeah, that’s a really great question. It’s definitely more of a controversial topic in the field, not because people don’t have the experience of having these recovered memories, but rather because of what we know about how memory works and how fragile it can be, that as clinicians, we have to be really careful that we’re not, in our efforts to help someone, inadvertently constructing a false memory.  I would say that most of the time, this delayed trajectory of PTSD symptoms is less so about the person not remembering the event, but more so like they just have continued on with their life and are probably suppressing, avoiding, and doing all sorts of things that are maybe keeping it at bay temporarily. And then there may be, in a lot of cases, some big life event that may bring it up, or perhaps another traumatic experience or something like that. WHAT IF I HAVE REPEATED TRAUMAS?  Kimberley: Yeah. I was going to ask that as well, as I was wondering. Let’s say you’ve been through a trauma. You recovered on that trajectory you talked about. Are you more likely to then go on to have PTSD if you repeat different events, or do we not have research to back that up? Caitlin: That’s a great question. I’m not sure specifically about, depending on which trajectory you were initially on, how that increases the likelihood later on. I can say that repeated exposure to trauma in general is associated with a greater likelihood of PTSD. I would say that, probably regardless of how quickly your symptoms onset, if at all initially, experiencing more and more trauma is going to increase the likelihood of PTSD. WHO CAN DIAGNOSE PTSD AND TRAUMA?  Kimberley: Right. Amazing. Thank you for sharing that. I know that was very in-depth, but I think it helps us to really understand the complexity and the way that it can play out.  Who can make these diagnoses? I know, as I mentioned to you before, even my daughter has said she found herself on some magazine website that was having her do some online tests to determine whether there was trauma. It seems to be everywhere, these online tests. Can you get diagnosed through an online test? Would you recommend that or not? Who can we trust to make these diagnoses? Caitlin: That’s a great question. I would not recommend using something like an online test or even a self-report questionnaire to help you figure out if you have PTSD. Now, it can give you a sense of the specific areas that I might be struggling with that I could then share with a licensed provider, who can then make the diagnosis. But if you were to just find a quiz online and take it, and it says you have PTSD, that would not be something that we would consider to be valid or reliable in any way.  I would recommend talking with a psychologist, a psychiatrist, any sort of general practitioner, an MD, or maybe even someone’s primary care physician. Definitely, if you can get in touch with a licensed provider who specializes in PTSD and can really be sure that that’s what’s going on for you.  Now, TikTok and all these things exist out there. As with anything on the internet, it can be used for good and it can also be very harmful. I think it just comes down to gathering information that may be helpful but then passing it on to someone who can sift through the misinformation and give you a clearer answer. Kimberley: Yeah. Thank you for that. I think, as someone myself who’s had their own mental journey, I do remember during different phases of my own recovery where our brains just don’t make sense. I had an eating disorder—a very bad eating disorder—and my brain just couldn’t see clearly in some areas, and me being so frustrated with that. I know lots of people with, let’s say, panic disorder feel the same way or health anxiety, their condition feels so confusing and makes no sense that in the moment of being grief-stricken by this and also very confused, it’s pretty easy to start wondering, “Could this have been a trauma or is this PTSD? This doesn’t make sense. Why am I having this mental health issue?” Especially if it’s not something that was genetically set up in your family. I’m wondering if you can speak to the listeners who may have dabbled in thinking maybe there is a trauma, a big T, a little T, or PTSD. Can you speak to how someone might navigate that? Caitlin: Most definitely. I’ll validate too that it’s really complex. We use the DSM to help us understand these different diagnoses, but there’s so much overlap. Panic disorder—obviously, panic attacks are the hallmark feature of panic disorder, but people can have panic attacks in PTSD as well. People with eating disorders might have issues with their self-image and their self-esteem. That can happen in PTSD as well, as I mentioned, even with mood disorders. There are symptoms in PTSD that sure look and sound a lot like depression.  If it feels confusing, “Well, wait a minute, I have this symptom. What does it belong to? What does it mean?” We do really have this very imperfect and overlapping classification system that we use. That being said, it’s a legit question to ask if somebody feels like, as you were saying, “I’ve been struggling with these symptoms, but it really feels like there’s something more here.”  When we diagnose PTSD, we go through all of the 20 symptoms, some of which I referenced earlier. For each symptom, we’ll ask about when that symptom started for the person relative to trauma and whether or not it’s related to trauma in some sort of way, if there’s some content there to work with.  For example, somebody maybe wasn’t having any issues with their mood whatsoever, and then they experienced trauma, and all of a sudden, it was just really hard for them to get out of bed. Well, that could potentially be a symptom of PTSD because it started after the trauma.  One thing that I hear a lot, because unfortunately, childhood trauma is really common, when I ask folks about this, they’ll say, “I don’t know. The trauma happened when I was so young that I don’t even remember who I was before this person that I am now, who’s really struggling.” In that case, people usually have a pretty good insight into this. Like, do you think that this is related in any way? Or maybe, if you have any recollection, you had a little bit of this experience and this symptom initially, and it got worse after the trauma. That, again, could potentially indicate that that’s a symptom of PTSD.  I would say for those folks who are listening, who are struggling with things like panic attacks, difficulty with eating, mood, whatever it might be, even OCD, which we talked about recently, really checking in with yourself about how and if those symptoms are related to your trauma. If they are, then find someone that you trust that you can talk to about it. Hopefully, a therapist who can help you piece this apart.  It could still be maybe the disorder you thought it was, maybe it is panic disorder, maybe it is OCD, maybe it is an eating disorder that’s still informed by trauma in some way or impacted in some way, which would be important to be able to process in treatment. Or it could just be PTSD entirely. And then that would be really important to know because that would significantly change what the treatment approach would be. Kimberley: Yeah. It’s so true of so many disorders. You could have social anxiety and panic attacks because of social anxiety, and a mental health professional will help you to determine what’s the primary, like, “Oh, you have social anxiety and social interactions are causing you to have panic,” and that can sort of help. I think as clinicians, we’re constantly ruling out disorders using our professional hat to do that. I think you’re right. Speak to a professional and have them do our assessment to help you pass that apart. Because I think in general, any mental health disorder will make you feel like something doesn’t feel right, and that’s the nature of any disorder.  Caitlin: Right. The good news, too, is that, within reason, some of the treatment techniques that we have can be used more broadly. Interoceptive exposures, we can use that for people who have panic disorder, just people who struggle with panic attacks, or maybe people who have OCD or GAD and just feel really sensitive to those sensations in their body that suggest that they might be anxious. Same thing with behavioral activation. We use that for depression, and that can really easily be added to any treatment, whether it’s treatment for PTSD or something else. You’re exactly right, getting clarity on what’s going on for folks, and then what are some of these techniques that might be most helpful for these symptoms? PTSD AND TRAUMA TREATMENT  Kimberley: Yeah. Thank you. You perfectly segue this into the next question, which is, can you describe the treatment or give us names of the treatment for this comparison of trauma versus PTSD? Are they the same treatments? Does it matter whether it’s a big T trauma or a little T trauma? Can you give us some idea of the treatments for these struggles? Caitlin: Definitely. Most of the evidence-based treatments that exist are specifically for PTSD. Obviously, they touch on trauma, of course, as the reason why somebody has PTSD and where all of these symptoms stem from. But there aren’t as many treatments that are, let’s say, specifically for trauma, at least not in terms of a standardized way of working through that. If somebody’s experienced trauma and they don’t have PTSD, and let’s say they don’t have any diagnoses, but they are still impacted by this experience, just doing behavioral therapy or whatever treatment feels like a good fit for what somebody is trying to work through might be sufficient. And then we have these evidence-based treatments that have been shown to really target PTSD symptoms and help reduce them. A few years back, I think it was 2017, the American Psychological Association reviewed all of the research on PTSD treatments. They reviewed it using lots of different criteria for what it means to feel better after treatment beyond just reducing PTSD symptoms, but also looking at other things too, like mood and suicidality and things like that. They essentially created this list of treatments that they rank orders in different tiers, depending on how effective they were shown to be.  In the top tier are four treatments. There’s cognitive behavioral therapy just broadly, cognitive therapy also broadly, and then the two specialized treatments are prolonged exposure (PE) and cognitive processing therapy or CPT. I can talk a little bit more about those two if you’d like.  In the second tier are things like acceptance and commitment therapy, EMDR—these treatments that people may have used themselves and have found really effective, and they are effective. They’re just maybe a little bit less effective for fewer people, if that makes any sense. It’s not to say that EMDR doesn’t work, but rather that there’s just more of an evidence base for things like PE and CPT. DIFFERENCE BETWEEN PTSD AND TRAUMA TREATMENTS  Kimberley: Great. To speak to those two top-tier treatments, can you compare and contrast them for someone just so that they feel they understand the difference? Caitlin: Yeah. If I had a whiteboard, I would just draw out the CBT triangle, but hopefully, folks listening know that in the CBT triangle, you have your emotions, your behaviors, and your thoughts, and all these things are constantly interacting with one another. We could say, just on a really simplified level, that when we are seeking treatment for PTSD, we want our emotions to be different. We want to feel less emotionally impacted by the trauma that we’ve experienced. PE and CPT are both under the umbrella of cognitive behavioral therapy, so they both use that triangle. They just get at it a different way. PE starts with the behaviors, knowing that the thoughts and emotions come along for the ride. CPT starts with the thoughts, knowing that the behaviors and the emotions come along for the ride.  Now, they’re both extremely effective at reducing PTSD symptoms. They’ve done head-to-head comparisons. They’re both great. You’re not going to find one that’s significantly better than another, but you might find one that feels like a better fit for what you’re currently struggling with.  Cognitive processing therapy, again, starting with the thoughts, cognitive processing, basically involves-- I almost think of this as looking at our thoughts and our beliefs about things and examining them from different lenses. I always picture plucking an apple from a tree. Like, okay, this is a belief that I developed from my trauma. This was really adaptive for me at the time because this belief told me that I can’t trust anyone and I have to always watch my back. Boy, did that help me when I was in combat and I was always watching my back and making sure I was safe. But as I look at it from these different angles, I might realize, well, I’m not in combat anymore, and I’m living in a pretty safe environment with safe people. So maybe this belief doesn’t really serve me anymore.  You work with your therapist to identify what we call stuck points, which are these really deep-seated beliefs that somebody has about themselves, other people, or the world that either developed from trauma or were reinforced by trauma, because sometimes people will say, “Well, I’ve never trusted people. I’ve always been in an environment where things weren’t safe.” And then there we go, the trauma happened, and it just proved me right. Cognitive processing therapy helps people work through these stuck points and come up with alternative perspectives on these thoughts.  Prolonged exposure is a lot more similar to what I imagine lots of the folks listening may have done with exposure therapy generally, or exposure and response prevention for OCD. Again, we’re starting with the behavior, knowing that if we target the behavior first, that’s going to change our cognitions, and it’s going to change our emotions.  PE involves two different types of exposure. The first one being in vivo exposure, which is really similar to just any sort of ERP exposure where you expose yourself to something in the environment that triggers a thought about the trauma or some sort of emotional reaction. You do those over and over again until they feel like no big deal to you, you feel really awesome about yourself, and you can conquer the world because you can.  And with your therapist, you do an imaginal exposure, which is where, in a really safe environment, you talk through the experience of your trauma and what happened to you. You do this actually in a unique way to really engage with that memory because, as we talked about, that internal avoidance is so common in people with PTSD. This imaginal exposure would be describing the experience in the present tense, painting a picture as though it was a film that was playing out right in front of our eyes, and really digging into the details of, what am I feeling in the moment that this trauma is happening? What am I hearing? What am I sensing? And doing that imaginal exposure, again, with your therapist in a really safe space until it doesn’t have an impact on you anymore.  I always say this to people when they start PE with me: I know that this may sound nuts right now. But a lot of people who do PE will get to a point where they’ll look at me and say, “I’m so bored telling this story again. I’ve told this story so many times. It doesn’t even bring up this emotional response for me anymore.” That feels really unlikely for people who are just starting out in treatment and are so impacted by this memory, and they do everything in their power to avoid it. But people can and very much do get to a place where they feel like they’ve conquered this memory and it doesn’t control them anymore.  That’s how PE and CPT work. Again, they both eventually target the same thing. It’s just sort of, which route do you go? COMPLIMENTARY PTSD TREATMENTS  Kimberley: Right. Amazing. Thank you. From my experience too, and actually, this is a question, not a statement—my experience, some people who I’m close with or clients who have been through PTSD treatment also then had to develop some coping skills, mindfulness skills, compassion skills, or maybe sometimes even DBT skills to get them across the finish line. Has that been your experience? What is your feedback from a more scientific perspective? Caitlin: Yeah, it really depends on the person. There are also combinations of these treatments. There’s a combined DBT and PE protocol out there for folks who do need a little bit more of those skills. Some people do feel like they would benefit from having some of these coping skills, maybe upfront or throughout the course of treatment. But they’ve also done research where they’ve started with that skill-building before they go into PE or CPT, compared to people who go right in. Actually, what they often find is that starting with skill building, sometimes it’s just colluding with avoidance, and it just lengthens the amount of time that somebody needs before they start to feel better.  I’m glad you asked this question because it’s so common for people with PTSD to feel like, “I can’t. I can’t do this thing. I can’t feel this thing. I can’t talk about this thing.” And they really can. Sometimes if we allow people to really challenge those “I can’t” beliefs, then they’ll realize, “I really thought that I was going to need all this extra support or I was going to need this or this, and I was able to just move right through this treatment.” Now, of course, again, that’s not the case for everyone. There are some folks who maybe have much more severe PTSD, maybe have some different comorbidities like personality disorders or something else where it might be helpful to involve some of that, or people who had really chronic exposure to, say, childhood trauma. But far and away, people are often much better able to jump right into some of these treatments than they think they are. HOW TO FIND A PTSD TRAUMA THERAPIST  Kimberley: Thank you for sharing that. I think that’s super helpful for us to feel hopeful at the end. One more question before you tell us about you and some of the amazing things that you’re doing. Where might people go? As we know, with OCD and health anxiety, we want a specialist to be helping us, ideally. I’ve noticed as a consumer that everybody and their Psychology Today platform says they treat trauma. I’m wondering how we might pass through that and find treatment providers who are skilled in this area. How might they find a trained professional? Caitlin: I’m glad you mentioned that about Psychology Today. That’s the advice that I give people when they’re using Psychology Today, or really any sort of platform. If this person is saying that they treat everything under the sun, then it’s probably not a person that you want to link up with for something really specialized because it’s-- what is the saying? “Jack of all trades, master of none.” And I start to get suspicious even that this person even does evidence-based treatment for trauma and PTSD when they’ve listed a thousand things. It’s definitely a red flag to consider for those who are listening and maybe have had this experience.  In terms of finding a therapist, if folks are interested in PE or CPT, there’s actually directories of therapists who’ve been trained and certified in those modalities. You can find them on-- I’m trying to think of the exact website. If you Google “Prolonged Exposure providers,” something will come up, I believe it’s through Penn. You can do the same for cognitive processing therapy. If you Google, I think it’s like “CPT provider roster,” you’ll get a whole list of providers as well. Now, just because somebody isn’t on there doesn’t mean that they haven’t been trained in these things. There’s just a certification process that some people go through, and then they can get added to this list. If your provider says, “I’m trained in PE, I’m trained in CPT,” I would probably trust that person that, for one thing, they even know what those things are, and I’d be willing to give them a shot. Also, and I know we mentioned this on the last episode too, for anyone listening who might have PTSD and OCD, I’ve compiled a list of providers on my website—providers who are trained to treat both OCD and PTSD. I have that broken down by state and then a couple of international providers as well. My website is www.cmpinciotti.com.  In terms of broad resources beyond finding a provider, there are lots of organizations that have put out some really great content about PTSD—videos, handouts, blogs, articles, all sorts of things. I think the biggest place that I send people is the National Center for PTSD. This is technically run through the Veterans Administration, but anyone can use these resources. They’re not only for veterans. It’s very, very helpful. I’d recommend people who want more information to go there.  You can also find things on the Anxiety and Depression Association of America, the National Institute of Mental Health, the National Alliance on Mental Illness, and so on. And then, of course, I mentioned the Trauma and PTSD in OCD Special Interest Group that I co-chair, that folks can sign up for that too, and we send out materials through there as well. Kimberley: Amazing. I am so grateful for you because I think we’ve covered so much in a way that feels pretty easily digestible, helps put things in perspective, and hopefully answers a lot of questions that people may be having but didn’t feel brave enough to ask. Where can people find out more about you? You’ve already listed your website. Is there any other thing you want to tell us about the work that you’re doing so that we can support you? Caitlin: On my website, in addition to the treatment provider directory, I also have some handouts and worksheets. Again, these are specific to co-occurring OCD and PTSD. That might be helpful for some folks. I also usually list on there different studies that are ongoing. I have two right now that are ongoing that I can-- oh, actually, I have three—I lied to you when I said two—that people can participate in if they’re interested. There’s one study that we’ll be wrapping up at the end of December. That’s about OCD and trauma. People can email [email protected] for more information. We also have a study that’s specific to LGBTQIA+ people with OCD that also covers some things related to trauma and minority stress in that study. If folks are interested in participating in that, they can email me at [email protected].  And the last one, and I’ll plug this one the most, that if folks are like, “Well, I want to participate in a study, but I don’t know which of those,” or “I only really have a few minutes of my time,” we have a really, really brief survey, and we’re trying to get a representation of folks with OCD from all over the country. For anyone who’s listening and who has OCD and is willing to participate, it’s a 10-minute survey. You can email me at [email protected]. All of these cover the topic of trauma and PTSD within them as well. Kimberley: Thank you. I’m so grateful for you. You’ve come on twice in one month, and I can’t thank you enough. I do value your time, but I so value as well your expertise in this area and your kindness in discussing some really difficult topics. Thank you. Caitlin: No, I appreciate it. Thanks for having me on. I hope that folks who are listening can feel a little bit more hopeful about what the future can hold for them. PTSD & TRAUMA LINKS AND RESOURCES  Find a PE provider: https://www.med.upenn.edu/ctsa/find_pe_therapist.html Find a CPT provider: https://cptforptsd.com/cpt-provider-roster/ For educational resources on PTSD: https://www.ptsd.va.gov/ To participate in a brief, 10-minute national survey on OCD: [email protected] To participate in the OCD/Trauma Overlap Study (closing at the end of December): [email protected] participate in a study for LGBTQIA+ people with OCD: [email protected]

Radical acceptance when things get hard can be a very difficult practice. In fact, it can be almost impossible. When things get hard, one of the things we often do is we spend a lot of time ruminating about why it’s so hard and what we could have done to prevent it from being so hard. And, instead of using radical acceptance, we often go into beating ourselves up, telling ourselves, “We should have done this; we could have done that. If only we had looked at it this way or treated it this way.” I want us to really zoom in on these safety behaviors that you’re probably doing. Hopefully, today, you leave here committing to reducing or eliminating those behaviors. Now, I get it. When things are hard, we don’t want to feel the suffering that goes with it. I get it. I don’t want to feel it either. You’re not alone. But when things are hard, often, instead of letting it be hard and feeling our feelings and being kind to ourselves so that we can move into effective behaviors, we get stuck resisting the emotions and doing these other behaviors that increase the shrapnel of the event. I call it ‘shrapnel’ because it does look like that. It creates more damage around us. Let’s look at how we might prevent this.  HUMANS SUFFER You’re suffering. The reason I know this is because you’re a human being, and all human beings have sufferings in their lives. Some of us, more than others. If you’re in a season where the suffering is high, I would basically say, the higher the level of suffering, the more you need to listen in. Maybe listen to this multiple times, get your notepad out, and let’s really go to work.  SOLVING DOESN’T ALWAYS WORK When you’re suffering and your suffering is high, again, it’s very normal to want to solve why you’re suffering, thinking that yes, that may prevent it from happening in the future, prevent us from having more pain, or prevent us from having to feel our feelings. That’s effective behavior, except... if you’re relying on that and you’re spending too much time doing that, chances are, you’re increasing your shrapnel. If that’s the case, let’s talk about other alternatives.  When we’re going through difficult things, there is a strong pull toward figuring out why. But my guess is, if you haven’t solved it yet, chances are you won’t. I know this is true for me. It might be true for you, but you’ve probably already identified the problem of one of the things that may be if, in 20/20 hindsight, you could have done differently. And that’s okay, right? There’s many times I’ve looked back and been like, “Yeah, it didn’t handle that well,” or “That didn’t go as well. Maybe now, knowing what I know, I could have done something different.” But often, we spend too much time resisting the fact that it is hard right now.  If you’re someone who’s spending a lot of time going over and over on repetition, all the things you could have done, chances are, you’re not radically accepting what is. What we want to do first is move to radical acceptance as fast as we can. We’re not saying that you can’t go back and do some effective addressing of what went wrong and what went right. You can do that for short periods of time. But if you’re someone who’s doing it repetitively, catch yourself. We want to move into radical acceptance that yes, things are hard right now. WHY DOES RADICAL ACCEPTANCE SUCK? Often, we resist practicing radical acceptance because of one core reason, and that’s because we don’t want to feel bad. We don’t want to feel the guilt. We don’t want to feel shame. We don’t want to feel the uncertainty. We don’t want to feel sad. We don’t want to feel angry, grief, or panic, whatever it might be. It might be physical pain. We don’t want to feel it. And so hand in hand goes this work of radically accepting the suffering that you’re experiencing in whatever form, whether it be emotional, physical, spiritual, or other, and then really being willing and creating a safe place to feel those feelings. I’m not saying ruminate on those feelings, make them worse, or agree with everything you’re thinking and feeling. No. I’m just saying, being able to observe that yes, sadness is here, or grief is here, or anxiety is here. It’s showing up in these ways in my chest, in my head, in my shoulders, in my neck, in my hips, in my tummy, wherever it’s showing up for you. First radically accepting it and then being willing to feel those experiences and those sensations. We alternate between those two. We radically accept, then be willing and open. Then we have to go back and radically accept, be willing, and be open. RADICAL ACCEPTANCE IS REPETITIVE I want to remind you that it’s okay that you have to do this on repeat. Often, with my patients—and I do this too, I have to admit—we practice radical acceptance, we practice self-compassion, we practice willingness for a little while, and then we get frustrated because it’s not making it go away. It’s not fixing it. It’s not making it disappear. So we go back to trying to solve, “Why is this happening? Why shouldn’t it be this way? What did I do wrong?” instead of knowing that this is a repetitive practice that we commit to over and over again. It’s like brushing our teeth. We don’t do it once and go, “Great, it should be done.” No, we go back, and we’ve accepted that we’ll do it every morning and we’ll do it every night. For some of you, at lunchtime too. I really want you guys to catch this deep urge and urgency to resist what really is and resist the feelings that go ahead and accompany that experience. We want to move back as fast as we can into radically accepting that it is what it is.  RESISTING RADICAL ACCEPTANCE Now, if you’re anything like me, a part of your brain is going to go, “But it’s not fair. This is not fair. It is too much. Other people don’t seem to be having these problems. It’s not fair that I have this problem. It’s not fair that mine is so big right now and theirs is not.” I get that too.  Also just acknowledge, you may even want to just validate and go, “Yeah, this is my season. They’ll have theirs.” I promise you, they’ll have theirs. Hopefully not. We don’t want to spread more pain around. But with being a human, it’s 50/50. It’s 50% hard and 50% wonderful, and that’s a part of being human. They’ll have their season; you’re in yours. It is temporary.  Again, resist the urge to stay in the rumination of “It’s not fair.” You can validate that by going, “Yes, it is not fair. This is a hard deck of cards that I’ve been dealt right now. I’m going to again try to reduce the shrapnel by not engaging in the why me and why did this happen and it shouldn’t have, and it’s not fair.”  I want to also say it’s okay that you land there. That is a normal part of the grief process to land in that bargaining phase of grief. What we’re really speaking to today is when you get caught in that.  I NEED RADICAL ACCEPTANCE TOO Now, I am speaking to you about this because I needed to hear this message more than any of you today. This is actually as much for me as it is for you. I think that as I go through very difficult seasons in my life, I find them incredibly humbling because it helps me to see the story that I have told myself, the story that things should go well for me, that things shouldn’t be hard, that I shouldn’t suffer as much as I do in certain areas, that I should somehow magically be able to solve this or control this, and that other people want me to be able to handle this, so therefore, I should be able to.  I forget my humanness. I keep getting humbled by my humanness. I feel like the world keeps coming to show me, “Kimberley, you’re just like everybody else.” Everybody suffers. How can you lean in and have this be an opportunity to deepen your self-compassion practice, deepen your mindfulness practice, and deepen your ability to feel any emotion that shows up? Because they will, many times in my lifetime. They will continue to show up in different ways because I’m a human, not because I’m a faulty person. All humans have these feelings.  For you, you also have to remember, these are normal human feelings. You didn’t do anything wrong. It’s not your fault that you’re having them so strong right now. Resist the urge to go into self-punishment for the fact that you’re suffering.  Again, radically accept that it is painful right now, and then move into willingness and openness to feel those feelings and create the safest, softest, gentlest landing for you as you navigate these really difficult emotions. As you do it, not to replace it, not to make them go away, but to help guide you through them.  YOU CANNOT BYPASS EMOTIONS You can’t bypass emotions. I have learned that one the hard way. You can’t bypass them. If you do, you’re probably increasing your problems. If you’re doing compulsions to get your uncertainty and your anxiety to go away, you’re going to have more of that obsession. If you’re avoiding the thing that’s hard, you’re probably going to feel disempowered, and it’s going to be a bigger problem. If you’re resisting your emotions and you’re resisting your experience, at some point, they will probably blow up and explode, and you’ll feel them a lot.  Our job, again—and this is my goal for myself, and I hope it’s your goal too—is I want to be a place, a container. I want to be able to experience the full range of emotional experiences safely so that in the future, when hard days come, when I lose loved ones, when I go through hard times, when I witness difficult things, I already know that I have the ability to wade through this.  WHEN YOU FEEL LIKE YOU CANNOT HANDLE IT ANYMORE  The people who are struggling with “I can’t handle this,” they’re the ones who have done everything they can to avoid feeling their feelings, and they haven’t gotten much experience with learning to master emotions. When we do learn that we can have emotions and we do learn that we can tolerate them, then we do learn that we can ride them out. There’s a sense of empowerment, like, “I can do really, really hard things.” As I’m navigating a tough season, I’m actually blown away and in awe of myself, knowing that I can handle a lot. I’ve handled a lot in other difficult seasons in my life, and I come out of it usually being like, “Wow.” Actually pretty impressed. I feel that way, especially when I stay out of that sort of rumination. I call it the inner tantrum. I have a tantrum like, “It’s not fair, and it shouldn’t be.”  RADICAL ACCEPTANCE SUMMARY I wanted to make this a very quick episode. Hopefully, it’s exactly what you needed to hear.  Number one, if you’re in a difficult season, that doesn’t mean there’s anything wrong with you. That’s just a human thing.  Number two, if you’re in a difficult season, let’s back off from trying to solve what you could have done better because, coulda, woulda, shoulda, it’s all 20/20 hindsight. You had no idea. Let’s just leave that alone. Be very aware of that and work towards catching it and moving towards radical acceptance, willingness, and self-compassion.  If you’re somebody who really needs to improve your self-compassion, we have a whole mindfulness vault called The Meditation Vault. You can go to CBTSchool.com, and it will guide you through self-compassion practices that were led by me. It’s all audio. It’s all there. I’ll teach you how to do it, and that hopefully will help you have my voice in your head so that you can start to practice self-compassion no matter what shows up for you, no matter what emotion you’re experiencing, no matter what hardship you’re experiencing.  I hope that’s helpful. Have a wonderful day. I’m sending you all the love, and I will talk to you next week.

Kimberley: Is ERP traumatizing? This is a question I have been seeing on social media or coming up in different groups in the OCD and OCD-related disorders field. Today, I have Amy Mariaskin, PhD, here to talk with us about this idea of “Is ERP traumatizing” and how we might work with this very delicate but yet so important topic. Thank you, Amy, for being here. WHY MIGHT PEOPLE THINK ERP IS TRAUMATIC?  Kimberley: Let’s just go straight to it. Why might people be saying that ERP is traumatic or traumatizing? In any of those kinds of terms, why do you think people might be saying this? Amy: I think there’s a number of reasons. One of which is that a therapy like ERP, which necessitates that people work through discomfort by moving through it and not moving around it or sidestepping it, is different than a lot of other therapies which are based more on support, validation, et cetera, as the sole method. It’s not to say that ERP doesn’t have that. I think all good therapy has support and validation. However, I think that’s part of it. The fact that’s baked into the treatment, you’re looking at facing discomfort and really changing your relationship with discomfort. I think when people hear about that, that’s one reason that it comes up. And then another reason, I think, is that there are people who have had really negative experiences with ERP. I think that while that could be true in a number of different therapeutic modalities and with a number of different clinicians and so forth, it is something that has gained traction because it dovetails with this idea of, well, if people are being asked to do difficult things, then isn’t that actually going to deepen their pain or worsen their condition rather than alleviate it? That’s my take. Kimberley: When I first heard this idea or this experience, my first response was actual shock because, as an ERP therapist and someone who treats OCD, I have seen it be the biggest gift to so many people. I’ve heard even Chris Trondsen, who often will say that this gave him his life back, or—he’s been on the show—Ethan Smith, or anyone really who’s been on the show talk about how it’s the most, in their opinion, like the most effective way to get your life back and get back to life and live your life and face fear and all of those things.  DO PEOPLE FEEL ERP IS A DIFFICULT TREATMENT? I had that first feeling of surprise and shock, but also then asked more questions and asked about their experience of ERP being very pressured or feeling too scared or too soon, too much too soon, and so forth. Do you have any other ideas as to why people might be experiencing this difficult treatment? Amy: I do. I think that sometimes, like any other therapy, if you’re approaching therapy as a technician and not as a clinician, and you’re not as a therapist really being aware of the cues that you’re getting from the very brave people sitting in front of you, entrusting their care to you—if we’re not being clinicians rather than technicians, we can sometimes just follow a protocol indiscriminately and without respect to really important interpersonal dynamics like consent and context, personal history, if there’s not an awareness of the power dynamic in the room that a therapist has a lot of power.  We work with a lot of people as well who might have people pleasing that if you’re going to be quite prescriptive about a certain treatment, you do this, and then you do this, and then you do this without taking care to either lay the foundation to really help somebody understand the science of how ERP works or get buy-in from the front end. I know we’ll talk a little bit more about that, as well as there’s a difference between exposure and flooding. There’s a difference between exposure that serves to reconnect people with the parts of their lives that they’ve been missing, or, as I always call it, reclaims. We want to have exposures that are reclaims, as opposed to just having exposures that generate negative emotion in and of itself.  Now, sometimes there are exposures that just generate negative emotions, because sometimes that’s the thing to practice. There are some people who feel quite empowered by these over-the-top exposures that are above and beyond what you would do to really have a reclaim. I’m going to go above and beyond for an exposure, and I’m going to do something that is off the wall. I am eating the thing off of the toilet, or I have intrusive thoughts about harming myself, and I’m going to go to the top of the parking garage, and I’m really going to lean all the way over. Would I do that in my everyday life? No. There are some clients for whom that is not something that they’re willing to do or it’s not something that’s important for them to do to reconnect with the life that they want to live, and there are others who are quite empowered.  If you’re a therapist and you don’t take care to listen to the feedback from clients and let their voice be a part of that conversation, then you may end up, again, as a technician, prescribing things that aren’t going to land right, and that could result in some harm. My heart goes out to anyone who’s had that experience, because I think that’s valid. Kimberley: I will be completely honest. I think that my early training as an ERP therapy clinician, because I was new, meant that I was showing up as a technician. When I heard this, again, I said my first thought was a little bit of shock, but then went, “Oh, no, that does make sense.” When I was an intern, I was following protocols and I was learning. We all, as humans, make mistakes. Not mistakes so much as if I feel like I did anything wrong, but maybe went too fast with a patient or pushed too hard with a patient or gave an exposure because another person in supervision was saying that that worked for their client, but I was learning this skill of being attuned to my client, and that was a learning process. I can understand that some people may have had that experience, even me. I’m happy to admit to that early in my training, many years ago. Amy: That’s a great point. I think if we’re all being honest with ourselves, whether it be within the context of ERP or otherwise, there is a learning curve for therapists as well. I think going back to the basic skills and tenets of what it means to have a positive therapeutic relationship is that so much of that has to do with the repair as well. If there are times, because there will be times when you misjudge something or a client says, “I really think that I’m ready to try this,” then we say things like when exposures go awry, when the worst-case scenario happens, or what have you.  That’s another philosophical question because I think in doing exposures, we’re not necessarily, at least my style, saying the bad thing’s not going to happen. It’s about accepting the risk and uncertainty, which is a reasonable amount. However, I think when those things happen where it does feel like, “Hey, this felt like too much too soon,” or this felt like, “Wow, I wasn’t ready for this,” or “I don’t feel like that’s exactly what I consented to. You said we were going to do this, and then you took an extra step”—I think being able to create an environment where you can have those conversations with clients and they feel comfortable bringing it up with you and you can do repair work is also important. That it’s not just black or white like, “This happened and I feel traumatized.” Again, I don’t want to sound like I’m blaming anybody who’s had that experience, but I’m just saying that I think that happens on a micro level, probably to all of us at some point.  I think it’s also important to acknowledge, and later we’re going to talk about it, but the notion of the word ‘traumatizing’ is a little bit difficult for me to hear as well because I think from the perspective of an evidence-based practitioner, the treatments that we have, even for so-called big T trauma, many of them integrate in exposure. All of my first-line treatments, including ones that maybe come at it a little bit more obliquely like EMDR or something like that, which is not something that I personally use, are certainly out there as like a second-line trauma treatment. But things like prolonged exposure and cognitive processing therapy, they all have this exposure component to them. Even the notion that if there’s trauma, you can’t go there or that talking about hard things is traumatizing. I don’t know. Can we talk a little bit about that? Because I don’t know if that’s something you’ve thought about too, that it’s hard to reconcile. Kimberley: Yeah. Let me give a personal experience as somebody who had a pretty severe eating disorder. I was doing exposure therapy, but I didn’t get called that, and I didn’t know what to be that at the time. But I had to go and eat the thing that I was terrified to eat. While some people might think, “Well, that’s not a hard exposure,” for me, it was a 10 out of 10. I wanted to punch my therapist in the face at the idea that she would suggest that I eat these things. I’m not saying this is true for other people; I’m just giving a personal experience. I’m actually really glad that she held me to these things because now I can have full freedom over the things that used to run my life. I know that there is nothing on any menu I can’t eat. If I had to eat on any plane, whatever they served me, I knew I was able to nourish my body with what was served to me, which I didn’t have before I did that.  The other piece is somebody who has also been through trauma therapy. A lot of it required me to go back and relive that event over and over. Even though I again wanted to run away and it felt like my brain was on fire, that too was very helpful. But what was really helpful was how I reframed that event. If I was doing it and, as I was doing it, I was saying, “This is re-traumatizing me,” it was a very bad experience. But if I was saying, “This is an opportunity for me to learn how to have our full range of emotions, even the darker stuff,” that ended up being a very important therapeutic experience for me. That’s just my personal experience. Do you want to speak to that? Amy: Yeah. I wasn’t planning on speaking to this part of it, but I will say as well that having had a traumatic event—a single event, big T trauma—that happened at my place of employment years ago. This is over 10 years ago now, which involved being held at gunpoint, which involved a hostage-type situation. It’s interesting when you talk about trauma, that you want to tell the whole story, but I’m like, “Oh, we don’t have enough time,” which is interesting because our brains first don’t want to tell the stories or we want to bury them. But suffice to say that after this very painful, very terrifying experience, after which all the hallmark symptoms of hypervigilance and quick to startle and images in my head and avoidance of individuals who looked like this particular individual and what have you. The most powerful thing for me in knowing this as somebody who works in exposure protocols, going back to work and being so kind to myself as I was, again, I come back to this word reclaim. It doesn’t happen overnight. It’s not something I wish there were. I do wish there’s, “Oh yeah, we just push this button in our brains, and then that’s just where we feel resilient again.”  But the process of building resilience for me was confronting this environment, reclaiming this environment. I think any exposure protocol has the ability to have that same effect if the framing is there and if it resonates with the person. Being somebody who’s such a believer in exposure therapy for my clients, I was able to step into a role where I came out of that situation feeling so empowered and the ability to hold all of my experience gently and with compassion, as opposed to sweeping it under the rug and then having it come out sideways. Kimberley: I really appreciate you bringing that up because, similarly, I stowed mine down for many years because I refused to look at it until I was forced by another event to have to look at it. I think that’s a piece of this work too. You have to want to face it as part of treatment. In my case, I either avoid the things that are so important to me or I am going to have to face this; I am going to have to. I showed up and made that choice. I think that’s also a piece of it, knowing that that’s an opportunity for you to go and be kind and to train your brain in different ways.  HOW TO MAKE ERP ETHICAL AND RESPECTFUL We’re speaking directly now about some ideas and solutions to making ERP ethical and respectful. Are there other ways that someone who’s undergoing ERP, considering ERP, or has been through it—other things we might want to encourage them to do moving forward that might make this a more empowering and validating experience for them? Amy: That’s a great question because I think we can talk about it both from the perspective of clients who are looking for a new therapist as well as what therapists can do. But if we start first with clients and maybe you’re out there, and it’s been something you’ve either been hesitant to engage with because of some of these ideas about it being harmful or you’ve had a negative experience in the past, I do think that there is a mindset shift into feeling really empowered and really willing.  The empowerment part is coming in and bringing in-- your fears about ERP are also fears that can be worked on. If you’re white-knuckling from the first moment of like, “Okay, I’m in here, I know I’m supposed to do this. I already hate it and it hasn’t started,” sharing that with a clinician. I know I’m used to hearing that. I’m very used to hearing that. I’ve had folks come in who have been in supportive therapy, talk therapy, or other modalities that haven’t been effective for many, many years. There is a part of me-- I’m sorry, this is a tangent, but it’s a little soapboxy tangent. I feel like when I think about my clients who’ve had therapy for sometimes 10, 20 years and it hasn’t been effective, I don’t think we talk enough about how harmful that is for people, like putting your life on hold for 10 or 20 years. I don’t hear the word necessarily ‘traumatizing,’ but that can be harmful as well. People will go through that.  BE OPEN WITH YOUR ERP THERAPIST After these contortions to maybe even avoid ERP because it’s scary, they’ll come in, and I welcome them, saying, “I’m really nervous about this,” because guess what? Saying that aloud is a step in the direction of exposure. You’re owning it. And then having a therapist who can say, “I’m so proud of you for being here.” This is exposure number one. Sitting down on this couch, here we are. Well done, check and check. Because I think that a therapist who’s looking at exposure, not just as what’s on a strict hierarchy, or even from an inhibitory learning perspective, like a menu—exposure is what you’re doing day to day to help yourself get closer to the life that you want and the values you have. When you said, “I can eat anything because I want to nourish my body,” that’s a value. When I say ‘empowerment,’ like empowerment to discuss that with your therapist. And then that shift into willingness versus motivation or comfort or like, “Oh, I want to wait till the right moment,” or “Things are tough now. I don’t want to add an extra tough thing.” I know you’re not here to tell anybody, “Well, this is the way you should think.” But if there’s any room to cultivate even a nugget of willingness to say, “I can do something difficult, and I am willing to do difficult things on the path toward the life that I want,” those would be two things that come to mind right away. Kimberley: Yeah, I agree. It takes me to the second piece for a client. I think a huge piece of it is transparency with your therapist or clinician. There have been several times where we’ve discussed an exposure—again, this was more in my earlier days—agreed that that would be helpful for them, gone to do it, and then midway through it, them saying, “I felt like I had to please you, but I’m so not ready for this,” or “I was too embarrassed because this is such a simple daily task and I should be able to do it.” I think it’s okay to really speak to your therapist and share like, “I don’t know how I feel about this. Can we first just talk about if I’m ready?” We don’t want to do that to the degree of it becoming compulsive, but I want to really encourage people who are undergoing treatment of any kind to be as completely honest as you can. Amy: Right. I think that, again, it’s an interesting dynamic because people are coming to specialists because we do have the knowledge and awareness of protocols and so forth. But again, I think mental health is-- well, I wish all medical health folks were a little bit more open to these kinds of conversations too. But that being said, I think having that honesty and knowing that-- if you go in and you say, “Oh, I’m a little bit nervous,” and you’re getting pushback of, “Well, I’m the doc, this is what you do. Here’s step one, here’s step two,” frankly, there are going to be therapists who are like that regardless of modality.  It was interesting because I was talking to somebody about this and about—I think if we frame it as a question—"Is ERP inherently harmful” is a really different question than “Can ERP be harmful?” I think any modality implemented without that clinical touch can be potentially harmful.  I know your motto is, “You can do hard things.” That kind of shift as well is so powerful at the beginning of ERP. You’ve been transparent. You’ve said, “Look, here are my fears about this.”  And then often, what I will do as a clinician if people don’t get to that place of like, I” can do things through the discomfort, there’s no going around it,” is ask them about things. If they’re adults, it could even be like, “When you were a little kid, did you have any fears, and how did you get over those? What was that like?” Not always, of course, but 9 nine times out of 10, it is some kind of like, “Well, I did the thing.” Or sometimes it’s more complicated, “Well, I did the thing and then I got support from others, and then I learned more.” But I think people have this innate capacity to learn by changing behavior and to do things that are outside of their comfort zone, and that doesn’t have to mean way outside of their comfort zone. Often, that notion of these hard experiences or these difficult thoughts that you need to-- people will come in and feel like, “Well, I need not to be thinking about them.” That’s not really an option. Being a human with a full life, there are going to be things that are provocative. But I think I’ve heard you talk about this notion of shifting from wanting protection from negative thoughts or discomfort to almost willingness and acceptance. I love that as well. Kimberley: I agree. I want to also maybe back up a little bit and speak to that just a little bit. I do hear the majority of people saying this, coming from those who are seeking treatment from unspecialized people. Even this morning, people are emailing me saying, “I’m following this OCD coach online, and they’re saying, ‘Follow my six-month program and you will be OCD-free.’” That sounds good. I’ll do whatever you say if that’s what I can give you. There is a power dynamic.  But then you’re in the program and being told that you have literally two months to go and you better double down or you will fail my program. I think that urgency to get better can cause you to sometimes agree to things or seek out treatment from people who aren’t super trained and who aren’t taking an approach of, “Let’s practice being uncomfortable, let’s practice having every single emotion kindly and compassionately so that there is no emotion you can’t ever have in your lifetime through the darkest ages.” They’re more coming from a, “I’m on a timeline here and I have to get this done, so I’m going to do these things that are absolutely terrifying.” I think a lot of people are speaking to this. Amy: I think that’s right. A lot of times, people have been-- I think we, as a field, like mental health professionals, there’s this delicate balance of wanting to instill hope and really talk about like this works and to not overpromise or not simplify the circuitous way that we get there together as a therapist and client, because there are a lot of sound bites out there. I know you and I have talked about this. It’s like these “better in 12 weeks” or “better in with these five tips” or what have you. I think even looking at research, and I have a strong research background, I was training to be a researcher when I was in grad school. I think it’s important as well to remember that even with research, we are looking at-- if we say like, “Hey, this is a 12-week protocol that’s been effective.” Okay, what does effective mean? Does effective mean that you get to pick up your baby again? Or does it mean, oh no, it probably means an X amount reduction in the Y box? Does effective mean it was that amount of reduction for everyone? Well, no, it’s averages and things like that.  I can wear both hats and say, this is an incredibly empirically validated treatment that works for many people. It’s not going to work the same way for every person, so why would we as clinicians go in and be like, “Here’s a timeline?” You can’t do that. Kimberley: Yeah. Let’s speak to the therapist now. What can therapists be doing to make this a more effective, compassionate, and respectful practice? Do you have anything that you want to speak to first? Amy: Yes. I think that if we start at the beginning of therapy itself and the steps that you go through, the very first step is assessment because exposure is something that we know is very effective for anxiety, to a lesser degree, disgust, and not quite right feelings as well, and some sensory issues, to a lesser extent. But exposure is effective for certain things. We want to make sure that those are the things that are occurring. So, making sure because somebody can have OCD, or can have anxiety, or something like that and also have other things going on. I think sometimes when exposure is treated-- exposure and response prevention. I know we talk a lot about exposure, but even response prevention, that side of things, it’s just this one size fits all. Okay, something you don’t like doing, we’re going to expose you to it, and something that alleviates your distress, we’re going to eliminate those. If you’re doing that outside of the context of where it’s clinically indicated for OCD, i.e., areas that provoke obsessions and compulsive behaviors, then you’re really missing the target.  I know there’s been a lot of discussion about neurodiversity and for autistic people who may have routines and things like that or may have stereotypies or stimming behaviors, things that are pleasant for them or self-regulatory to really get a good assessment in there. Again, you’re not having people do exposures or engage in response prevention in places where it’s not clinically indicated. I think even if somebody has a trauma history, for something like PTSD, exposure is often, as I mentioned, a part of treatment protocols. The way in which we are doing those kinds of exposures and really centering the sense of agency in the client who’s had that sense of agency taken away by prior experiences is really important. I think assessment is the first thing that comes to mind, followed-- Kimberley: I would add-- sorry, I didn’t mean to cut you off, but I would add even assessment for depression. A lot of what we teach in ERP school for therapists and what I teach my staff is, if a client has depression, I might do more exposures around uncertainty and not around their worst-case scenario happening because sometimes that can make the depression come in so strong that they can’t get out of bed the next day. We can tailor exposure even to make depression, and so forth.  I think it is so important that we do get that assessment and really understand the big picture before we proceed. Even understanding other anxiety disorders, health anxiety, the history of trauma with health, and so forth, or even the things you were taught as a child, can be really important to understand before we proceed with exposure. Amy: I love that you added that in—the things that we were taught as a child—because I love this story. I mean, I love it and hate it, and you’ll understand why in a moment. But when I was on my internship—this was back in 2008, 2009—there was a fellow intern. He and I were co-presenting on a case, and we had the other interns. They were asking questions, and this was a makeshift IOP case. We were both doing a little bit of individual therapy, and people in the audience were asking questions, and somebody asked about childhood. This was an adult. The other intern said, “We don’t care about that stuff.” I said, “Time out, I care about it,” and we all laughed.  I get where he was coming from in the sense that he was like, “Hey, here are the symptoms, here’s the protocol for the symptoms, and it is important.” Like you said, I mean, even from a CBT, this is very consistent with CBT and how we form core beliefs and schemas and our ideas about the world and fairness and justice, and all of that is a part of it. We don’t want to lose the C part, the cognitive part as well in ERP. But I love that you said that about depression as well, because even something co-occurring can just nudge. It just nudges the way that we do exposure and so forth. Kimberley: Yeah. I think culturally too. Think about the different traditions that come with different cultures or religions. Sometimes some of their rituals can seem compulsive. If I didn’t know that that’s why they’re doing these, I could easily, as an untrained or ineffective therapist, be like, “Just expose yourself.” We’ve got to break this ritual, without actually understanding, like, is this actually a value-based ritual that you’re doing because of a religion or a culture or tradition that is in line with your values? I think that’s very, very important. After assessment, what would you say the next steps are? Amy: I think that-- and this is the part where I’m really going to own that. I get really excited, and I just want to jump into treatment. This is me, I’m calling myself out. But I think psychoeducation, that not only very clearly lays out the evidence and the why, like here’s the process, here’s why we’re asking you to do these things that are really difficult, here are the underlying patterns, and here’s what we’re looking out for, and so forth.  I think not only that, but also laying out very clearly what the expectations are. “This is how this is going to look,” and maybe at that point as well, clinicians saying—this is very collaborative—"I am here to provide this information, and then together we are going to formulate a treatment plan and formulate these exposures.” I have heard so many people who do a lot of ERPs say how proud they are by the end of therapy when clients come in and they say, “I was thinking I need to do this as my exposure.” They’re really taking that ownership.  I think not only again talking about the science and all the charts and things like that, but really talking about this as a collaborative, consensual process, that it’s like, “I’m handing this off to you, and this is going to be something you have for the rest of your life.” Kimberley: Yeah. I’ll tell a similar story. I had a patient who-- I’ll even be honest, I don’t think this was in my internship. This was in my career as an OCD therapist. But my client was just doing the exposures that he and I had agreed to. He would come back and be very frustrated with this process until he came to me and said, “I need you to actually stop and explain to me why I’m doing this.” I thought I had done a thorough job of that. I truly, really, honestly did. But he needed me to slow down and explain. We got out the PET scans of the brain, and I had a model of the brain. I showed him what part of the brain was being triggered and where the different parts of why-- from that moment, he was like, “I got you. I know what we’re doing. I’m on board now. I got this.”  I think that I was so grateful that he was like, “Hold up, you need to actually slow down and help me to understand because this still doesn’t make sense to me.” This was a very important conversation. In my case, I think it’s checking in and saying, “Do you understand why we’re doing this? Do you understand the science of this?” I think it’s so important. What else might a therapist do? Amy: I love that. I was just going to say, I love that you create that culture because that’s what I was talking about earlier. Sometimes we don’t quite get it right. And then it’s like, “What can I do better?” It’s such a powerful question.  Knowing the why of ERP and then also the why, like, why is it worth it for you? Why is this? ACT has these wonderful metaphors about it. We’ve heard the monsters on the bus analogy. You’re driving the bus, and all your symptoms are the passengers yelling out or different fears you might have. But so often we don’t talk about, where are you driving the bus toward? Where are you going?  I get misty when I think about this. I get almost a little teary because I think that people with OCD have such incredible imaginations, and yet, having OCD can make it so hard to dream and dream about what you truly want. Especially if it’s quite entrenched, it can just feel like, “Well, that’s a life that other people have. I don’t get to have that.” On the one hand, there’s this expansive imagination about illnesses, danger, harming others, or what have you. These things that are just dystonic—you don’t want to be thinking about them.  I love to see people exercise that other part of their imagination and really encourage them to dream because if you have that roadmap, or rather that end destination of what you want your life to be, those very concrete moments that you want-- for some people, it’s like, “I want to have a family,” or “I want to travel,” or “I want to have the freedom to be around whomever I want to be around, regardless of the thoughts that come up,” whatever it is. Sometimes it can feel scary to even dream and envision that, either through values work or if it’s somebody who had a later onset thinking about where were you heading before. How did this derail you? What were you heading toward? I think that’s really important as well. If we don’t do that-- I mean, frankly, I wouldn’t want to do anything if I didn’t know my why. Kimberley: No, agreed. I think that another thing—I often talk about this with my therapists in supervision—is one thing that I personally do-- and this is just me personally. Every therapist has their own way of doing it, but I often will ask my patients, “What kind of Kimberley do you need today?” I have the question as an opening where they can be like, “No, we’re good. Let’s just get to work.” We knew what we were going to do and so forth. My patients now know to say, “I need you to actually push me a little today.” They’re coming to me saying, “I want you to push you.” Or they’ll say, “I’m feeling very vulnerable today. I’m on my period,” or “It’s been a hard week,” or “I haven’t slept.” I don’t consider that me accommodating them. I consider that me being attuned to them. It might be that I might go, “Okay, but there’s been several weeks in a row that you’ve said that. Can we have a conversation?” It’s not that I’m going to absolutely let them off with avoidant compulsions, but I love offering them the opportunity to ask, what kind of Kimberley do you need? Sometimes they’ll say, “I need you to push me today, but I also need you to really encourage me because I have run out of motivation and I don’t have a lot.”  I think that as clinicians, the more we can offer an opening of, what is it that you’re ready for? What do you want to expose yourself today? Is there something coming up that you really need to be working on? I think those conversations create this collaborative experience instead of like, “I’m the master of treatment, and you’re my follower” kind of model. Amy: Right. I love that, and I love the idea that we can be motivational, encouraging, and celebratory in the face of exposure. Like exposures, I do feel like there has been a shift, and perhaps with the shift away from the strict habituation paradigm in the field, where it’s not like you have to just do the thing and be scared, be scared, be scared, be scared, be scared, and then it goes down. You can explore, “Hey, are you feeling stronger now? Are you feeling like I’m nervous, but I’m also curious?”  Again, some of this is just personal style, but I use a lot of humor. There are often a lot of inside jokes with clients and things like that. I don’t see that as incompatible with really good exposure work because you’re learning that you can be scared and laughing. You’re learning that you can feel discomfort and empowerment. These kinds of things are huge. But again, I think when I was newer to ERP, there was a little bit of like, “Nope, we’re not cracking a joke, because that would be avoiding negative emotion.” Kimberley: Yes. I remember that. Or being like, “I hope I don’t trigger them. I’m not going to [unintelligible].” The joke is what created an attunement and a collaboration between the two of us, which I think can be so beautiful. Another question I ask during exposure is, would you like to keep going? Would you like to make it a little harder? How could we? Even if we don’t, how might we? No pressure, but how might we make it so that they’re practicing this idea of being curious about making decisions on their own? Because the truth is, I’m only seeing you for 50 minutes a week. You have to then go and do this on your own. We want the clients, us as therapists, to model to them a curiosity of like, “Oh, it’s here.” Am I going to tell myself this is terrible and I can’t handle it? Or am I going to be curious about what else I could introduce? Would I like to send them a text to a loved one while I do this exposure? How would I like to show up? What values do I want to show up with? Those questions can take the terror out of it. Amy: Yes. I think that all of this is hitting on something. I’ve noticed that oftentimes this notion of ERP is traumatizing. Again, not to discount anybody’s personal experiences with it if that has been negative, but it’s often based on this caricature of ERP that all those things that we’re saying don’t need to have that element of consent. It needs to have that collaborative nature, really good assessment, really good psycho-ed. I think that’s something I just realized because I don’t like feeling defensive about things. If I feel defensive, I’m like, “Uh-oh, this is a me thing.” I think in this case, it’s because I’m seeing a lot of misinformation about ERP, or perhaps just poorly applied ERP. Kimberley: Yeah, for sure. I want to be respectful of time. We could make this into a whole training easily, but let’s end here on the healing because we’ve talked about everything today—ideas, concepts, mindsets, conceptualizations. But I also want to really make sure we are slowing down and creating a safe place where some people may actually, like you said, have had not great experiences. What might we do, and what might patients do in terms of healing moving forward? Amy: It’s a good question. There’s a couple of things. I think if it’s something that we were talking about with the transparency and the talking, number one, finding support and finding support from, ideally, somebody who’s going to understand ERP enough that they can speak to. That doesn’t have to be the type of therapy that you’re getting with them, but understands it well enough to have a conversation like this. Just knowing it should never feel disrespectful, it should never feel non-consensual, and if that was your experience, then—I mean, I hate to say this, but I do think it’s true—I know I would want to know if somebody felt that way. If somebody was working with me and they felt that way, I know that can be quite a burden for people to reach out to someone with whom they’ve had a negative experience.  But I think if you’re able to do that, that can be really helpful and really restorative, even if you’re not looking for a response, even if it’s just something that you’re letting them know. If you still have a relationship with that therapist, or let’s say it’s a clinic where you saw a therapist and you ended up moving to a different therapist, consider sharing it with them directly. I think we live in a very contentious culture of, “Well, I’ve made my mind up. That’s bad, and I’m moving on.”  But truly, I think validation also starts with self-validation. My hope is that even though we’re both clearly ERP therapists who believe very strongly in its positive application for many people, we want to validate that if you’ve felt any harm, that’s valid. I think that also starts with self-validation as a first means of healing and then seeking support. Kimberley: Yeah. What I think too, if you’re not wanting to do that, which I totally understand, sharing with your new clinician. One of the questions we have about our intake is what therapy was helpful and why, and what therapy wasn’t helpful and why. As you go with a new therapist, share with them, “This was my experience. This is what I found to be very effective. This is what I am very good at, but these are the things that I struggled with, and here’s why.” And then giving them the education of your process so they can help you with that, I think, is really important.  I think you hit the nail on the head—also being very, very gentle. The administering of therapy is not a perfect science; it’s a relationship. It’s not always going to go well. I wish it could. I truly wish there was a way we could, but that doesn’t mean that you’re bad, that therapy won’t work for you in the future, or that all therapists are similar to what your experience was. I think it’s important to know that there are many therapists who want to create a safe place for you. Amy: That’s so well said. Kimberley: Anything else you want to add before we finish up? Amy: No, no, I think this has been great. Again, anybody out there, I don’t know. I feel like, as therapists, sometimes we’re the holders of hope. If this could give you any hope, and again, ERP may not be the route that you choose, but just anyone who’s felt like therapy hasn’t been what you wanted, you deserve to find what’s going to feel like the best, most helpful fit. Kimberley: Amy, I have wanted to do this episode for months now, and there is no one with whom I would feel as comfortable doing it as much as you. Thank you for creating a place for me to have this very hard conversation and a conversation I think we need to have. I’m again so grateful for you, your expertise, your kind heart, and your wisdom. Amy: Thank you. 

Kimberley: Welcome back, Ethan Smith. I love you. Tell me how you are. First, tell me who you are. For those who haven’t heard of your brilliance, tell us who you are. Ethan: I love you. My name is Ethan Smith, and I’m a national advocate for the International OCD Foundation and just an all-around warrior for OCD, letting people know that there’s help and there’s hope. That’s what I’ve dedicated my life to doing. Kimberley: You have done a very good job. I’m very, very impressed. Ethan: I appreciate that. It’s a work in progress. Kimberley: Well, that’s the whole point of today, right? It is a work in progress. For those of you who don’t know, we have several episodes with Ethan. This is a part two, almost part three, episode, just catching up on where you’re at. The last time we spoke, you were sharing about the journey of self-compassion that you’re on and your recovery in many areas. Do you want to briefly catch us up on where you’re at and what it’s been like since we met last? Ethan: Yeah, for sure. We’ll do a quick recap, like the first three minutes of a TV show where they’re like, “So, you’re here, and what happened before?”  Kimberley: Previously on. Ethan: Yeah, previously, on real Ethans of Coweta County, which sounds super country and rural. The last time we spoke, I was actually really vulnerable. I don’t mean that as touting myself, but I said for the first time publicly about a diagnosis of bipolar. At that time, when we spoke, I had really hit a low—a new low that came from a very hypomanic episode, and it was not related to OCD. I found myself in a really icky spot. Part of the reason for coming or reaching that bottom was when I got better from OCD into recovery and maintenance, navigating life for the first time, really for the first time as an adult man in Los Angeles, which isn’t an easy city, navigating the industry, which isn’t the nicest place, and having been born with OCD and really that comprising the majority of my life. The next 10 years were really about me growing and learning how to live. But I don’t know that I knew that at the time. I really thought it was about, okay, now we’re going to succeed, and I’m going to make money, live all my dreams, meet my partner, and stuff’s going to happen because OCD is not in the way. That isn’t to say that that can’t happen, and that wasn’t necessary. I had some amazing life experiences. It wasn’t like I had a horrible nine years. There were some wonderful things. But one of the things that I learned coming to this diagnosis and this conclusion was how hard I was being on myself by not “achieving” all the goals and the dreams that I set out to do for myself. It was the first time in a long time, really in my entire life, that I saw myself as a failure and that I didn’t have a mental illness to blame for that failure. I looked at the past nine years, and I went, “Okay, I worked so hard to get here, and I didn’t do it. I worked so hard to get here in a personal relationship, and I didn’t get there. I worked so hard to get here financially, and I didn’t even come close." In the past, I could always say, “Oh, OCD anxiety.” I couldn’t do it. I couldn’t finish it. I dropped out. That was always in the way. It was the first time I went, “Oh wow, okay, this is on Ethan. This is on me. I must not be creative enough, smart enough, good enough, strong enough, or brave enough.” That line of thinking really sent me down a really dark rabbit hole into a really tough state of depression and hypomania and just engaging in unhealthy activities and things like that until I just came crashing down. When we connected, I think I had just moved from Los Angeles to Atlanta and was resetting in a way. At that time, it very much felt like I was taking a step back. I had left Los Angeles. It just wasn’t a healthy place for me at that time. My living situation was difficult because of my upstairs neighbor, and it was just very complicated. So, I ended up moving back to Georgia for work, and I ended up moving back in with my parents. I don’t remember if we talked about that or not, but it was a good opportunity to reset. At that time, it very much looked and felt like I was going backwards. I just lived for 10 years on my own in Los Angeles, pursuing my dreams and goals. I was living at home when I was sick. What does this mean? I’m not ready to move. I’m not ready to leave. I haven’t given up on my dream. What am I doing? I think if we skip the next three years from 2019 on, in retrospect, it wasn’t taking a step back; it was taking a step forward. It was just choosing a different path that I didn’t realize because that decision led to some of the healthiest, most profound experiences in my life that I’m currently living. I can look back at that moment and see, “Oh, I failed. I’ve given up.” This is backwards. In reality, it was such a beautiful stepping stone, and I was willing to step back to move forward, to remove myself from a situation, and then reinsert myself in something. Where I am now is I’m engaged, to be married. I guess that’s what engaged means. I guess I’m not engaged with a lawyer. I’m engaged, and that’s really exciting. Kimberley: Your phone isn’t engaged. Ethan: Yeah, for sure, to an amazing human being. I have a thriving business. I’m legitimately doing so many things that I never thought I would do in life ever, whether it had to do with bipolar or more prominently in my life, OCD, where I spent age 20 to 31, accepting that I was home-ish bound and that was going to be my life forever and that I’m “disabled” or “handicapped,” and that’s just my normal. I had that conversation with my parents. That was just something that I was going to have to live with and accept. I’m doing lots of things that I never expected to do. But what I’ve noticed with OCD is, as the stakes seem raised because you’re engaging yourself in so many things that are value-driven and that you care about, the stakes seem higher. You have more to lose. When you’re at the bottom, it’s like, okay, so what? I’m already like all these things. Nothing can go wrong now because I’m about to get married to my soulmate, and my business is doing really well. I have amazing friends, and I love my OCD community. The thoughts and the feelings are much more intense again because I feel like I have a lot more to lose. Whereas I was dismissing thoughts before, now they carry a little bit more weight and importance to me because I’m afraid of losing the things that I care about more. There’s other people in my life. It’s not just about me. With that mindset came not a disregard but almost forgetting how to be self-compassionate with myself. One of the things that came out of that bipolar diagnosis in my moving forward was the implementation of active work around self-compassion. I did workbooks, I worked very closely with my therapist, and we proactively did tons and tons of work in self-compassion. You can interrupt me at any time, because I’ll keep babbling. So, please feel free to interrupt. I realized that I was not practicing self-compassion in my life at all. I don’t know that I ever had. Learning self-compassion was like learning Japanese backwards. It was the most confusing thing in the world. The analogy that I always said: my therapist, who I’ve been with for 13 years, would say to me, “You just need to accept where you are and embrace where you are right now. It’s okay to be there. Give yourself grace.” She would say all these things.  I always subscribe to the likes of, “You have to work harder. You can’t lift yourself off the hook. Drive, drive, drive, drive.” That was what I knew. I tried to fight her on her logic. I said, “If there’s a basketball team and they’re in the finals and it's halftime and they’re down by 10, does the coach go to the basketball team and say, ‘Hey guys, let’s just appreciate where we are right now; let’s just be in this moment and recognize that we’re down by 10 and be okay with that.’” I’m like, “No, of course not. He doesn’t go in there and say that. He goes, ‘You better get it together and all this stuff.’” I remember my therapist goes, “Yeah, but they’re getting out of bed.” I’m like, “Oh, okay, that’s the difference.” They’re actually living their life. I’m completely paralyzed because I’m just beating myself down.  But what I’ve learned in the last three or four years is that self-compassion is a continuous work in progress for me and has to be like a conscious, intentional practice. I found myself in the last year really not giving myself a lot of self-compassion. There’s a myriad of reasons why, but I really wanted to come on and talk about it with you and just share some of my own experiences, pitfalls, and things that I’ve been dealing with.  I will say the last two years have probably been the hardest couple of years and the most beautiful simultaneously, but hard in terms of OCD, thoughts and triggers, anxiety, and just my overall baseline comfort level being raised because, again, there’s so many beautiful things happening. That terrifies me. I mean, we know OCD is triggered by good stress or bad stress. So, this is definitely one of those circumstances where the stakes seem higher. They seem raised, so I need more certainty. I need it. I have to have more certainty. I don't, really. I’m okay with uncertainty, but part of that component is the amount of self-compassion that I give myself. I haven’t been the best at it the last couple of years, especially in the last six months. I haven’t been so good. Kimberley: I think this is very validating for people, myself included, in that when you are functioning, it doesn’t seem like it’s needed. But when we’re not functioning, it also doesn’t feel like it’s needed. So, I want to catch myself on that. What are some roadblocks that you faced in the implementation of this journey of self-compassion or the practice of self-compassion? What gets in the way for you? Ethan: I will give you a specific example. It’s part of my two-year journey. In the last year and a half, I started working with a nutritionist. Physical health has become more important to me. It may not look like that, but getting there, a work in progress. But the reality of it is, and this is just true, I’m marrying a woman who’s 12 years younger than me. I want to be a dad. I can’t wait to have children. The reality of my life—which I’m very accepting of my current reality, which was something I wasn’t, and we were probably talking about that before—was like, I wanted to be younger. I hated that everything was happening now. I wasn’t embracing where I was and who I was in that reality. I’m very at peace with where I am, but the reality of my reality is that I will be an older father. So, a value-driven thing for me to do is get healthier physically because I want to be able to run around and play catch in 10 years with my kid. I would be 55 or 60 and be able to be in their lives for as long as I possibly could. I started working with a nutritionist, and for me, weight has always been an issue. Always. It has been a lifelong struggle for me. I’ve always yo-yoed. It’s always been about emotional eating. It’s always been a coping mechanism for me. I started working with a nutritionist. She’s become a really good friend, an influence in my life, and an accountability partner. I’m not on a diet or lifestyle change. There’s no food off the table. I track and I journal. But in doing this, I told her from the beginning, "In the first three months, I will be the best client you’ve ever had,” because that’s what I do—I start perfectly. Then something happens, and I get derailed. I was like, my goal is to come back on when I get derailed. That is the goal for me. And that’s exactly what happened. I was the star student for three months. I didn’t miss a beat. I lost 15 pounds. The goal wasn’t weight loss, mind you; it was just eating healthier and making more intentional choices. Then I had some OCD pipe up, my emotions were dysregulated, and I really struggled with the nutrition piece. I did get back on track.  Over the last year, I gained about seven pounds doing this nutrition. Over the last six months, I was so angry at myself for looking at my year’s journey. This is just an example of multiple things with self-compassion, but this is the most concrete and tangible I can think of at the moment. But looking at my year and looking at it with that black-and-white OCD brain and saying, “I failed. I’m a piece of crap. I’m not where I want to be on my journey. I’ve had all of the support I could possibly have. I have all the impetus. I want to be thinner for my wedding. I want to look my best at my wedding. What is wrong with me? In these vulnerable emotional states or these moments of struggle, why did I give in?” In the last couple of months, I literally refused to give myself any compassion or grace around food, screw-ups, mess-ups, and any of that. I refused. My partner Katie would tell me, “Ethan, you have to love--” I’m like, “No, I do not deserve it.” I’m squandering this opportunity. I just wholeheartedly refused to give myself compassion. Because it’s always been an issue, I’m like, “What’s it going to take?” Well, compassion can’t be the answer. I need tough love for myself.  I think I did this in a lot of areas of my life because, for me, I don’t know, there’s a stigma around self-compassion. Sometimes, even though I understand what it is on paper-- and I’ve read your workbook and studied a lot of Kristin Neff, who’s an amazing self-compassion expert. On paper, I can know what it is, which is simply embracing where you are in the moment without judgment and still wanting better for yourself and giving yourself that grace and compassion, regardless of where it is.  I felt like I couldn’t do that anymore because I wasn’t supposed to. I wasn’t allowed. I suddenly reframed self-compassion as a weakness and as an excuse rather than-- it was very much how I thought about it before I even learned anything about self-compassion, and I found myself just not a very loving person myself. My internal self-talk was really horrible and probably the worst. If somebody was talking to me like this, you always try to make it external and be like, “Oh, if somebody talked to you like this, would they be your friend? Would you listen to them?” I was calling myself names. I gave myself a room. It was almost in every facet of my life, and it was really, really eating at me. It took a significant-- yeah, go ahead. Kimberley: When I’m with clients and we’re talking about behaviors, we always talk about the complex outcomes of them, like the consequences that you were being hard on yourself, that it still wasn’t working, and so forth. But then we always spend some time looking at, let’s say, somebody is drinking excessively or doing any behavior that’s not helpful to them. We also look at why it was helping them, because we don’t do things unless we think they’re helping. What was the reason you engaged in the criticism piece? How did that serve you in those moments? Ethan: It didn't, in retrospect. In the moment, I think behaving in that way feels much like grabbing a spear and putting on armor. I don’t know if it’s stigma or male stigma. I mean, I’ve always had no problem being sensitive, being open to sensitivity, and being who I am as an individual. But with all of this good in my life, my emotions are more intense. My thoughts are more intense. My OCD is more intense. I felt like I needed to put on-- I basically defaulted to my original state of thinking before I even learned about self-compassion, which is head down, bull horns out, and I’m just going to charge through all of this because it’s the only way. It’s just like losing insight. When you’re struggling with OCD, it’s like you lose insight, you lose objectivity. It’s like there’s only one way through this.  I think it’s important to note, in addition to the self-compassion piece, this year especially, there’s been some physical things and some somatic symptoms that I’ve gotten really stuck on. I’m really grateful that-- and I love to talk about it with advocacy. It’s like, advocates, all of us, just because we’re speaking doesn’t mean that we have an OCD-free life or a struggle-free life. That’s just not it. I always live by the mantra: more good days than bad. That is my jam. I’m pleased to report that in the last 13 years, I’ve still had more good days than bad, but it doesn’t mean that I don’t have a tough month.  I think that in the last couple of years, I’ve definitely been challenged in a new way because there’s been some things that have come up that are valid. I have a lot of health anxiety, and they’ve been actual physical things that have manifested, that are legitimate things. Of course, my catastrophic brain grabs onto them. You Google once, and it’s over. I have three and a half minutes to live for a brown toenail, and-- Kimberley: You died already. Ethan: I’m already dead. I think it all comes back around to this idea of self-stigma, that even if you know all this stuff like, I’m not allowed to struggle, I’m not allowed to suffer, I have to be a rock, I have to be all things to all people—it’s all these very black and white rules that are impossible for a human being to live by because that’s just not reality. I mean, I think that’s why the tough exterior came back because it was like, “All right, life is more challenging.” The beautiful thing about recovery is, for the most part, it didn’t affect my functioning, which was amazing. I could still look at every day and go, “I was 70% present,” or “I was 60% present and 40% in my head, but still being mindful and still doing work and still showing up and still traveling.” From somebody that was completely shut down, different people respond in different ways to OCD. From somebody who came from completely shutting down and being bedridden, this was a huge win. But for me, it wasn’t a huge win in my head. It was a massive failing on my part. What was I doing wrong? How was it?  Just as much as I would talk every week on my live streams and talk about, it’s a disease, not a decision, it’s a disorder. I can say that all day long, but there are times when it tricks me, and I stigmatize myself around it.  It’s been very much that in the last year, for sure. It’s been extremely challenging facing this new baseline for myself. Because, let’s face it, I’m engaging in things that I’ve never experienced before. I’ve never been in a three-year relationship with a woman. I’ve never been engaged. I’ve never bought a house. Outside of acting, I’ve never owned a business or been a businessperson. I mean, these are all really big commitments in life, and I’m doing them for the first time.  If I have insight now and it’s like, I can have this conversation and say, “Yeah, I have every reason to be self-compassionate with myself.” These are all brand new things with no instruction manual. But it’s very easy to lose sight of that insight and objectivity and to sit there and say-- we do a lot of comparing, so it’s very easy to go, “Well, these are normal human things. Everybody gets married. Everybody works. This should be easy.” You talk about, like, never compare struggles, ever. If somebody walks to the mailbox and you can’t, never compare struggles. But that’s me going, “Well, this is normal life stuff. It’s hard. Well, what’s wrong with me?” Kimberley: Right. I think, for me, when I’m thinking about when you’re talking, I go in and out of beating myself up for my parenting, because, gosh, I can’t seem to perfect this parenting gig. I just can’t. I have to figure it out. What’s so interesting is when I start beating myself up and if I catch myself, I often ask myself, what would I have to feel if I had to accept that I’m not great at this? I actually suck at this. It’s usually that I don’t want to feel that. I will beat myself up to avoid having to feel the feelings that I’m not doing it right. That has been a gateway for me, like a little way to access the self-compassion piece. It’s usually because I don’t want to feel something. And that, for me, has been really helpful.  I think that when you’re talking about this perceived failure—because that’s what it is. It’s a perceived failure, like we’re all a failure compared to the person who’s a little bit further ahead of us—what is it that you don’t want to feel? Ethan: It’s a tough question. You’ve caught me speechless, which is rare for me. I’m glad you’re doing video because otherwise, this would be a very boring section of the podcast. For me, the failing piece isn’t as much of an issue. It was before. I don’t feel like I’ve failed. In fact, I feel like I’m living more into where I’m supposed to be in my values. I think for me, the discomfort falls around being vulnerable and not in control. I think those are two areas that I really struggle with. I always say, sometimes I feel like I’m naked in a sandstorm. That’s how I feel. That’s the last thing you want to be. Well, you don’t want to be in a sandstorm—not naked, but naked in a sandstorm—you don’t want to see me naked at all. That’s the bottom line. No nudity from Ethan. But regardless, you’re probably alone in the sandstorm. You feel the stinging and all of that. No, I’m just saying that’s what I picture it feels like.  Kimberley: Yeah, it’s an ouch. That feels like an ouch. Ethan: It feels like a big ouch. I think that vulnerability, for me, is scary. I’m not good at showing vulnerability. Meaning, I have no problem within our community. I’ll talk about it all day long. I’ll talk about what happened yesterday or the day before. I’ll be vulnerable. But for people who don’t know me, I struggle with it.  Kimberley: Me too. Ethan: Yeah. We all have our public faces. But vulnerability scares me in terms of being a human being, being fallible, and not being able to live up to expectations. What if I have to say I can’t today? Or I’m just not there right now and not in control of things that scare me. Those feelings, I think, have really thrown me a bit more than usual, again. I keep saying this because things feel more at stake, and they’re not, but I feel like I have so much more to live for. That’s not saying that I didn’t feel like I didn’t have a reason to live before. That’s not what I’m saying at all. I’m simply saying, dreams come true, and how lucky am I? But when dreams come true with OCD, it latches onto the things we care about most and then says, “That’s going to be taken away from you. Here are all the things you have to do to protect that thing.” I think it’d been a long time since I’d really faced that.  To answer your question in short, I think, for me, vulnerability and uncertainty around what I can’t control, impacting the things that I care about most, are scary. Kimberley: I resonate so much with what you’re saying. I always explain to my eating disorder clients, “When you have an eating disorder and you hit your goal weight, you would think we would celebrate and be like, ‘Okay, I hit it. I’m good now.’” But now there’s the anxiety that you’re going to go backwards. Even though you’ve hit this ridiculous goal, this unhealthy goal, the anxiety is as high as it ever was because the fear of losing what you’ve got is terrifying. I think that’s so true for so many people. And I do agree with you. I think that we do engage in a lot of self-criticism because it feels safer than the vulnerability, the loss of control, or whatever that we have to feel. What has been helpful for you in moving back towards compassion? I know you said it’s like an up-and-down journey, and we’re all figuring this out as we go. What’s been helpful for you? Ethan: A couple of things. I think it’s worth talking about, or at least bringing up this idea of core fear. I’ve done some recent core fear work, just trying to determine, at the root of everything, what is my core fear? For me, it comes down to suffering. I’m afraid of suffering. I’m not afraid of dying; I’m afraid of suffering. I’m afraid of my entire life having to be focused on health and disease because that’s what living with OCD when I was really sick was about. It’s all I focused on. So, I’m so terrified of my life suddenly being refocused on that.  Even if I did come down with something awful, it doesn’t mean that my life has to solely focus on that thing. But in my mind, my core fear is, what if I have to move away from these values that I’m looking at right now and face something different? That scares the crap out of me.  The first thing around that core fear is the willingness to let that be there and give myself compassion and grace, and what does that look like, which is a lot of things. This fear—this new fear and anxiety—hasn't stopped me from moving forward in any way, but it sure has made it a little bit more uncomfortable and taken a little bit of the joy out of it. That’s where I felt like I needed to put on a second warrior helmet and fight instead of not resisting, opening myself up, and being willing to be naked in a sandstorm.  One of the things that I’ve learned most about is, as a business owner yourself, and if you’re a workaholic, setting boundaries in self-care is really hard. I didn’t really connect until this year the connection, the correlation between self-care and self-compassion. If I don’t have self-compassion, I won’t allow myself to give myself self-care. I won’t. I won’t do it because I don’t deserve it. There’s a very big difference between time off, not working, sleeping, but then actually taking care of yourself. It’s three different things. There’s working, there’s not working, and then there’s self-care. I didn’t know that either. It was like, “Well, I didn’t work tonight.” Well, that’s not necessarily self-care. You just weren’t in a meeting, or you weren’t working on something. Self-care is proactive. It’s purposeful. It’s intentional.  Giving myself permission to say no to things, even at the risk of my own reputation, because I feel like saying no is a big bad word, because that shows that I can’t handle everything at once, Kim. I can’t do it all. And that is a no-no for me. Like, no, no, no, everybody needs to believe that you can do everything everywhere all at once, which was a movie. That’s the biggest piece of it.  Recently, I was able to employ some self-care where it was needed at the risk of the optic seeming. I felt like, "Here I am, world. I’m weak, and I can’t handle it anymore." That’s what I feel like is on the other end.  I was sick, and I had been traveling every week since the end of March. I don’t sleep very well. I just don’t. When I’m going from bed to bed, I really don’t sleep well. I had been in seven or eight cities in seven or eight weeks. I had been home for 24 hours. This was only three weeks ago, and I was about to head out on my last trip, and the meeting that I was going for, the primary reason, got canceled, not by me. I was still going to meet with people that I love and enjoy. I woke up the day before I was traveling, and I was sick. I was like, “Oh man, do I still go?” The big reason was off the table, but there were still many important reasons to go, but I was exhausted. I was tired. I was sick. My body was saying, “Enough.” I had enough insight to say, I’m not avoiding this. This isn’t anxiety. This is like straight up.  When I texted the team—this is around work and things that I value—I was like, “I’m not coming.” I said, “I’m not coming.” They responded, “We totally understand. Take care of yourself.” And what I read was, “You weak ass bastard. You should suck it up and come here, because that’s what I would have done. Why are you being so lame and lazy?” That is what I read. This is just an instance of what I generally feel if I can’t live up to an expectation. I always put these non-human pressures on myself.  But making this choice, within two days, I was able to reset intentionally. This doesn’t mean I’m going to go to bed and avoid life. I rested for a day because I needed to sleep to get better. But the next few days were filled with value-driven decisions and choices and walks and exercising and getting back on nutrition and drinking lots of water and spending quality time with people that I care about, and my body and brain just saying, “You need a moment.” Within a couple of days, everything changed. My OCD quickly dropped back down to baseline. My anxiety quickly dropped back down. I had insight and objectivity.  When I went back to work later that week—I work from home—I was way more effective and efficient. But I wouldn’t have been able to do that. It was very, very hard to give myself self-compassion around making that simple decision that everybody was okay with. Kimberley: I always say my favorite saying is, “I’m sorry, but I’m at capacity right now.” That has changed my life because it’s true. It’s not even a lie. I’m constantly at capacity, and I find that people do really get it. But for me to say that once upon a time, I feel this. When I was sick, the same thing. I’m going to think I’m a total nutcase if I keep saying no to these people. But that is my go-to sentence, “I’m at capacity right now,” and it’s been so helpful.  Ethan: In max bandwidth.  Kimberley: Yes. What I think is interesting too is I think for those who have been through recovery and have learned not to do avoidant behaviors and have learned not to do compulsions, saying “I need a break” feels like you’ve broken the rules of ERP. They’re different things. Ethan: You hit them down. I was literally going to say that. It also felt when I made that decision that it felt old history to me, like old Ethan, pre-getting better. I make the joke. It was true. I killed my grandfather like 20 times while he was still alive. Grandpa died. I can’t come to the thing. I can’t travel. I can’t do the thing. This was early 2000s, but I had a fake obituary that I put into Photoshop. I would just change the date so I can email it to them later and be like, it really happened. I would do this. It’s like, here was a reason. It was 100% valid. Nobody questioned it. It was not based on OCD. It was a value-driven decision, and it felt so icky. My body felt like I might as well have sent a fake obituary to these people about the fake death of my grandfather. It felt like that. So, I wholeheartedly agree with you. Kimberley: I think it’s so important that we acknowledge that post-recovery or during recovery is that saying acts of compassion sometimes will feel like and sound like they’re compulsions when they’re actually not.  Ethan: That’s such a great point. I totally agree with you. Kimberley: They’re actually like, I am actually at capacity. Or the expectation was so large, which for you, it sounds like it is for me too—the expectation was so large, I can’t meet that either. That sucks. It’s not fun.  Ethan: No, it’s not. It’s not because, I mean, there’s just these scales that we weigh ourselves on and what we think we can account for. I mean, the pressure that we put on ourselves. And that’s why, like the constant practice of self-compassion, the constant practice of being mindful and mindfulness, this constant idea of-- I mean, I always forget the exact thing, but you always say, I strive to be a B- or C+. I can never remember if it’s a B- or C+, but-- Kimberley: B-. Ethan: B-. Okay, cool.  Kimberley: C+ if you really need it. Ethan: Yeah. To this day, I heard that 10 years ago, and I still struggle with that saying because I’m like, I don’t even know that I can verbally say it. Like, I want to be a B... okay, that’s good enough. Because it sounds terrifying. It’s like, “No, I want to be an A+ at everything I do.”  I know we’re closing in on time. One of the things I just wanted to say is thank you not only for being an amazing human being, an amazing advocate, an amazing clinician, and an okay mom, as we talked about. Kimberley: Facts. #facts. Ethan: But part of the reason I love advocating is I really didn’t come on here to share a specific point or get something across that I felt was important. I think it’s important as an advocate figure for somebody who doesn’t like transparency or vulnerability to be as transparent and vulnerable as possible and let people see a window into somebody that they may look at and go, “That person doesn’t struggle ever. I want to be like that. I see him every week on whatever, and he’s got it taken care of. Even when it’s hard, it isn’t that hard.”  For me, being able to come on and give a window into Ethan in the last six months is so crucial and important. I want to thank you for letting me be here and share a little bit about my own life and where I met the goods and the bads. I wouldn’t trade any of it, but I appreciate you. Kimberley: No, thank you. I so appreciate that because it is an up-and-down journey and we’re all figuring it out, myself included. You could have interviewed me and I could have done similar things. Like here are the ways that I suck and really struggle with self-compassion. Here are the times where I’ve completely forgotten about it as a skill until my therapist is like, “Uh, you wrote this book about this thing that you might want to practice a little more of.” I think that it’s validating to hear that learning it once is not all you need; it is a constant practice. Ethan: Yeah, it definitely is. Self-compassion is, to me, one of the most important skills and tools that we have at our disposal. It doesn’t matter if you have a mental health issue or not. It’s just an amazing way of life. I think I’ll always be a student of it. It still feels like Japanese backwards sometimes. But I’m a lot better at putting my hand-- well, my heart’s on that side, but putting my hand in my heart, and letting myself feel and be there for myself. I never mind. I’m a huge, staunch advocate of silver linings. I’ve said this a million times, and I’ll always say, having been on the sidelines of life and not being able to participate, when life gets hard and stressful, deep down, I still have gratitude toward it because that means I’m actually living and participating. Even when things feel crappy or whatever, I know there’ll be a lesson from it. I know good things will come of it. I try to think of those things as they're happening. It’s meaningful to me because it gives me insight and lets me know that there’ll be a lesson down the road. I don’t know if it’ll pay itself back tomorrow or in 10 years, but someday I’ll be able to look at that and be like, “Well, I got to reintroduce myself to self-compassion. I got to go on Kim Quinlan’s podcast, Your Anxiety Toolkit, and be able to talk to folks about my experience.” While I didn’t quite enjoy it, it was a life experience, and it was totally worth it for these reasons. Now I get to turn my pain into my purpose. I think that’s really cool. Kimberley: Yeah, I do too. I loved how you said before that moving home felt like it was going backwards, but it was actually going completely forward. I think that is the reality of life. You just don’t know until later what it’s all about. I’m so grateful for you being on the show. Thank you so much for coming on again. Ethan: Well, thanks for having me, and we’ll do one in another 200 episodes. Kimberley: Yes, let’s do it. Ethan: Okay.