OCD 101

OCD stands for Obsessive Compulsive Disorder. It is included under the umbrella category of neurodivergence, which includes autism, ADHD, dyslexia, Tourettes, and a host of other conditions. OCD shows up in obsessive thoughts and repetitive behaviors, both of which are an attempt to cull distress but actually create more distress in the long term. OCD often begins in childhood or during puberty. Onset can also occur during or after pregnancy, or during a major life stress or trauma. It’s one of the hardest mental health issues to fully treat. It is the tenth highest reason for disability in the world!

OCD gets missed for a number of reasons. The first is that there are very distinct stereotypes in the media and our society about what OCD is. People think they don’t have OCD, or a loved one doesn’t have OCD, if they aren’t counting things, tapping, or washing their hands excessively. OCD most commonly gets missed in mental health treatment when the person’s rituals are avoidance or mental rumination, as these are harder to notice by an observer. The second reason is that OCD and Generalized Anxiety Disorder (GAD) present in very similar ways, and most people with OCD also have GAD. OCD gets lost for these reasons and people suffer for years or lifetimes without treatment. Along with treating PTSD, OCD is the second diagnosis of focus in my private practice.

One of the same symptoms in people with anxiety and people with OCD is excessive worry. The big differences? OCD sufferers experience intrusive and unwanted images. These intrusive images may make them feel like a bad person, or may be very upsetting in nature. Intrusive images for people with OCD look like a cinematic masterpiece playing out in their mind; it is incredibly graphic. People with anxiety however, experience fear and worry, but it doesn’t play out in their minds like a movie. OCD also differs from GAD in that people with OCD have rituals and compulsions they use to resolve the worry. Stereotypical OCD rituals include knocking three times on a desk or needing to keep the thermostat at an even number. Less obvious rituals include mental rituals, the invisible symptom of OCD that is easy to miss because you don’t see a person doing it, and the person suffering from OCD may think they are just “thinking” a lot. People with GAD have safety behaviors, things they do to relieve the worry, like planning, list making, and "talking it through" with a loved one. If it's confusing to tell the difference between OCD and GAD it's because they are so similar, and co-occur so often. As OCD Specialist Dr. Jeremy Shuman, PsyD taught me: "when does dough become bread in the oven?" You can't have a definitive moment to say ah yes, this dough is bread now! However, there are very helpful clinical tools like the GAD-7 (for Anxiety) and the YBOCS-II (for OCD) that can determine if the Anxiety or OCD is sub-clinical, mild, moderate, or severe. I do measures both with all of my clients, to make sure we aren't missing anything.

Obsessions vs Compulsions

Obsessions are looping thoughts, impulses, or images that are unwanted and upsetting. Obsessions may include fears of contamination and getting sick; fears of harm (to self and others) with violent intrusive images; a need for symmetry or for things to be exact or perfect; and unacceptable thoughts often rooted in religion, relationships, or existential questions. 

Compulsions are repetitive behaviors or mental acts that provide some temporary relief from the obsession, until a new trigger arises. Compulsions include rituals, such as vigilance and washing your hands over and over again; mental rituals such as feeling the need to go over things in your mind again and again (rumination), including praying, or checking lists; reassurance seeking from others or self; and avoidance, including proactive rituals to avoid something bad happening. 

OCD is diagnosed when these obsessions and compulsions occupy hours of someone’s day, cause them distress, and when the person has little power or control over them.

OCD follows the same predictable sequence most of the time.There is a trigger that prompts the person to have what is called an obsessional doubt. This doubt has a consequence for their life, which would cause them anxiety. Finally, there is a compulsion that would cull the anxiety temporarily, until another trigger is experienced. It can look like this:

TRIGGER: Intrusive and unwanted violent, sexual, or racist thought or image.

OBSESSIONAL DOUBT: What if I am an evil/harmful/bad etc. person?

CONSEQUENCE OF THE DOUBT: I could hurt someone. People could find out the truth about me. If people thought I was a bad person, I would be alone.

ANXIETY: It would be terrible for to hurt someone! I couldn't live with myself. It would be terrible to be alone.

COMPULSION: Say a "good thought" in my head. Review past events to make sure I never harmed anyone. Ask a friend to reassure me I am good.

So in this example, you can see that the trigger was an intrusive thought. This person's OCD was activated by their own brain, not by an external event. You can see that the compulsions, other than seeking reassurance, also happen inside this person's brain. No one would ever know they have OCD because it doesn't manifest in physical rituals. The person themselves may not even know they have OCD, because they assume they are just "thinking" or really are an evil person. This is one of the most common expressions OCD I see in my work with clients who came to me originally for Anxiety, PTSD, and CPTSD. There is this underlying issue of OCD that no one every caught before.

Generational or Inherited OCD

OCD is one of the mental health issues that is passed genetically. OCD has a heritability rate of 40-50%, much higher than PTSD, anxiety, and depression. Every single time I diagnose a client with OCD, they mention that someone else in their family (or many family members) has it or has “OCD tendencies”. 

Heritability is the percentage of gene expression determined by biological familial inheritance. It does not include environmental factors or chance. I can think of so many environmental factors my ancestors were exposed to that would increase the likelihood of developing a disorder like OCD. Religious and political persecution, loss of land and livelihood, threat to life. I understand my family’s OCD as a response to impossible circumstances, passed along (lovingly, I like to think) in attempt to keep us safe in an unpredictable and often dangerous world. 

Traumatic Event-triggered OCD 

Many people begin to experience their symptoms during a time of change or stress, like puberty or a traumatic event. A traumatic event can make someone’s symptoms skyrocket, but it is not the core reason OCD is there in the first place. The world we live in, with its uncertainty and unsafety for so many of us, doesn’t help those of us who deal with OCD. The pandemic is a great example of this, with so many of us needing to develop rituals around contamination and safety. I have heard from many clients and loved ones with OCD that since COVID their symptoms have worsened dramatically. 

OCD is another great example of how the genetic, environmental stress, and trauma can all come together in mental illness. It is as complex as we are! OCD illustrates how the genetic component of mental health influences the ways in which our nervous system tries to keep us safe. 

One in four people with PTSD also have OCD. Additionally, OCD and PTSD even have overlapping symptoms. With both mental health issues people experience unwanted thoughts and images, safety behaviors that minimize dysregulation, and avoidance of certain people, places, things that are triggering.

While there are many therapeutic treatments for PTSD, including EMDR and talk therapy, neither are successful for treating OCD. In fact, talk therapy exacerbates OCD, with the sessions ending up being 45-60 min of reassurance, feeding the reassurance-seeking compulsion. With the proper therapy however, OCD treatment is highly effective. 

More questions about OCD? Here are some resources to learn more below. I also offer OCD therapy in Missouri and New York states, as well as OCD consultation for clinicians licensed anywhere.

https://iocdf.org/

https://icbt.online/

https://www.treatmyocd.com/learn/blog

Articles Referenced:

Valentine, Keara. “Here’s the Key Difference between OCD and Anxiety.” NOCD, 6 May 2021, www.treatmyocd.com/blog/is-ocd-a-form-of-anxiety.

 Mataix-Cols  D, Boman  M, Monzani  B,  et al.  Population-based, multigenerational family clustering study of obsessive-compulsive disorder.   JAMA Psychiatry. 2013;70(7):709-717. doi:10.1001/jamapsychiatry.2013.3

https://www.mirecc.va.gov/visn16/docs/ocd-and-ptsd-fact-sheet.pdf

EMDR & Parts Work

Weaving these two gentle and effective trauma treatments together for healing childhood/complex trauma and dissociation.

In my EMDR basic training, my teacher repeatedly advised those of us working with clients who have childhood trauma/ cPTSD and dissociation to work with parts before going into any specific trauma processing. This preparation work with parts is to make sure that all parts are onboard with the EMDR processing, to hear their thoughts and concerns, and create safety for them before going into a memory.

To review, and if you want to read more I wrote about parts work here. Parts work, also called ego state therapy, inner child work, Internal Family Systems and more has been a core part of Psychotherapy from the jump. Different therapists have expanded upon those theories and created new and updated frameworks to use with clients. In parts work, we acknowledge that our psyche is made up of different parts, instead of a singular self. Some parts hold pain from the past and are called exiles, others keep those younger, feeling parts safe and are called protectors. At the center of these collection of parts is the Self, a core part that holds our most authentic and grounded self.

In therapy, we are always working with all of these parts. Frequently, protectors show up first. They have concerns about us feeling our feelings and processing trauma. Can we handle it? Will it be overwhelming? Will we fall apart if we do? How do we know we can trust you, the therapist? Protectors can show up in the work the same way they keep us safe in our day to day lives: through dissociation, avoidance, minimizing, and sometimes even survival coping like drinking, self harm and more. THIS is exactly why it is so paramount that these protectors are onboard with the work, or at the very least are down to take a step back and give it a try. Remember, these parts are trying to help us by keeping the work at a stalemate! They really believe they are keeping the wounded parts of us safe by not allowing the work to happen.

Recently in my own EMDR, right as I was releasing emotion and an exile of mine was finally being heard through the trauma processing, a protector stepped in and shut the whole thing down. This protector introjected into my moment of feeling and processing to remind me that what I was working on was nothing compared to the stories I have heard from others. "See it isn't so bad!" this protector shouted, jumping in front of my wounded parts who were crying and processing. I stopped crying. I stopped feeling.

In EMDR, we would call this a blocking belief. "Other people have it/ had it worse" is a belief that blocks the processing from happening. It's my defense of minimizing, which I have used my whole life, and it's a fierce protector of mine. I have been kept safe by this protector through some pretty bad situations, that I survived by believing, "it could be worse, other people have it worse". In many ways, the protector is right, someone is always suffering more. Just interpreting this as a blocking belief, and not seeing it as a part, limits the work. This is one of the many ways parts work is so necessary for the EMDR work to happen! Once my therapist and I named this blocking belief as a protector, then we could work with that part so she wouldn't jump in front of our work and my feelings, so I could finally have some lasting relief and fully process.

We all have parts, but we especially have them if we have experienced trauma during childhood. As we form our sense of self in those early years, through attachment and major developmental stages, we are particularly vulnerable to fragmentation of the self in order to survive. Something traumatic or wounding occurs, and we develop an exile. If this part holds what happened to us, then we can compartmentalize that away in order to still attach to our caregivers, do well in school, and build peer relationships. Protectors develop during this years to keep us alive and safe. Dissociation, avoidance, minimizing, people pleasing, over achieving, managing others through codependency, self harm, suicidal thinking and more are all ways to keep those feelings that exile holds at bay. Later in life, when we walk into therapy, wanting things to change, that is only possible if these protective parts are willing to let the work happen. They have kept these feeling parts safe for so long, it's not going to take just walking into the therapy office for them to step aside. While we may have signed up for EMDR, protectors didn't necessarily agree to it. They can step in front of the work through dissociation in a session, turning off the faucet of feelings, not showing up to sessions, and more.

As therapists, it is vital that we hear thoughts, concerns, and questions from these protectors. We also need to make sure exiles know this processing will happen safely, within their window of tolerance. They have kept these memories and feelings safe for so long, it can be terrifying for them to open that box. We may know that EMDR addresses these memories in a way that won't put them out of their window, but these exiles don't know that.

Trauma therapist Janina Fisher who uses both EMDR and parts work with her clients teaches a Safe Place Protocol for beginning this work. She has clients invite their parts to the safe place the client has created in EMDR, or creates a new place with them that is good for a meeting of the parts. Here, protectors, exiles, and anyone else can be fully heard in their feelings and concerns around therapy and trauma processing. This protocol is coupled with the BLS (Bilateral Stimulation) used in EMDR, either eye movements, tapping, or using buzzers. Janina teaches that this work is as important or maybe even more than the trauma processing aspect of EMDR. If the system of parts can feeling more cohesive, protectors feel unburdened from their post, and the client is feeling compassionate towards all parts, this can be just as transformative as closing our an EMDR target. It certainly leads to the work flowing more easily, clients staying present in the room, and coming back for sessions.

If more extreme protectors like or suicidal thinking or behavior is showing up, getting that client to safety through skills groups like DBT and 12 step groups, medication, safety planning, and any higher level of care is necessary before going any further. This is still EMDR! The preparation phase can look different for each client depending on their needs.

It makes all the sense in the world to me to combine two of the most highly effective trauma treatments together in this way so we can work more holistically with our clients, or show up to our own healing with all parts welcome.

To learn more about using parts work & EMDR you can check out the following resources:

EMDR Toolbox by Jim Knipe

EMDRIA for trainings on joining these two modalities can be found here

Information on doing EMDR with me can be found here

Everything I Wish I Had Known About EMDR

There are many things I wish I could tell younger versions of myself. "Don't date her", or "This apartment doesn't get heat in the winter". As a young therapist struggling with the impact of trauma on my own life, I wish I could go to her and show her all that EMDR has to offer. Personally and professionally.

Finding the right type of therapy for yourself as a client or a clinician isn't easy. There is so much out there - it can be hard to sort through all the noise. What is trendy right now may not be the thing that works for you. Many of us go to therapy without specific goals because it's just something we think we should do - something Mychal Denzel Smith wrote about for the NYT Opinion section and talked with me about. A lot of us therapists default to talk therapy only - which absolutely has its benefits and completely changed my life in my early 20's - even though we know our clients need more.

I wish I could show my young therapist self, my coming to terms with my own trauma self, EMDR. EMDR stands for Eye Movement Desensitization and Reprocessing. Don't let some of those big words fool you - it's actually quite simple. Our brain stores traumatic material in the here and now memories, which is why they feel so fresh and triggering. These memories haven't been fully digested by the brain's natural processing routine because in order to keep us safe, our brain thinks it needs to keep this memory right up front. This way, hopefully, it won't happen again. However, it means we don't get to move on, feel safe in the present, or create new beliefs about ourselves to replace the ones from trauma. The eye movements are clinically proven to help trigger that natural memory digestion process. The desensitization happens as the material becomes less disturbing through the reprocessing. Eventually we can say, "yeah that happened to me, and it sucked, but it's in the past". Eventually we can "I don't believe I'm worthless anymore, I truly believe I am worthy of love and respect". Eventually we can think of that time in our lives and not feel our mouth go dry or our hands start to shake.

EMDR has 8 clear and predictable phases. History taking, client preparation, assessment, desensitization, installation, body scan, closure and reevaluation of treatment effect. Rapport and relationship building happen during the history taking and client prep, as well as grounding skills. As a young therapist I was flooded with coping skills. Everyone wanted them, and there were simply too many to choose from. It often felt like I was throwing spaghetti at a wall trying to get something to work. Since myself and clients had so many choices, it felt like none of them were good enough. I often found myself saying in session: "Let's try this! No? What about this! Or this?" In EMDR, there are 3 or 4 clear resources to use for grounding and getting back into the window of tolerance. Container (literally a safe storage place in your mind to put unfinished work, triggers, overwhelming feelings), Safe Place (literally a safe place to go to in your mind and body that makes you feel calm and grounded) and whats called RDI (Resource Development and Installation) where you identify positive memories, relationships, and experiences and use those as grounding tools. All of the above is coupled with the eye movements, or any kind of back and forth of the body (tapping with small buzzers you hold in your hands, butterfly hug with tapping, tapping feet on the ground back and forth, all of this is called BLS aka bilateral stimulation).

The other phases focus on processing the traumatic material. What I wish I had known about EMDR - and what honestly kept me away from it for so long, was that this traumatic material is not just specific trauma memories! EMDR uses what is called a three-pronged protocol. Prong #1 is that classic past trauma memory. Prong #2 are triggers in the here and now. Prong #3 are future fears. EMDR addresses the past, present, and future of trauma. For clients who have a long history of trauma starting in childhood, it can feel way too overwhelming to start in the past. This was my main concern - I really didn't want to only work with specific trauma memories with clients! There is just so much more, we are so much more. Which EMDR addresses with this past, present, future protocol. So much of my work with clients is processing triggers that come up in the here and now, and fears for the future related to their trauma.

These processing phases have somatic, cognitive, and memory based components. You are not just processing traumatic memories and images of triggers or fears, but also where you feel that distress in your body, and the beliefs about self and the world that are attached to that image. I had no idea how holistic EMDR actually is, how it takes into account all aspects of our experience, not just one.

I also didn't realize how easily parts work, also known as ego state therapy or Internal Family Systems can be woven into EMDR, and with clients who have childhood trauma and/or dissociation, how parts should be included work! Parts can be invited to Safe Place for meetings with the whole internal system and to be heard from by the core self. Parts need to be checked in with before any deeper processing begins to make sure everyone is onboard and ready to dig into that memory, trigger, or fear. A huge part of my practice is weaving parts work and EMDR, something else I wish I had known was possible! That EMDR could be used to deepen the work I was already doing with parts.

An EMDR target is any specific memory, trigger, or fear that can be used to process. Targets however can expand to include so many other aspects of what clients come to therapy wanting to address.

As a client, I wish I had known the freedom EMDR had in store for me. How certain memories or beliefs about myself could be so directly targeted and processed. I didn't think the work was for me because my trauma didn't fit a specific narrative that at the time was associated with PTSD. As a therapist, I wish I had known how accessible EMDR is for clients and for me as a therapist in training. How EMDR addresses every aspect of the work I was already doing with clients, how it could've answered the question I asked myself everyday: "I know this client needs more than this, but what?"

I feel like I finally have that answer now.

To learn more about EMDR check out emdria.org