Finding a Good Therapist for OCD In US and Canada

The International OCD Foundation(IOCDF)has an an OCD Treatment Provider List for the United States and Canada. There is a dearth of qualified Exposure and Response Prevention(ERP)/Cognitive Behavioral therapists, and it can be frustrating to find effective therapy, but this is the place to start.

What to look for:

• Behavior Therapy Training Institute(BTTI) faculty
  
• Graduates of BTTI
• If they are a graduate of BTTI and have a website, check to see if they mention ERP at all. Some take the training, but their sites show no trace of it.
  
• Specific mention of ERP in their listing
  
• Cognitive Behavorial Therapy(CBT) in combination with ERP
  

Keep in mind that this list is made up of therapists who requested to be on it, and there is a disclaimer that the IOCDF does not screen or research any of the therapists, but I do think it increases your odds of finding someone who is well versed in current treatment.

Related Link:
Tips on Finding a Therapist from Austin OCD Center
Finding a CBT Therapist

Introducing my ERP Therapist

He's going to show up quite often in this blog, so I'm going to call him "Leonard, " and introduce him as my wise, sharply observant Exposure and Response Prevention therapist. To go with the metaphor of an owl, Leonard has spent enough years treating people with OCD, that he can hone in on a rodent-like obsession scurrying through the fields and snap it right up. He likes to tell me he's helping me become my own therapist, and encouraging to trust my own thinking--which the OCD vehemently opposes!

His ability to hunt the feared consequence of any given obsession, and uncannily predict the kinds of protests the OCD will make to any given challenge, is truly invaluable. He doesn't get mired in the mud of obsessional thinking. He's not a mind-reader; he's just had 7 or 8 years with the bulk of his clients having OCD.

This is the difference between him and my previous therapist, who though she helped me with everything but the OCD, thought my continuous websearching at work was because I was bored. Yeah, I'm bored at work, but I was also avoiding doing even the most basic of tasks because I might not do them perfectly. OCD tends to form around a grain of truth, and a therapist who doesn't understand ERP therapy, or the ways of OCD, will get sidetracked pretty quickly.

It's hard to imagine I didn't drive for 12 years

I learned to drive at 15. I had the spectre of perfectionism looming over my lessons, where I assumed that I should be able to just learn without trial and error, and that something was seriously wrong with me because I did indeed make errors, like changing lanes without putting on my signal. My instructor was patient, and even gave a particularly riled up driver the finger when I was struggling along. I started a list of all the driving mistakes I made, and felt overwhelmed with all I had to fix. I kept driving through college, maneuvering a Chevette, which had absolutely no oomph after 35 mph. Then on to driving a van as part of my workstudy.

But when my husband and I got married during graduate school, his car was a stick shift, and I had learned on an automatic. I only had one experience with a manual transmission, and that was the day I got my driver's license and my father took me out in his tiny Honda, and expected me to know how to operate the clutch. It was the longest block of my life. I started by rolling backward and ended with much lurching, and felt entirely responsible for my deficiency, rather than realizing my father was expecting me to learn by magic.

My husband took me to a parking lot with the stick shift car, and I was sufficiently scared of making any mistakes that I didn't ask for another lesson. In the meantime, my husband was more than glad to drive me anywhere I wanted to go. He'd wait for me, find a place to sit or walk. When we got a new car 5 years later, I asked that it be an automatic transmission so I could drive if I needed to. But after one nerve wracking trek down to the grocery store, with every muscle tense, and my hands clamped on the steering wheel, I shied away from driving again.

Later, my husband told me that he was so willing because he was afraid that if I had an accident while driving, that it would send me over the edge with my anxiety. For 12 years we did everything together, "joined at the hip". Anxiety can tell you something important, an actual threat that needs to be heeded, but parasitic anxiety lives only to perpetuate itself. Much of my perfectionism was a child's way of dealing with the world--"If I am perfect, then I will be loved. Don't ever make a mistake." And the OCD latched onto this, amplifying the fear. I couldn't imagine myself driving, and therefore, until I could be certain I could drive, I avoided it.

Learning to Live with Uncertainty

My ERP therapist is fond of saying, "The goal of treatment of OCD is to learn to live with uncertainty." The selective filters of OCD are insidious in their stealthiness. I used to feel angry and frustrated when listening to my therapist describe all the ways in which I do tolerate uncertainty, except of course in my OCD hot spots.

My first impulse was to say, "So what?" Yeah, I drive without worrying that every odd clank I hear means that I hit a pedestrian. Yeah, I work at a hospital, and often ride elevators with patients and family and doctors come in and out of my office all day, and even though I run through all sorts of scenarios of contamination in my mind, they pass through. Sometimes I do obsess that I'll start obsessing about these things. . .

My next impulse was to want him to shut up. I don't want to think about other things I could obsess about. Ironically, the first time he told me that I tolerate the uncertainty of getting in the car and driving to work, risking death and destruction, I then backed my car out of the therapy center parking lot directly into a car parked in front of the neighboring garage. The car was there for smoothing out a dent in the roof from a golf ball, and I put a much larger dent in the side of the door. But I dealt with it. It sucked. I put $400 dollars on my credit card to pay for the necessary parts. It was a very expensive therapy session. But I still don't obsess about driving.(Though this wasn't always the case.)

But if it's a body symptom that I notice, a spot, an asymmetry, a miniscule white area, a twinge, a bump, then my OCD is all over it. I want certainty about what it means, right now. I want to know the future, how it will all turn out. I crave doing tons of research trying to figure out what it means. I keep checking the area, prodding it, touching it, comparing both sides, using a flashlight, a magnifying mirror. I want to know what it is, definitively and for all time. This isn't something humans get. I can usually diagnose myself with great accuracy, but it doesn't stick. If it were someone else, I would assume it was benign--a mole, a normal variation. And I would go to doctors frequently for reassurance, but relief would only last a second, because what if they missed something?

And yes, sometimes doctors do miss something. That's a part of the pain of living. I hate that. But putting my life on hold to figure out symptoms, to ward them off, figure them out, analyze and classify them is even more painful.

OCD the Perpetual

I'm back at the computer, same scenario, fairly random websearching when there are other things I want to be doing. I still get surprised when this happens. My ERP therapist says it's OCD's job to perpetuate itself, that it will show up.

I may need to write a script for this, because OCD is getting free reign, and I still fall for its promises that if I just look at one more email, one more link, one more site, then it will leave me alone and I will *feel* ready to get up and do something else.

Any phrase beginning with "Just one more" can't be trusted.

One more sentence.
One more minute.
One more time.
One more page.
One more word.

OCD Toolbox: Listening to Scripts/Imaginal Exposure

My husband had this habit, when records were still current, to play one side over and over, the arm continually lifting up and going back to the beginning. This drove me crazy, but it's the same principle that helped me to deal with my indecision. Jon Grayson discusses this in his book, and once I started writing and recording and listening to scripts as both exposures and support for doing exposures, I was able to give the healthy part of myself more airtime. OCD usually has a monopoly on all channels, and has worn deep paths into my brain, but scripts gave me some alternatives.

Traditionally, tapes were made on the itty bitty cassettes in answering machines that can loop over and over. I used QuickVoice recording software, which is very inexpensive, and fairly straightforward to use, which enabled me to record my scripts sitting at my computer with no additional microphone or device needed.

I then listened to the script continuously on my iPod Nano. I have about 50 scripts that I wrote and recorded. In the case of decision making, when I went grocery shopping, I would listen to a script I wrote about it never being possible to make a "perfect" decision and that OCD will change the criteria of "perfect" the minute I start to reach for an item, and that my life was waiting.

The key was finding what gave me the most unease about an OCD fear, and directly addressing that in the script, putting it out there, rather than running from it. Yeah, I might choose the "wrong" item and feel my face go hot, and a panicky ache in my chest. I might really screw up, and be haunted by regret about my poor decisions and never have any peace from the obsessing about obsessing.

For about a year, I took the shopping script with me almost everywhere I bought things, and listening to it continuously, logging many hours, and gradually, in combination with flipping a coin when I really felt stuck, I freed up a lot of time in my life instead of circling the aisles of the grocery store, looking at every item, reading every label, picking stuff up and putting it down, over and over.

Related Posts:
OCD Toolbox: Flipping a Coin

OCD Flashback #2: Verbatims

I was 19, and had my first boyfriend. We would have long conversations on the phone, and then after I hung up, I'd work on reconstructing the conversation in its entirety. I filled scraps of paper with keywords. If I could not remember the order in which something was said, or what brought up a particular subject, I would sit there, frozen, going over it, hoping to jar the elusive chronology loose, dredge up the missing details. If I could not remember every line, I would feel a tightening in my chest, a vertigo of fear and anxiety.

The thought of losing even the smallest scrap of conversation drove me to document everything. I was hugely frustrated when I discovered the keywords were not enough to remind me what they were about. I knew this need to reconstruct was not normal. It ate up a lot of time and mental space. I half-heartedly wrote that if I wanted to be a therapist, at least I would be very good at writing verbatims of case sessions.

I was all alone in my fears. I couldn't tell anyone what I was doing. They would think I was loopy. I was living in a new country. I was homesick. My father had left. I really never expected anyone to love me. I was afraid of losing this boyfriend. OCD latched onto this with a vengeance--Just write it all down. Capture it. Preserve your relationship by hoarding every word.

Related Post:
OCD Flashback #1

Ritualizing in my Head: Retracing

After writing the acupuncture post, I found myself retracing whole sentences in my mind as I tried fall asleep last night. I used to think this was the obsessional part, but actually it's the thought, "Maybe there's something wrong with the post," that is the obsession, and retracing is the compulsing, the ritual that I use to calm the anxiety.

As much as I hate when I start retracing, it does damp down on the anxiety. This is counterintuitive, since I've had many times in my life that I've wished to excise this repetitiveness from my brain, but to stop retracing truly does feel very scary.

And if the critical voice starts chiming in with Why can't you stop? What's wrong with you? I feel even worse. The short answer is that I have OCD, that's what's wrong with me.

I can stop retracing. If fragments of sentences pop into my head, I don't have to get into a war with them. I could even tell myself that any post I write can be "wrong"--there's no way to be certain I'll never have someone disagree with anything I write. It sucks to sit with this anxiety, but being immersed in mental rituals sucks too.

Related Post:
Ritualizing in my Head: Freezing

Unhelpful Strategies #2: Acupuncture

About seven years ago, my mind was such a deluge of OCD intrusions, that when my previous therapist suggested I try acupuncture, I actually did. It's not that she had ever tried it herself or recommended it to anyone before, but she was desperate. There was a Western trained doctor nearby who had added acupuncture to his practice. He'd never used it to treat OCD, but he was more than willing to go ahead.

I was in the middle of a massive storm of fixating on whether or not I should take SSRI anti-depressants, and acupuncture hadn't yet been contaminated by obsessive panicky ruminations. I wanted relief, wanted some space in my head for other things besides retracing and researching every aspect of my life.

I did a typical exhaustive search of the medical literature, and didn't find evidence of acupuncture working for OCD, but neither did it appear that it would harm me. It was an exposure of sorts ultimately, because I look back now and wonder how I tolerated someone applying needles to my body, buzzing them, and creating some sort of smoke. Health anxiety is one of my root OCD themes. I once fainted from a finger stick when I attempted to give blood. Giving consent to invasive treatment was not my norm. Plus the doctor's attempt to give me reassurance that the moles on my back were ok had the rebound effect of stirring up all previous mole anxiety.

After the doctor recommended I take a Chinese herbal tincture to correct my "imbalance," OCD began waking up, and gnawing away at me. I researched every ingredient, and after becoming intimately acquainted with the industry, I reluctantly tried it, because I would do just about anything to avoid having to say no to someone with authority. It tasted like bitter tea, and was just vile enough that the healthy part of myself flashed an SOS, and I dropped out of my acupuncture treatment.

I was disappointed that the seas in my mind did not part and reveal a path on dry land. I don't think I expected acupuncture to help, but I had the vengeful critical voice saying "If you don't try it and it would've worked, you are negligent and a bad person."

Related Post:
Unhelpful Strategies #1: Setting a Timer

Squirrel Mind

I had some Squirrel Mind this morning. I've been paying attention to what I eat for about 6 months, and tracking my calories(which I do as an exposure by reminding myself I'll never have the exact accurate number of calories accounted for). This morning I was down 2 pounds, and Squirrel Mind flared--What if this means I've got cancer? What if something is wrong with me? This feels dangerous, therefore it must be.

I had a bout of major Squirrel Mind about 6 years ago. I read a book on factory farming, and was so haunted by scary images that I decided to become vegan, and also give up sugar at the same time. I started losing weight, and everytime I got on the scale, the Squirrel would start twitching. I could tell myself logically that I had changed my diet drastically, and it made sense that I was losing weight, but the Squirrel thought "Involuntary weight loss, illness, death."

Have you ever seen a squirrel dart out in front of your car, stop just out harm's way, and then spin around, run back in front of your car? This is standard squirrel behavior--major indecision in the middle of giant barrelling vehicles.

My ERP therapist likes to remind me that yes, I could have cancer, but my best guess is that I don't. No human gets more than a "best guess." OCD would like absolute certainty that I don't have cancer, and that I will never get, and I will erode much of the life I do have trying to get that certainty by fixating on getting that certainty.

OCD Toolbox: Flipping a Coin

I noticed a gap between my last two posts, ie. how did I get from vetting my food choices endlessly to having a mediocre lunch on Wednesday and going on with my day. As an aside, OCD perfectionism makes it hard to credit myself for any work I've done, as if somehow I was magically transported from point A to point B, in spite of my general wretchedness. But I know that's not what happened.

One of the most helpful strategies, that my ERP Therapist introduced me to, is flipping a coin. This short circuits all the OCD crap about choosing the "just right" item that won't trigger a cascade of obsessing and compulsing. Instead, I make the choice to jump into the fray, and accept whatever randomly comes up, and live with the anxiety it may cause, until it dissipates of its own accord.This is both terrifying and incredibly liberating.

Often, in facing a menu, I'd go back and forth, back and forth between 2 options, so as an exposure I'd say, If it's tails I'm getting the first item, if it's heads I'm getting the second item. I don't usually have a coin on me, so I started using my watch--if the second hand is in the first 30 seconds of the dial it's one, and in the second 30 seconds it's the other. This also works with digital watches--if the last digit is even vs. odd.

This works best with "yes" or "no" questions, or choosing between 2 things, and only if I go into it intentionally as an exposure, fully aware that I might not like what I end up eating, and get a spike of anxiety that I didn't adequately examine my choices.

It helps to remind myself that even with an hour of indecision, and thinking through every possible option, I could still end up with something I don't like, and I've wasted an hour. I have no special fortune telling powers, and no amount of menu perusing is going to guarantee an obsession free meal.

Of course OCD is clever and tries all sorts of ways to insinuate itself--should I use the coin toss? Is this the right time to do the coin toss? I would fight back by flipping a coin to answer that question.

Related Posts:
OCD Toolbox: Listening to Scripts

OCD Flashback #1

Writing my post yesterday sent me back to when I was 13 or 14. I'd go to the mall, by myself, and circle the food court trying to decide what to eat for lunch. I had a big heavy winter coat on, mostly likely puffy. I'd keep circling, reading every menu, more than once. Being indoors with the dry heat blasting, sweat would start to roll down my sides and into my waistband. I'm sad thinking of this poor girl and how exhausted she'd be by the time she finally ordered something for lunch. The food court was like a spot for OCD galactic meltdown. Not only did I need to choose where to get my lunch, but then which menu items.

In my 20's and 30's, if I had a day off, I'd become ravenous putting off lunch because I wasn't certain which task was "best" to do at any particular time, and if I did stop to eat, then I would have to decide what to eat, whether to eat at home or go out, and if I went out, I had a gauntlet of OCD questions to deal with--which would be the right place to eat? How would I know it was the right place? What did I have yesterday? Will I repeat myself?" All the while, hungry, not thinking clearly, sore footed, and generally frustrated with myself. A bone weary tiredness and a gigantic energy suck.

I loved places where I found something I liked, and could get it every time and it always tasted the same. This would be like a short cut to heaven! But life being what it is, nothing is ever completely consistent, and I am not psychic and cannot predict if the cook is having a bad day, and there is no Guidebook to Exactly What I Should Be Ordering.

I felt at war with myself. Part of me would just be "Order something already dammit. I'm hungry. I have other things to do." And the OCD would be going, "You will feel dread, doom, and not be able to focus on anything else if you pick something wrong, and it will suck up all the rest of your free time trying to make the dread feelings go away." Another sneaky slide into "obsessing about obsessing."

My ERP therapist used to work in a town with an incredible independent donut shop, which I would drive by on my way home, and I would stop and always get two donuts, even if I really was only hungry for one, because if one of them was disappointing, I had a back-up donut. The thought of boxing myself in with just one choice was panic inducing. I. can. not. make. a. mistake.ever. OCD will erode the most basic pleasures of life, including eating.

Related Post:
OCD Flashback #2

Yay for Dealing with Mediocrity

I had really mediocre bibimbap for lunch today at some express place I'd never been to, and what a relief to simply experience that it was like a salad bar selection of tired veggies, with spicy ketchup rather than Korean spicy red pepper paste, and then move on with my day.

In the past some of my most dogged ocd thoughts eroded my ability to enjoy eating out. I approached a menu like a test I had to study and answer perfectly, so there was a lot of pressure on making the "right" choices, because if I didn't, and the food wasn't good, then that meant I was an absolute failure, and I would try to "undo" that by going over my choice, and how I went wrong, and how to make sure I didn't do it again.

Then the obsessing about obsessing would start:
"Will I keep obsessing about this all evening?"
"Why do I do this? What is wrong with me?"

I once went out with a friend who picked up her menu, saw the first special, said "oh, that sounds good" and ordered it. That was alien behavior for me. I would've broken out in a cold sweat, assuming I should've examined each menu item closely and weighed my options.

OCD can be incredibly exhausting, especially when the observing part of myself could see that there was no real criteria for what the exact right choice was, and no way of predicting with complete certainty whether I would like what I ordered, and that judging myself defective in some way if I received mediocre food was disheartening, not to mention the cascade of "Am I enjoying this enough?" when I actually got a dish I liked. That is an existential question that cannot be answered.

So yay for today and my bad bibimbap! And surviving it. And making sure I don't go back to that place, which is what I suspect someone without ocd would do.

Related Posts:
OCD Toolbox: Listening to Scripts
OCD Toolbox: Flipping a Coin

Unhelpful Strategies: #1 Setting a Timer

I'm going to start a catalog of strategies that were not helpful for me in dealing with OCD. Last night's post about getting stuck at the computer reminded me of the advice a previous therapist gave me, "Set a timer." Essentially this results in adding the extra motion of resetting the timer repeatedly every time it goes off, but does nothing in helping me actually move away from the computer. It also results in a cascade of "What is wrong with me? Why can't I get up when the timer goes off?" The answer of course is that I have OCD.

On occasion I have used a timer as an exposure, and that is a whole different approach. That involves intentionally choosing to do something imperfectly, "wrong" or "badly" by limiting the amount of time spent on it. This can be effective, but I have to be in Exposure Mode so I don't slip back into "What's that beeping sound? Maybe it will go away so I can keep ritualizing."

The Pointless Ritual

Ok. I am at the computer, and I have slogged through my google alerts, did a survey for Preserve Toothbrushes, checked my email, and now my fingers are itching again to just keep looking at stuff on the web.

This is where I get frustrated, because it appears so pointless. There are things I'd rather do. I'm home from work, I ate dinner, and I have actual tasks that in another context I'd be happy to have the time to do. It's banal, minor, inconsequential appearance makes it easy to slip in under my radar. I'm Exposure Woman. Exposures should be BIG. Right?

I'm writing here to get some momentum to go upstairs. I know I need to identify what my feared consequence is. I usually short circuit that with "there isn't one. I'm just hopeless and/or a bad person." Sometimes I go with "I don't feel done yet. I am afraid of feeling anxiety when I get up and leave the computer," and then promptly start working through weeding bookmarks or looking at every message in my email, some of which I have looked at many times, and still not done anything with.

And then OCD gets clever and says "Keep trying to figure out why you are afraid to get off the computer. You really need to know the definitive answer on this." In the past this would be followed by an lengthy search of the psychological literature.

One of my therapist mantras is,"I don't need to know the answer to this right now," combined with recognizing the exposure material in the very fact that I don't want to get up, so therefore the best thing would be to get up. Bleah.

Some rituals feel important, like they have a point, that they protecting me from doom(even though of course they are not). The pointless ones suck up a huge amount of time though, and often get through unscathed by exposure. Ok. Writing this down helped. Here I go.

Related Post:
Unhelpful Strategies: Setting a Timer

Ritualizing in my Head: Freezing

The snail in my last post made me think of another creature, the rabbit. I read the newsletter of the International OCD Foundation for 5 years, and though there were many accounts of ERP working, it always seemed to be for people who had physical rituals. Washing hands. Counting. Reciting Prayers. I didn't think I had any rituals. It was all thoughts going on in my head, just obsessions.

Once I started working with an ERP therapist, I began to realize that one of the ways I tried to make obsessions go away was to freeze like a rabbit. If somehow I stay still enough, and avoid going on with my day, or my life, then I can make the anxiety go away. The very thought of carrying on sent a shot of of anxiety pumping through my veins.

This is where I ran into difficulty with Cognitive Behavioral strategies. I joined an anxiety support group in graduate school, and the psychologist in charge introduced us to ways our thoughts can be distorted, like "all or nothing thinking," or "emotional reasoning." We were to fill out worksheets identifying our thoughts and disputing them. At first this was a relief to know there were others who had similar ways of thought, that I wasn't completely alone in this, and that perhaps being able to label the thoughts would help them go away.

But as with much in OCD, this wasn't enough. It was as if I needed to freeze like the rabbit, hoping to fool the predator. I would fill out my worksheet, get a moment of relief and then try to hold my thoughts still and prevent them from spiraling out again into anxiety. OCD wanted absolute certainty that a feared consequence won't happen. Even the slightest chance of a catastrophe and the OCD wanted to gnaw at it and figure it out, and my goal was to prevent this exhausting process from happening, compounded by an OCD perfectionism that demanded I dispute the thoughts "perfectly" and got into an existential debate about which thought to start with and making sure I got every single one.

Related Post:
Ritualizing in my Head: Retracing

OCD and Living in my Head

I tend to go awry on new projects. The OCD is opportunistic and latches onto anything new with leech-like vigor. My intention was to find an avatar for this blog and several hours later I was past the time I needed to leave my computer, looking for an image that "felt just right."

Perhaps you have had this experience of not feeling finished, even if you can't articulate exactly what finished would mean.

OCD is seductive and says, "Just search another minute, or 15 minutes, or until the top of the hour or until you've looked at every single link in a list. . ." and before you know it, you are oblivious to your life, and completely in your head.

I did find an illustration. I still had misgivings, but just enough self-awareness to know that it would be good exposure for me to go with it in spite of this. It is an etching by George Cruikshank from a series he did of human capabilities, in this case ironically illustrated by a snail. Inhabitiveness resonated when thinking of the old habits I inhabit, like compulsive researching. My fingers are itching to do some major research of who this author was, and etymology of the word, but for this blog to be about Exposure Therapy, I am practicing just writing.

OCD steals the present moment. I had no real sense of what was going on around me while I searched for an image. I was firmly in my head. I'd like to move into the rest of my body. The snail at times also seems like my totem animal. I feel like I am moving very slowly in moving beyond OCD. But I am moving, and to acknowledge that is a big step.

Embodying a Life Beyond OCD

I had the idea to create a blog about OCD, and my ongoing experience in facing it through Exposure and Response Prevention Therapy(ERP). The idea floated into my mind this evening, and here I am writing something. This is definitely an exposure! One of the phrases that tipped me off to my OCD was "information hoarding" in an article by Renee Reinardy about 3 years ago in the OCD Foundation Newsletter, which sparked all sorts of recognition of patterns in my approach to life.

Don't do anything without extensive research, or a long complicated mental analysis of the best way to do anything. My computer was littered with bookmarked sites and downloaded articles which I usually never revisited in my quest for the perfect knowing of how to proceed. I lived in a state of exhaustion within my head, my hand molded to the mouse and my eyes fixated on the screen. Even now, I want to research what to say next, but here I go.