Alison Dotson's Blog

Earlier this year, Made of Millions—a nonprofit dedicated to helping the millions of people around the world who have a mental illness—published “Remapping Recovery: How Gen Z’s Quest for Better Care Is Pioneering New Paths Forward in Mental Health.”

Why this study, and why now? Aaron Harvey, co-founder of Made of Millions, said, “When we started in 2016, we used data that had been available for decades. So this research was an opportunity for us to better understand what the journey looks like for today’s youth, and specifically, how the internet’s democratization of mental health education and advocacy has shortened timelines and improved outcomes.”

As a person with a mental illness myself (but I’m part of Gen X, a generation that somehow sounds much closer to Gen Z than it is), I wanted to know more, especially the findings about my own diagnosis, obsessive-compulsive disorder (OCD), so I downloaded a copy. Some of the findings surprised me. Some of them gave me hope. And some of them confirmed that we still have work to do to make mental health care more accessible and inclusive.

When some of the gaps in access to mental health care are due to systemic inequality, it’s easy to feel overwhelmed, to feel a little hopeless and a little helpless. In the absence of sweeping systemic changes, what can we do to mitigate some inequities as we continue to fight? To be clear, I don’t believe the burden should be on the individual to fix a system, but I know I feel better when I can do something. To that end, I’ll include some ideas for getting help yourself or helping others.

What did Remapping Recovery find?

But first, let’s go over some of the findings. These two stood out to me:

Gen Zs take nearly two times longer to research mental health conditions compared to their parents, but are also half as likely to report being misdiagnosed.

and

. . . in more than 90 percent of self-diagnoses, . . . Gen Zs are coupling their self-diagnosis with a professional one, or plan to.

They stood out to Lauren O’Shaughnessy of Made of Millions, too. She said, “These findings were surprising because there’s a popular narrative right now that social media is encouraging young people to abandon traditional healthcare altogether and attach themselves to the first mental health condition they stumble upon. This perspective undermines Gen Z’s intelligence and ability to self-educate.”

O’Shaughnessy said that it’s not a lack of wanting professional mental health care that keeps Gen Z from taking advantage of it. Rather, it’s the barriers to access: “financial constraints, long waitlists, and practitioner shortages,” she said.

What can be done?

Gen Z are resourceful and will find information and support outside traditional systems. In an ideal world, this would only be a stopgap solution and would be supplementary, not a whole mental health care plan, but it’s important to know about the alternatives.

Esther Fernandez of Made of Millions said, “While it can be difficult to find someone who takes your insurance, there are definitely ways to tap into your community to see what is available to you. Using directories online is a good start. A local advocacy group might be hosting low-cost webinars, conferences, or support groups. A university might offer sliding-scale sessions with graduate students. Researchers might offer free medication or therapy sessions in exchange for research participation.”

What did Remapping Recovery find?

“On average, it took respondents about 2.5 years between symptom onset and diagnosis.”

In the OCD community, we’ve been saying for as long as I can remember (actual decades) that the time period between onset of symptoms and diagnosis is 13 to 17 years. But this study’s respondents included kids under 18, a group that’s been omitted from other studies, and that time period is much, much shorter. (Keep in mind that Remapping Recovery isn’t a follow-up to those studies.)

Harvey credits this change at least in part to OCD advocates “who have spent the last decade making topics like intrusive thoughts part of our youth’s everyday vernacular.” Young people are finding community and non-stigmatizing information about mental illness online—and of course, they’re finding misinformation there as well.

A couple of years ago, I stumbled across a TikTok about taboo intrusive thoughts that was so stigmatizing it still upsets me. When I commented to explain that sexual and violent intrusive thoughts are a common symptom of OCD, the replies were from angry (and probably scared) people who don’t understand what OCD is. All I could think was How will this affect someone who hasn’t even started their recovery journey?

Helpful, well-researched videos about OCD—and other diagnoses—are abundant on TikTok and other social media sites, but one wildly wrong one can have a devastating impact if viewers don’t know how to determine which sources are credible.

What can be done?

Uma Chatterjee, a member of Gen Z—oh, and neuroscientist, so she knows a little something about research—said, “Learn how to vet your sources and build literacy and you don’t have to understand everything. You have to understand who to look for and how to cross-check that information to make sure it’s accurate and it’s coming from someone who doesn’t have a vested interest in you being sick or buying their product cause they have the secret sauce to fix something that no one else has.”

The National Association for Media Literacy Education (NAMLE) outlines several questions people should ask to help determine whether the media they’re consuming is accurate and unbiased. Some include:

Who made this?Who was and was not involved in the creation of this?When was this made?Why was this made?What does it want me to do?Who is the target audience?Who paid for this?Who makes money from this?

While these questions can be applied to any form of media, Fernandez said it’s important to note that social media is different from traditional media. For one thing, anyone with an account can (for the most part) post what they want. Fernandez said, “Just because someone has a large following doesn’t mean their content is credible. The algorithm is also tailored to you, so you might get caught in an echo chamber of information and communities pushing certain agendas. If your feed is full of influencers going viral talking about the same topics, you might start to believe that everything they say holds truth.”

If something on social media seems too good to be true—or maybe too bad or too unbelievable—don’t stop with that first source. See if that same information is published elsewhere, and if that other place is a credible source.

What did Remapping Recovery find?

Eighty-five percent of Gen Zs either agree or somewhat agree that there’s a lot of stigma surrounding mental health, a number that increases to 90 percent among Gen Z Black, Indigenous, and People of Color (BIPOC). In fact, BIPOC respondents were 33 percent more likely to say that facing social stigma was one of the most difficult parts of their journey.

Chatterjee, who is brown, said reducing stigma in the BIPOC community largely falls to two groups of people: (1) Members of marginalized communities who have a diagnosis themselves and (2) allies. Beliefs about mental illness can be so deeply rooted, it is difficult to change the minds of folks in older generations, and without their support, younger generations are less likely to learn about mental illness or access helpful resources.

“You would think that educating peers would be easier,” Chatterjee said, “and that’s often just not true because they also grew up in the same type of stigma and they don’t have the ability to fight the stigma they have internalized about it, which means they won’t get help. So it’s just really isolating.”

What can be done?

When BIPOC are expected to shoulder the burden of reducing the stigma surrounding their own mental health diagnosis, it only adds to the inequities they face in other aspects of life.

While nothing can replace being accepted and understood by their own families and communities, “I think there’s more that people can do who are not part of these communities,” Chatterjee said, “like providing friendship and support and going out of your way to create spaces for validation. It’s nice to invite someone to a [mental health] conference, but you can also invite them over to your house and ask them how they’re doing and see if there’s anything they need, like a meal.”

Most of the “tips” in the “What can be done?” sections are far bigger actions than anyone with a mental illness should have to take on, and I want to reiterate that what is really needed is an overhaul to systems in the United States. But in the meantime, let’s try to chip away at it with community, support, and educational resources that don’t require an appointment, insurance, money, or a world where stigma and inequities aren’t real barriers to evidence-based care. Studies like Remapping Recovery matter because they shine a light on gaps that are hurting people with mental illness.

Hello! It’s been a while. I’m back now because over the past couple of years I’ve been seeing and hearing more about a new-to-me type of therapy for obsessive-compulsive disorder (OCD), inferenced-based cognitive behavioral therapy (I-CBT). I’ll be frank: I didn’t get it. I can explain exposure and response prevention (ERP) in about a minute, and that includes an example of how it works. I can’t do that with I-CBT—I’ll start to try to explain it to people and I have to stop. That’s frustrating! That’s why I asked Mike Heady to answer a bunch of my questions, which he very graciously did—including my follow-up questions. This is a long one, but I hope you find it helpful.

I was diagnosed with OCD over eighteen years ago, and one of the first things I learned about it was that the “gold standard” treatment was exposure and response prevention (ERP). In the past couple of years I’ve started to hear more about I-CBT. Full transparency: I’ve read a few articles about it, listened to a presentation on it, and attended a panel with OCD therapists who implement it with their clients and I still don’t understand it. I know I’m not the only one who’s a little confused, especially after years of telling people ERP is the best way to treat OCD. I invited you here because you were recommended as someone who’s well versed in I-CBT, and I genuinely want to understand how it all works.

First, tell me about yourself! How long have you been an OCD therapist, and how did you decide to focus on OCD? How long have you been using I-CBT with your clients? Do you still use ERP?

I have been specializing in the treatment of OCD, anxiety disorders, and related conditions for 17 years. After I graduated with my masters, I applied for a year-long mentorship program with the Anxiety & Stress Disorders Institute of MD. Think of it as a post-doc. I had the pleasure of shadowing some incredible clinicians like Carl Robbins and Sally Winston. While I was in the mentorship, I was also an adjunct professor of psychology at McDaniel College where I taught part-time for 10 years. Today, I am one of the owners and directors of the Institute. My decision to focus on these disorders is a mixture of being a fellow anxious person and being committed to understanding the unique puzzle these disorders present. I love to learn how and why things work which, in turn, informs how you approach them.

I began learning I-CBT in 2018 when Carl Robbins, our director of training, brought it to my attention. He had a few email correspondences with the late Kieron O’Connor, who is the co-developer of the approach. Carl was captivated and his curiosity and excitement rubbed off on me. In March of 2020 when the COVID-19 pandemic caused a shutdown, I was able to really dive into the I-CBT manual and start implementing it. So, it’s fair to say I’ve been using I-CBT for just over four years.

In my clinical practice, I continue to use ERP from an ACT-informed perspective when needed. It’s just now I am able to offer clients options that I could not before.

Pretend you’re in line for coffee at the OCD conference and you only have a minute—literally 60 seconds—to explain I-CBT to the person behind you. You have to grab your coffee and go, Mike! What do you say?

I would probably offer you an analogy. Imagine you are attending the best magic show to ever be. This magician is doing the impossible because you are watching an object disappear right before your eyes. You know things don’t just disappear but that is what you experience. You cannot explain it and for a moment you question your senses and reality itself. I-CBT shows you the magician’s secrets to how the illusion was pulled off. The sleight of hand. The misdirection. The showmanship of it all. Now imagine after you learn these secrets, you attend the show again. Do you remain tricked? I-CBT isn’t about tolerating fear or focusing on effortfully removing compulsions. Not that there is anything wrong with those approaches. I-CBT is about showing you how obsessions formed and tricked you into thinking you were in danger or that you were the danger when you clearly are not. If one knows and trusts the obsession to be irrelevant, what is left of OCD?

Now pretend you’re relaxing in the lobby. You have all the time in the world, and someone approaches you and says, “I understand ERP, but I want to learn more about I-CBT. Tell me everything. How does it work? When did it come about? What is research saying about its efficacy?”

I-CBT began when Kieron O’Connor observed that obsessions commonly took the form of a conclusion about a circumstance in the here and now rather than an intrusive thought that got stuck because it was scary. This seemingly innocuous observation has serious implications for how OCD is understood and how it’s treated. Basically, I-CBT would suggest that obsessions are faulty conclusions to doubt something about the here and now that ought not be doubted. They are obsessional doubts as opposed to normal doubts. Obsessional doubts are unique to those with OCD and related conditions (body dysmorphic disorder, eating disorders, and hoarding). There are several reasoning devices that are collectively referred to as inferential confusion, and I-CBT aims to deconstruct these processes through a series of modules, thus helping the client remove obsessional doubting (aka inferential confusion) and re-orient trust back into how they reason (normal reasoning) in all other areas of their life.

If we take the stereotypical case of hit-and-run OCD, a person driving a car to work runs over a pothole and within seconds is feverishly checking mirrors and trying to figure out if they hit someone, and eventually they turn around to check the sides of the road just in case. What happened in those moments, according to this approach, were not intrusive thoughts of maybe hitting a person that were taken as credible because they were scary and sticky. Rather, it was a reasoning process that was initiated once the pothole was hit, which is true of literally everyone who hit that pothole that day, with a significant exception. Most everyone else reasoned that the pothole may have damaged their tire or rim, which led them to keep an eye out for a wobbly car or a low tire pressure signal. But the person with OCD had a very different reasoning process with that pothole. They concluded that it could have somehow been a person rather than a pothole. And this conclusion felt absorbing and credible and urgent. How it was that they concluded what they did and why that conclusion was so credible and absorbing is where I-CBT focuses treatment. In this way I-CBT is said to work upstream from standard treatment models. It does not focus on fear and compulsions, but rather preceding reasoning processes that set them in motion.

Here is a schematic to illustrate this process:

Summary of Data/Efficacy:

It was in 1995 that the first theoretical paper with this observation about how obsessions come about was published. Four years later the first empirical investigation into this kind of doubting process was published by Paul Emmelkamp and Fred Aardema. Eventually, these distinct reasoning processes were collectively operationalized into a process referred to as inferential confusion. In the 25 years since, dozens of peer-reviewed studies on inferential confusion have validated it as a significant predictor of OCD independent from negative mood states and the obsessive beliefs categories noted by the obsessive-compulsive cognitions working group (OCCWG), which were inflated responsibility, perfectionism, intolerance for uncertainty, importance of thoughts, the need to control thoughts, and the overestimation of threat.

There is mounting data showing inferential confusion and feared self predicts OCD symptoms before any of the belief domains arise. This mediator analysis, which was a large replication study of 350 people diagnosed with OCD, demonstrated that inferential confusion and feared possible self sequentially mediated OCD symptoms completely independent of all obsessive belief domains and negative mood states and by itself explained 42 percent of the total variance of OCD. And, since I-CBT accepts that belief domains are relevant in OCD, despite them being downstream processes of inferential confusion and feared self processes, when we add relevant belief domains, total explained variance is about 58 percent, which is very significant. Data is mounting that shows inferential confusion as a mechanism of change, meaning that the resolution of inferential confusion predicts the reduction in OCD symptoms. Approximately six peer-reviewed studies showed this. In fact, a soon-to-be-published moderator analysis of a multisite randomized controlled trial (RCT) that looked at I-CBT, ERP, and mindfulness showed that the only cognitive process to predict the OCD symptom reduction in all groups was inferential confusion. This was directly compared to intolerance for uncertainty/perfectionism, importance and control of thoughts, and responsibility/threat. Aside from data validating inferential confusion as a central cognitive factor in OCD there is also data supporting numerous meaningful distinctions between normal intrusive thoughts that we all get and those that are relevant to OCD. For a more detailed description of these differences see Audet et al. (2020).

Once inferential confusion was demonstrated as distinct from other cognitive factors suggested by other treatment models, a new treatment model was constructed with the explicit purpose of resolving inferential confusion. This treatment was originally called inference-based therapy (IBT) and is now called inference-based CBT (I-CBT). It is primarily a cognitive treatment in that no deliberate or prolonged contact with distress (i.e., exposure) is required nor is any deliberate response prevention. The treatment focuses on helping the client build awareness of how they reasoned themselves into the obsessional doubting (faulty conclusion) so that they can return to their normal reasoning that they trust in all non-obsessional areas of functioning.

The first randomized controlled trial by O’Connor et al. was published in 2005. It showed two important outcomes: First, ERP and I-CBT were both equally effective at reducing OCD symptoms (neither was superior) and the second was that I-CBT appeared to be superior to ERP in helping a subgroup of those OCD sufferers with overvalued ideation. This RCT was small and needed replication in a larger sample. In 2015, an independent lab in the Netherlands conducted the second RCT with a larger sample and replicated the findings of the first RCT. In 2016, a large open trial with a waitlist control group demonstrated I-CBT to be effective across all OCD symptoms dimensions and showed that reduction in inferential confusion predicted the reduction in OCD symptoms. In 2022, the third RCT replicated yet again that I-CBT shows similar effectiveness as ERP at reducing OCD symptoms (neither treatment was superior). Most recently, the group in the Netherlands published a very large (about 100 participants per group) RCT with a non-inferiority design to see if I-CBT was equivalent to ERP as well as whether I-CBT was a more acceptable treatment option. Results on equivalence were inconclusive and both treatments were again shown to be similarly effective at reducing OCD symptoms. However, regarding treatment acceptability, I-CBT was found significantly superior to ERP. Treatment acceptability was measured with the Treatment Acceptability/Adherence Scale. Overall, participants in the I-CBT group found it less exhausting, less distressing to engage with, and less intrusive to their lives compared to the CBT/ERP group. I-CBT was also rated as less likely to drop out of compared to the CBT/ERP group (Wolf et al., 2024). A soon-to-be-published RCT, this one also with a non-inferiority design, will clarify the equivalence of I-CBT to ERP. This means to date there are six controlled trials testing I-CBT’s effectiveness and all agree that I-CBT is effective and not inferior or superior to ERP, albeit, more tolerable.

The body of research supporting I-CBT is substantial and growing. Approximately 100 peer-reviewed studies from independent labs across the world are demonstrating inferential confusion to be a central cognitive factor in OCD as well as I-CBT as a safe and effective treatment for adults with OCD. A growing body of evidence is demonstrating the relevance of feared possible self to OCD symptoms as well as its mediating role between inferential confusion and OCD symptoms. All this to say that the data points toward I-CBT’s assertion that inferential confusion and feared possible self precede other known cognitive factors in the development of OCD.

Can you break down how I-CBT would address the hit-and-run example above? What would you say to the client? What exercises would they work through? How would you know it’s “working”?

The how, in detail, is complex. [Kieron O’Connor wrote a breakdown of a case study that will help explain it, in addition to the description provided below.] I will briefly elaborate on a few modules here but not all.

In the case of hit-and-run OCD, I-CBT would focus on the initial doubt (what if that was a person?) and begin the 12 modules. The first 4 modules are considered psychoeducational. There is not challenging; rather, there is information gathering and organizing. Let’s look module by module how hit-and-run OCD would be addressed:

Module 1: The OCD sequence and identifying the initial doubt. The goal is to help the client be able to organize numerous OCD stories into the sequence and identify the initial doubts. In addition to this, the client also notes that the problem began with the doubting, not with the trigger or with any other part of the sequence. If the doubting were resolved, what would be left?

Hit-and-run OCD sequence:

Trigger: Drove over pothole

Doubt: What if that was a person?

Consequence of the doubt: A person could be hurt or dead.

Emotion: Guilt, fear

Compulsion: Check mirrors, check memory, turn car around to look for body, scan newspaper for report of a hit-and-run, etc.

Module 2: The doubt has its reasons. From the vantage point of the OCD, what about this doubt makes it convincing? Why attend to it rather than discard it? Here the goal is to hear out the client’s reasoning. It’s a validation of what goes on in their mind. We categorize the reasons into Possibility, Hearsay, Personal Experience, Out of Context Facts, and General Rules. The client would apply this to other OCD examples not necessarily their own but to get competent with the reasons.

If I hit a person I would feel a bump and I did feel a bump (out-of-context fact).

Hit-and-runs do occur so its not impossible that I did it (possibility).

Good drivers keep their eyes on the road and I might not have been perfectly attending to the road (general rules).

I heard that distracted drivers are more likely to hit pedestrians (hearsay).

When I was a teen learning to drive I hit a mailbox because I wasn’t paying attention, so that means I am prone to being a distracted driver (personal experience).

Module 3: The obsessional story. Obsessional doubts are not removed from our normal construction of reality, which means they are embedded in a story. The story is powerful in its ability to make things feel real and credible, so we demonstrate the power of the story and how a story’s ingredients absorb you into its reality. In this module the client is made aware of how stories generate a credible account of events even if imagined. Lastly, the client produces a counter-story for their OCD that starts from the same trigger but ends with a different conclusion (it was a pothole or debris that I ran over…). This is not to dispute or refute the obsessional story but rather to bring awareness to the availability of numerous stories that could be constructed with the same triggering event and that their specific obsessional story was just one of many possible stories.

Module 4: Feared possible self. Why this theme of OCD and not another? Here the client explores what underlying vulnerability set them up to reason with the pothole in this way rather than a completely different non-harm OCD situation. We help the client reveal that they have a story about the self that creates a hypervigilance for here-and-now circumstances that are relevant to being a negligent, irresponsible, careless or evil, bad, immoral, polluted . . . kind of person.

Modules 5–8 are intervention modules.

Module 5: OCD doubt is 100 percent imaginary. Here we help the client explore normal versus obsessional doubting. How they are constructed differently. It is their construction that renders them imaginary or not. Through examples the client gets competent at this distinction and then applies their understanding to their own doubting. They will see it is constructed obsessionally (through inferential confusion) and therefore is imaginary or hypothetical and not reality in the here and now.

Module 6: OCD doubt is 100 percent irrelevant. If the doubt is obsessionally constructed and not normally constructed then it is not relevant to the here and now. We explore why possibility is not relevant to reality by itself. We explore how all of the reasons OCD uses do not make the doubt relevant to the here and now. We explore what information would need to exist to make the doubt relevant to the here and now.

Module 7: The OCD bubble. Here we explore the absorbing and dissociative nature that inferential confusion creates. It lures you into its bubble where you are removed from reality in the senses and common sense and instead attend to possibilities and imaginations as more credible and relevant than reality through the senses. It goes into how OCD feels real and credible and urgent by disconnecting you from the present moment. An experiential exercise highlights the crossover point where you were in reality and then were absorbed into the OCD bubble and floated away from reality into your imagination.

Module 8: Reality sensing. Now that you are aware of obsessional versus normal doubting and understand all the ways in which this imagined and irrelevant story has tricked you, you now practice getting in contact with your senses and common sense in previously obsessional circumstances. This means the driver with hit-and-run OCD uses their five senses and common sense to drive down avoided roads and act upon what the senses are saying. If they hit a bump, they are trusting their senses rather than doubting them and indulging imaginations. Some of the practice here would be to help them connect to how they know anything about their present moment. How do you know when the chicken is cooked? How do you know when your spouse is upset with you? How do you know when the car is moving versus still? By making explicit how we know anything about the present moment (through senses) it is then generalized to their previously obsessional areas. This practice helps the client realize they already use and trust their senses without effort in everyday circumstances. Now we just ask them to do that normal sense work in the circumstances where the OCD bubble had previously caused distrust.

Module 9–12: Consolidation/relapse prevention

Module 9: The alternative story. Client is now rooted in reality with their previously obsessional circumstances, and we help them generate a more reality-based story. This story is an elaboration on the module 3 counter-story, but we add in how and why the client knows, through five senses and common sense, that their drive down a bumpy road is just that, a bumpy road. This story is rehearsed in non-obsessional moments (so it does not act as a disputation or refutation or compulsive reassurance). Again, this is not to replace the OCD story but to create an alternative option to be available to the client. Which do we trust and know to be real and which comes from the imagination?

Module 10: Tricks and cheats of the OCD con artist

Module 11: The real self

Module 12: Relapse prevention

While the last three modules are important, they are more connected to resolving the inferential confusion about the self (aka feared possible self) and then troubleshooting problems.

Each module has in-session worksheets, homework, and quizzes to test learning objectives. This is used at the discretion of the clinician based on client need. In short, you know the model is working when the client begins to trust their senses and self in day-to-day moments instead of getting lost in obsessional narratives. A signal of this could be the removal of compulsions and avoidances on their own volition or because it just made sense to not do the compulsions. If one is regimented in their clinical style they could administer the Y-BOCS and Inferential Confusion Questionnaire pre-treatment, midway through treatment, and post-treatment. Scores should ultimately drop below 92 to be in subclinical range. I usually just let my client report back how they are doing.

In summary, I-CBT systematically helps the client reorient themselves to their senses and common sense in situations where OCD had coaxed them away. Through a series of cognitive processes and experiential exercises, the client learns that they have been tricked by a clever and immersive faulty reasoning process applied to selective situations that drew them further into the land of the hypothetical and imagination. In effect, I-CBT breaks the obsessional doubting spell by showing you how it was constructed, selectively applied, and in contrast to how you reasoned in all other areas of living.

Something I’ve been having trouble understanding is how to avoid a spiral into compulsions while engaging in I-CBT. If you told me certainty was possible, I’d want proof of that. If you mentioned reasoning I could easily start to question why I have the obsessions I do—that was a huge problem for me and something I still struggle with. How do you make sure your client doesn’t devolve into reassurance seeking while on their path to certainty?

From an I-CBT perspective, obsessional doubt is when the person has knowledge about a situation in the here and now and then doubts this knowledge. The how and why one doubted is what I-CBT addresses directly. It offers insight into why this obsession and not others and yes, certainty in one’s senses and self in the here and now is as available for those with OCD as those without OCD. The latter doubt what they know. While it is true to note that no one has certainty about the future it is also a red herring. Obsessional doubting is occurring in the here and now, as are the compulsions, not the future. There is sensory and common sense data here and now and those with OCD are reasoning with that information and drawing conclusions in the now. In this way, I-CBT is not disputing or refuting one’s thoughts but rather discovering the process of how they arrived at conclusions about themselves and the world.

The chance of OCD trying to misuse treatment as a compulsion is present for all treatment approaches. So long as one is being guided by a knowledgeable therapist, I think the risk of I-CBT facilitating compulsions is no different than ERP.

And do I have it all wrong? Does I-CBT not say certainty is possible? If it doesn’t, why do you think I could have gotten the impression it does?

Yes, there is certainty; however, I-CBT does not say there is certainty about the future, nor does it say there is certainty in situations that lack sufficient information to draw reasonable conclusions of knowing. For instance, imagine you applied to five universities and have a favorite, but you have yet to hear anything back from the schools. The doubt—what if I didn’t get into my college of choice?—is an example of a situation where not enough information is available to know. Another example: Imagine your doctor orders a biopsy of a lump and it’s not back yet and you say, what if my biopsy results show cancer?

These are all example of situations where there isn’t enough information to know, so true uncertainty exists and must be tolerated. However, if someone says, “What if that pothole was a person?” or “What if I am a violent serial killer?” these situations have available sensory and common sense information (which we all have) that lead to knowing. Those with OCD doubt this knowing. Think of it this way: If you came home from work and saw smoke and flames rising from your house, would you dismiss that sensory and common sense data and instead conclude that I might just be seeing things and you can’t know anything for sure and maybe it’s on fire, maybe it’s not, guess I’ll have to tolerate not knowing? Of course not. You would call 911 and say your house was on fire. You have certainty your house is on fire. So yes, certainty exists in this way and those with OCD have similarly available here-and-now sensory data to know the obsession isn’t true, but they doubt that information. Again, I-CBT is interested in showing you the how and why you doubt this way and how to resolve it.

When I’ve talked to fellow OCD-havers about I-CBT, some of them have said they don’t think they could easily engage with their senses because testing their physical reactions to obsessions is a compulsion. Let’s say someone has pedophilia OCD and they feel arousal but their therapist has just told them to trust what their body is telling them in the moment. How would you ensure they don’t now believe they really are a pedophile because their body has sent them the message that they are?

There is no testing in I-CBT. I-CBT is more than an instruction to engage your senses so the treatment process cannot be taken out of context in this way. The non-concordant arousal you mention is an example of an out-of-context fact from an I-CBT perspective. It could be a fact that arousal occurred, but the context is what makes the information relevant to being a pedophile or not. I-CBT specifically addresses this kind of irrelevant association that OCD uses to confuse you. The same argument could be used for headaches and brain tumors. Sure, brain tumors are associated with headaches but there is a context that makes that association relevant or not. The devil is in these details.

Sorry, I didn’t mean that I-CBT asks clients to test themselves, but I understand how it came across that way. It’s a concern I’ve heard people voice, that since they have struggled with the compulsion to test their senses (did I like that? Did my heartbeat speed up when I thought of stabbing someone? Did I feel it move?) they’re wary of the idea that they would be asked to trust their senses.

What’s an example of context that would make it irrelevant? What if the context is that someone is reading an article about Jeffery Epstein and how he brought girls to his island so people could have sex with them, and then you kinda picture it and you feel a sensation?

If someone reads about or hears about or pictures sex, it is within normal to experience signs of arousal. If I experienced arousal from tight-fitting pants, I am not desiring my pants nor does it speak to my orientation. Stimulation of any kind causes a response. By itself, arousal does not inform desire or consent. Yet the doubting is trying to make it so by inventing a possible context that does not exist, namely desire. (See the comment from your previous question–did I like that?) This is an example of a doubt. We know when we like something. We know when we desire and consent to something. If we are asking if we liked it, we are doubting.

Are there any types of OCD that I-CBT couldn’t treat as well as ERP?

Current evidence would suggest I-CBT is effective for all symptom dimensions of OCD (Aardema et al., 2017). However, to take it one layer further, I would say I-CBT treats all inferential confusion (obsessional doubting). There may be circumstances where a client looks to have OCD but it is really trauma or GAD where inferential confusion is not as significant a factor. 

What is your position on using both I-CBT and ERP?

They can be used together or sequentially; however, care needs to be taken as these are very different interventions for different mechanisms of change. ERP pursues extinction learning via habituation or inhibitory learning. I-CBT pursues the resolution of inferential confusion. One needs to know the distinctions between these two mechanisms, so treatment is coherent.

A few modifications to ERP would remove much of the potential tension. First, focusing on in vivo or interoceptive exposures rather than imaginal exposures is suggested. Imaginal exposures as they are utilized in the RCTs of ERP, pursue the evocation and sustainment of distress often with efforts to increase the reality value of the imaginal script in the pursuit of extinction learning. This specific implementation would go against the effort to resolve inferential confusion as it deliberately draws on the imagination to absorb you into hypothetical scenarios to generate distress. The more reality value the better from the ERP perspective. The second is requiring the client to tolerate uncertainty about situations that do not require such toleration. As noted previously, certain doubts require tolerating uncertainty because there is not enough information to conclude knowledge, as in GAD; however, OCD doubting does not operate this way. These interventions implemented in these ways can create confusion for the client.

Otherwise, these approaches are not in conflict despite seeing OCD differently. In fact, there is data soon to be published that shows inferential confusion predicted OCD symptoms reduction in three treatment groups, I-CBT, MBSR, and ERP. So, ERP can reduce inferential confusion too, but it’s not required.

I’ve noticed division among therapists—some believe only ERP works for OCD, some believe I-CBT is better than ERP, and some are willing to try both as long as it works for their clients. Why do you think this has been a hot-button issue?

It’s unfortunate but not unexpected. Ultimately, I think it is because the contributions of I-CBT are challenging to the status quo. It is disruptive.  Deeply held ideas are slow to adapt. I think of it as pushback rather than division. Some have felt that I-CBT advocates have made claims that outpaced the evidence others are concerned about leading young therapists astray. Neither of these criticisms are about the actual approach. They are more about qualms with isolated comments from individuals. I think these criticisms are equally applicable to CBT/ERP advocates as they are to I-CBT advocates and in my opinion, it’s not about those issues fundamentally. There has been occasional hairsplitting about what constitutes evidence-based which appears an almost moving target at times but to clear up any obfuscation, I-CBT is evidence-based. It satisfies all the fundamental pillars of empirical support for psychotherapies. To be reviewed by the American Psychological Association for their designation of “Empirically Supported Treatments” I-CBT needs to complete a meta-analysis. This is largely a procedural step, and it will be completed soon. More data is always needed but as it is today, I-CBT is a reasonable choice. It is listed as an evidence-based treatment for OCD by Scotland’s NHS.

I do not want to overemphasize the pushback either. By and large, the OCD community of clinicians and sufferers have embraced I-CBT. The community of clinicians interested in and learning about I-CBT in the US began with a dozen or so in 2021 and is now about 4,000 in 2024.

Please help me welcome Michael Schramm, one of the nicest and most positive people I know! He is truly a day brightener, and I’m so happy to host him today and learn more about his experience with OCD. If you live in the Wichita, Kansas, area be sure to see him—and other amazing advocates and therapists—speak at the OCD Gamechangers event this weekend.

You’re about to share your personal experience with OCD at an OCD Gamechangers event in Wichita, Kansas. Why did you decide to tell your story on stage?

I decided to tell my story on stage because I know how isolating having OCD can be, and if it helps someone in the audience feels less alone, it is absolutely worth it. When I was diagnosed at 16 this was a disorder I knew nothing about, and didn’t know anyone who had OCD that I could relate to and have that bond with. By telling my story I hopefully can be someone that the audience can have that feeling of you know what? I am not as alone in this as I thought I was, that there are other people that I can talk to and keep in touch with.

The other reason is to show myself how far I have come in my own OCD journey; I never thought for the longest time that I could do something like this. When I experienced my first Gamechangers event in 2020 I thought it was so incredible how all these people where sharing their stories, and I thought that would be great if I could do the same one day, and here I am getting ready to do the exact thing that in 2020 I dreamed of doing. To show myself that OCD doesn’t get to dictate everything I do.

Give us a little sneak peek of what you’ll be sharing: When were you diagnosed with OCD, and how long did you have symptoms before you realized that you might have OCD?

I was diagnosed with OCD at the age of 16 in 1998 at Menninger Clinic in Topeka, Kansas. I had been receiving therapy all throughout my childhood. My symptoms started at a very young age around 5 or 6. The first intrusive thought I remember was when I was coming home on the school bus a girl got sick on the bus. I was worried I couldn’t get back on the bus because if I did I would get sick on the bus. It got so bad my mom had to start riding the bus with me; when that didn’t work my mom had to start driving me to school for a while. The other memory I had when I was child was having visions of people in my head called The Spirit People that resembled what I thought looked like Jesus. They would tell me I would have to do things like tap a certain number of times, or walk between the couch and the chair or something bad would happen to my family. It wasn’t until I was a freshman in high school that my talk therapist suspected I had OCD. She referred me to an OCD specialist at Menninger Clinic and he diagnosed me as having OCD.

Once you knew you had OCD, did you tell friends and loved ones? If so, how did you go about it? Were you nervous to do it, relieved to get it out, happy to finally talk about it?

We told family members for sure, because I had such a difficult childhood with all that had been going on with intrusive thoughts. We just didn’t know that was what it was, so we wanted to let them know. It was a lot easier to tell them.

As far as friends, I told my best friend and he was very understanding, though I was nervous that he wouldn’t quite get it or understand, but I didn’t tell anyone else for quite a long time because I just was not ready for that yet. When I diagnosed was a very rough year because I had been bullied and picked on all year long my first year of high school, which led me to transfer to a new high school. That was a good change for me.

When I was first diagnosed I started doing ERP in a group with others that had just been diagnosed as well. It was just nice being around others that had been going through their own OCD journeys as well, and to know I wasn’t the only one going through this.

What has helped you the most in your recovery process?

ERP [exposure and response prevention], and medication have helped. But what I always come back to is the OCD community. I went to my first IOCDF conference in 2018 in Washington DC when I was going through a rough patch at the time.

I was very nervous to go, but my parents thought it could be very helpful for me, and was it ever! I went there knowing no one, and met so many people who just got me, and understood me.

The next year I went to the Austin IOCDF conference and was much more comfortable and that was the year I really started to make friends that I stay in contact with on a regular basis to this day via phone conversations, Zoom meetings, and social media.

Knowing I am not alone in this has helped me more than anything. I am just blown away with how loving, supportive, and caring the OCD community is. I think of it as my extended family now.

What do you wish people understood about OCD?

That OCD is a very stigmatized disorder and it is not just about wanting things clean or wanting things color coordinated. OCD comes in so many different forms. This is a disorder that is very debilitating and that is hard to live with, and when I see things such as shirts, etc. making fun of OCD it is hurtful.

If you could give just one piece of advice to someone with OCD, what would it be?

That you can live a very fulfilling, meaningful life even though you have OCD. There are so many resources, medications, people out there that can help you live that meaningful life. You are not alone in this fight.

My last Q&A was with Claire Ross Dunn, the author of the novel At Last Count, and I’m back to talk about the book!

At Last Count was a fast read, but not in a light and fluffy way (although I love those books too!). Since the main character, Paisley, has obsessive-compulsive disorder (OCD), there is a heaviness to the story, and what kept me reading even when I felt a little heartbroken for her was my desire to know what the heck happened when she was a teenager: Why had she been living in the same dingy apartment since she turned 18, and how could she afford even that in a big city (Toronto) on a part-time salary?

Chapters alternate between the life of current-day (2007), 39-year-old Paisley and that of 13-year-old Paisley in 1981. Both timelines give readers an accurate portrayal of how OCD can manifest (Paisley’s obsessions are around a fear of fire and her compulsions involve checking and counting in series of eight) and how it can disrupt a person’s life. Paisley is smart, has her degree, and has a part-time job, but she has a hard time getting out of the house.

She did not need a relationship. She did not want people in her apartment where she might have to act normal when she wasn’t feeling normal, and most of all, she did not want to have to share her secrets.

At Last Count

I appreciated that although Paisley is nearly 40 her life isn’t together. It’s sad, but it’s real. Since At Last Count is fiction it’s not meant to reflect a perfect world in which Paisley gets a diagnosis as a child, sees a trained and knowledgeable therapist who guides her through exposure and response prevention (ERP), and goes on with her life armed with all the right tools. What it does do is show the reader how confusing her symptoms were to experience, how people who have no idea what OCD is are concerned about Paisley’s counting, and how she wasn’t diagnosed in childhood despite displaying the symptoms for years. Some of her solutions to dealing with her OCD and making it “better” are common but ineffective and downright harmful, showing readers what is a normal lack of knowledge of the disorder.

‘Will things get better if I count eight sets of eight? Will I prevent a fire if I touch each light switch and outlet eight times? Not likely. But I do it anyway.’

Paisley, At Last Count

Readers will feel for Paisley as she struggles—even if they don’t have OCD or understand much about it, the torment is palpable. At Last Count is a sweet, sad, sometimes scary, and somewhat mysterious novel about a woman with OCD, but it’s not just about OCD. For those of us with the disorder, that part is the cherry on top.

As varied as our OCD stories can be, it always amazes me when I relate with someone’s story as much as I have with that of today’s guest, Claire Ross Dunn. We both have a thing with the number eight, we both have obsessions around a fear of fire, and we both put our book drafts in a drawer for several years before we finally got them published. And I am so glad Claire wrote her book, At Last Count! (Stay tuned for a review in a few weeks.) Read more about Claire’s inspiration for the book, how she navigated OCD before resources were widely available, and how she’s doing now. Thank you, Claire!

You recently published your first book, At Last Count, a coming-of-age novel whose protagonist has OCD. What inspired you to write At Last Count?

I did not set out to write a book about OCD. I started a writers’ circle with two friends around 2005 to create a space where I could just write for pleasure. The world of film and television, which is where I predominantly make my living, can be quite high stress, and I was glad to find a space for writing just for the joy of it. I started writing a short story about an introvert who falls in love with a bookseller at a very famous bookstore in Toronto, that is now closed, called the Albert Britnell Book Shop. It was a classic bookstore with floor-to-ceiling wooden bookshelves with ladders, and very knowledgeable staff; a dreamy place. So I was working on this short story, and two arts council literature grant deadlines to write books came up. We challenged each other to submit, and I received both of them. Suddenly I realized I had to write a novel, even though I didn’t know how. That’s how At Last Count started.

It wasn’t until many drafts and two fiction writing courses later, after I had submitted to three publishers and had been very gently rejected, that I realized suddenly that I was writing a book about OCD, and about my own experience in my youth with OCD. So ultimately, even though I didn’t know it, I guess my own OCD was the inspiration. But it took a very roundabout course. I think I had to coax my own brain into it.

Writing a book (and getting it published, no less!) is no small feat. Writing a book about a disorder that caused you so much personal pain even more so. Can you tell us about the writing experience? Did you question your decision?

Did I question that decision? Absolutely—only about a hundred times. I felt tremendous levels of stress submitting the book to publishers. That would have been around 2012. I knew the book was good enough to submit, because I had worked with several editors and mentors, all of whom I trusted. And so I was surprised at the level of stress I was feeling, given how often I pitch to producers and broadcasters in my life in television. What was up with all the stress? I literally couldn’t breathe.

After all three publishers said no thank you, and they all were very kind about it—they liked the book, but it wasn’t right for them—I felt tremendous relief. It was in that moment that I suddenly realized I had written about my OCD experience. I had conceived a book that was entirely fictional about a woman and her complex love affair with a childhood nemesis, but I’d actually written it from this very true place of having suffered from this OCD as a young person. And I just wasn’t sure what to do with any of it.

On a practical level, I was afraid that people in TV would find out that I had struggled so much with this anxiety disorder as a youth. I was probably through the worst of it by my mid-20s, but I will admit that I still have shadows of it to this day. There are things I will and won’t do, things that I know to stay away from because they are triggers, and just a general higher level of anxiety than the regular person.

So when those three publishers said no thank you in 2012, I shoved the book in a drawer for eight years. I told myself that trying to publish a book was folly—I’ve read that the rate of people getting their book published lies somewhere between 1 and 2 percent, so the chances of it happening are really low. I told myself that I had a successful career in television, and didn’t need to publish a book.

I didn’t really think about the book again until 2020, when COVID struck. The Canada Council for the Arts came out with a $5,000 grant to digitally pivot any project artists had on deck—a brilliant way they were trying to sustain the artist community that had been so badly affected by the pandemic—so I decided to apply. I couldn’t think of anything I could do for $5,000 in television, but suddenly I had this brainwave: I could record an audiobook of At Last Count. That, I felt I could do for $5,000.

Even then, I thought: I don’t have to admit to anybody that the book is inspired by my own experience with OCD. It will just be a small COVID project, no one will know, and it will keep me artistically occupied during the pandemic. But as luck would have it, I hired a wonderful and very experienced editor, Alex Schultz, who I thought should kick the tires on the book before I hired actors and an audiobook director. And he loved the book so much, he offered to submit it to a publisher, Invisible Publishing. Of course I was overjoyed, but I was also suddenly plunged right back into the dilemma that I’d had before, which was that if a publisher were to like it and want it, I would likely have to talk about the OCD. So I crossed my fingers and toes hoping that that wouldn’t be the case, but right before Alex passed it to the publisher, he called me and said, “I have to ask you about the OCD. Is this your personal experience?” My knees literally shook during that phone call, even though Alex is as lovely as can be. I was just terrified to talk about it.

So for the first time in my life, I had to admit to someone I didn’t know very well that I had OCD. It was scary, but I got through it. I’m so glad I did. I had the same conversation with the publisher when they offered to publish it, and even though that was scary, too, my knees shook less. Each time I have the conversation, I get a bit more used to talking about it. Still, as we went through the pre-publication process, which takes about a year and a half, I started to wonder if I’d made the right choice. Of course I knew I had, on a very deep level, because there’s truly nothing more joyful for a writer than publishing a novel, and I adore my publishers.

What do you hope readers will walk away with after reading At Last Count? Do you think they’ll be surprised by the depiction of OCD in the book—at least if they don’t know much beyond the surface?

I hope readers will come away with a few different things.

One, an empathy about the internal experience of OCD. There is not one thing that is fun about it, to put it mildly. It’s a terrible, awful thing, something you wouldn’t wish on anybody. I struggled with it alone when I was young, because it was the 70s, and because there was no Internet where I could do research myself, or join an online organization, and I was an only child, and honestly, a good secret keeper. No one knew I was having trouble, and so I was terribly alone in it. I’ve had amazing responses from readers—both those who have struggled with OCD, and those who have known very little about it before reading the book. In fact, recently, the publisher has begun selling the book to high schools, which of course thrills me because it means the book gets exposed to two different sets of readers—adults, and teens—and I spoke about it to a conference of psychologists for a school board who were very happy to have good, fictional reading material available for their students that accurately depicts the internal experience of OCD.

The second thing I hope readers come away with is the notion that you don’t have to believe everything your brain tells you. OCD, to me, is a very talented trickster. It tells you things that sound like absolutes. It wants you to believe them to feed its engine. The more you give in to the rituals, the more believable and vital they seem. And it’s a moving target, so if you manage to get out of one set of compulsions, it looks for another to keep you in check. It took me a long time to figure out that those are just thoughts, not facts.

The last thing I hope readers come away with is the power in asking for help. In the book, Paisley finally gets help with her love interest Garnet, even though she’s kept her secret so long, and it’s just what she needed. As I mentioned before, I struggled with OCD in the ’70s and ’80s, when there was no internet, and it wasn’t possible to find resources online. There might have been an OCD organization somewhere, but if there was, I had no way of knowing about it. Now it’s so different.

During the pandemic, after I knew that the book was going to be published, I thought that I had better read up on OCD, because I had had the very strange experience of having struggled with it, at its worst, for probably 20 years, but knowing very little about it. I went online and found the IOCDF (the International OCD Foundation, based out of the US). They did an amazing job of pivoting during the pandemic, bringing so much of what they do online, in livestream interviews with knowledgeable guests, webinars, and virtual conferences. I had the remarkable experience of listening to others talk about OCD, both experts and those who struggle with it, and realizing that I was not alone. It was an epiphany for me: people were using the exact words that had come out of my mouth, the exact same thought patterns that I had struggled with. It was just shocking and revelatory, in that I finally realized how not alone I was.

What makes me happiest is that the book can be read on two levels—yes, to get a real picture of what having OCD is like—but also, it can be read purely for the story: this complex, layered, intense love affair between two people who manage to help each other out of a tough place. The book is uplifting (I won’t say more for fear of spoilers), but people who love a good page-turner romance can easily read the book for that alone. Much of the feedback I’ve received has been that while I wrote about something that is very hard, I also wrote a joyful book that has hope at the end. That seems to have been recognized as an achievement. And that was an important thing for me: to give people hope. Because I live a pretty great life. I am married to a prince of a husband, we’ve been married for 31 years, we have two wonderful children, and I have a good career, doing the thing I most love to do, which is writing. All of these things are possible, even for someone with OCD.

How long have you had OCD? Can you share some of your symptoms with us?

I figure it was since about the age of seven or eight or so. I can’t be sure, but I do remember certain points of my life when I was definitely struggling with it. It was worst until my mid 20s. And although I think there is no magic bullet for such a thing, my OCD really abated after I got together with my husband, Kirk, who is calm and kind and was a big stabilizer in my life. After Kirk proposed to me and we’d set a date for the wedding, I immediately found a therapist and said, I have a year and a half to get myself sorted. Ready, set, go. (Nothing like a concrete goal like a wedding to motivate you.) OCD was a big piece of what we worked on together.

My dominant OCD symptom was counting and checking. My number was eight (because this you could conveniently count on two hands, thumbs to the tip of each finger), and I counted lots of things eight times, over and over. I had a massive fear of fire, so I got into patterns when I was young, checking the stove, every light fixture and electrical outlet in the house eight times. When things were very bad, I would do the whole sequence of checks eight times. You can imagine, it was pretty time-consuming. Uncertainty about these things spun off into other areas, like false memory (I didn’t cook, but I’m worried the stove is on, so maybe I did cook and don’t remember?), and scrupulosity—needing to feel very clean about everything I do, dot the i’s, finish a task perfectly. And asking for reassurance or apologizing for the most simple things over and over. It’s exhausting and can trigger all sorts of feelings of self-loathing. Why can’t I beat these thought patterns? What’s wrong with me?

The other way OCD manifested was extreme feelings of responsibility and concern about the safety of others. This was a deep spiral and repetitive cycle of concern for me.

I still struggle with negative thought patterns, and a concern about people’s safety, but I live a very high-functioning life. I no longer count. I am never relegated to the house, unable to leave because of fear of fire. One of the really important concepts I learned from attending these IOCDF webinars was the notion of approximation. OCD tells us that every aspect of our lives must be perfect: I must be 110 percent sure I didn’t leave the stove on, and if I have to check it eight times, then that’s a good thing.

But where we want to get to is the idea that good enough is the gold standard. I can check the oven once before I leave the house, I know it’s off, and even if I doubt it, I can walk out the door and go to my appointment. OCD tells us that the more we check, the more clarity we’ll get, but instead it creates confusion, and we become less clear. And OCD is always happy to offer the solution: check again. It’s okay. You’ll feel better. It takes some training to believe that that feeling of imperfection is okay. And the more I practice living in that imperfection, the healthier I am.

Once you knew what you’d been experiencing was OCD, did you tell anyone—family, friends, strangers? How did they receive the information?

By the time the book published, I would say maybe five or six people all told knew that I had OCD. I honestly have no recollection of the earliest people I told. I don’t think I would have even had a term for it back then. So it must have been when I was much older that I realized what the diagnosis was. I remember seeing a book on psychology on my brother-in-law‘s shelf, and in it was a chapter on OCD with an OCD questionnaire, which I took standing there, trying to act all nonchalant as I read this book. And of course I passed with flying colors. So that was a lightbulb moment. But, for example, I didn’t tell my children until the book was about to be published. That was a big moment. And they were awesome about it. By that time they were both in their 20s. So they listened to my story and then said, you rock, Mum. You got through this hard thing. Amazing. And that time, my knees didn’t shake.

If you could offer just one piece of advice to someone with OCD, what would it be?

It would be that thing I spoke about above: you don’t have to believe everything your brain tells you. Thoughts aren’t necessarily facts. And if we can discern the difference, get evidence-based help by qualified professionals, and tell OCD that it has no place in our life, then we can get on with having our awesome, good-enough lives. Maybe we can’t get rid of OCD 100 percent. But we can tell it firmly that while it can come along for the ride, it doesn’t get to drive.

Help me welcome Brooke Miller, who advocates for awareness of obsessive-compulsive disorder (OCD) and eating disorders, bipolar II, and panic disorder. Brooke has been through many trials and has a lot of wisdom to share, so read on for her story and how she balances it all. Thank you, Brooke!

Can you share a little of your background with us, including your experiences with OCD, an eating disorder, bipolar II, and panic disorder?

Well, buckle up because my mental health journey has been quite a ride!

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Looking back, my first encounter with OCD behaviors happened when I was around 8 to 10 years old. Folding my dirty laundry before tossing it in the hamper became a must-do ritual to avoid any imagined disasters. As I grew older, my OCD manifested in various forms like contamination fears, perfectionism, harm obsessions, “just right” tendencies, and even magical thinking.

Throughout school and college, I had high achievements and appeared flawless on the outside, but inside, anxiety and stress were slowly eating away at me. It took a lot of courage to seek help for the first time, but unfortunately, my initial therapy experience wasn’t fruitful. Undeterred, I tried a couple more therapists who, although well-meaning, didn’t specialize in exposure response prevention (ERP), which is crucial for OCD recovery.

In 2012, after becoming a mom, my OCD took on a whole new dimension, making it nearly unmanageable. It was a wake-up call, and I finally reached out to a local mental health community outreach program. They connected me with a therapist who is an absolute rock star in OCD and ERP. With his guidance, I learned what true OCD treatment and recovery entailed, and together, we dove into the hard work.

Feeling optimistic, I thought I could handle things on my own and took a break from therapy. Little did I know, a relentless form of OCD called “Pure O” struck me, but I kept it hidden, resulting in missed opportunities for treatment. Eventually, I returned to my therapist’s care as I experienced my first panic attack fueled by a brand new OCD subtype—relationship OCD. Intrusive thoughts and images flooded my mind, causing immense shame and convincing me that I was a cheater.

My self-loathing spiraled, leading to significant weight loss, anorexia nervosa, and a dangerous cycle of punishment. It was a turning point when I finally accepted that I needed help. I underwent an intensive treatment program, followed by outpatient therapy with a dedicated treatment team for both OCD and my eating disorder. It was a journey of ups and downs, relapses and recoveries, but I made slow but steady progress.

Just when I thought things were finally falling into place, life threw another curveball. In 2022, I experienced a manic episode and was diagnosed with bipolar II. Balancing the intensity of my OCD exposures while ensuring stability became my new challenge. With the right medication and ongoing therapy, I began to regain my equilibrium and made remarkable strides in my OCD recovery. It felt like I was finally getting a handle on things.

But the surprises weren’t over yet. Fall of 2022 brought yet another diagnosis: Panic disorder. Frequent and intense panic attacks became a daily struggle. For weeks, my treatment team and I worked tirelessly to manage them. Thankfully, a combination of medication and interoceptive exposures began to bring them under control.

And here we are today! I’m doing really well, managing all my mental health disorders and making progress in my recovery every single day. It hasn’t been easy, but my journey has taught me resilience, perseverance, and the incredible strength of the human spirit.

Remember, my story is just one among millions. We all face unique challenges, but we also share the capacity to overcome and thrive. Let’s continue to support each other, break the stigma, and remind ourselves that mental health is a journey worth taking.

You share a lot of your recovery journey on your blog, Smashing Stigmas. What inspired you to start writing about your experiences?

I firmly believe that those with lived experience are the true experts when it comes to mental health. Unless we’ve walked in someone’s shoes, it’s difficult to grasp the challenges of living with a mental health disorder. That’s why I am dedicated to amplifying the conversation about mental health in our society. Through my blog, Smashing Stigmas, I openly share my personal journey of struggles and triumphs on the path to recovery. My goal is to instill hope in others, showing them that with the right support and resources, they too can experience healing. No one should feel alone in their struggles, and by shedding light on mental health, we can create a world where these experiences are openly discussed and embraced. It’s my passion to use my own recovery journey to uplift and inspire others on their own paths toward wellness.

You’re also an IOCDF Advocate! Why did you decide to join this program? What do you hope to achieve in your role?

I am beyond thrilled and deeply honored to be an IOCDF Advocate! My heart’s desire is to make a meaningful impact by raising awareness, shattering stigmas, and ensuring everyone has access to vital mental health resources. Through sharing my personal journey, I aim to empower individuals grappling with OCD and related disorders, offering them hope and reminding them they are not alone. With this role, I aspire to educate the community, ignite passion for advocacy, and foster a world where mental health is embraced and supported by all.

How do your different diagnoses affect each other, if at all? Has it been a challenge to balance different treatment methods and make sure one doesn’t have a negative impact on another?

I was genuinely amazed to discover how interconnected my different diagnoses are and how they can influence one another. Strikingly, the treatment methods for my OCD, anorexia, bipolar II, and panic disorder showed remarkable similarities, which brought a glimmer of hope to my journey towards recovery. One invaluable approach that played a pivotal role was ERP, a technique employed to tackle my OCD, anorexia, and panic disorder. Through this method, I gradually confronted my fears, dismantled obsessive patterns, and reclaimed control over my life.

Medications have also played a crucial role in my healing process. To balance the serotonin levels in my brain, I take a selective serotonin reuptake inhibitor (SSRI), which has been immensely helpful. Additionally, I have utilized a mood stabilizer to minimize the intensity of depressive and manic episodes associated with bipolar II. It’s been a delicate balance, requiring time and perseverance, but finding the right combination has been instrumental in managing my mental health.

In the past, managing one condition often meant the other would spiral out of control. It felt like a relentless game of whack-a-mole, where as soon as I focused on one aspect, the other would worsen. However, the challenges I faced have been mitigated by the unwavering support of my incredible treatment team. Their collaborative efforts and dedication have been nothing short of a lifeline. My therapist, dietitian, psychiatrist, and primary care provider have worked in harmony, ensuring that I receive the best possible holistic care. I am eternally grateful to them for their unwavering support and guidance on this arduous journey.

Today, I stand as a testament to the power of perseverance and the importance of compassionate care. While it hasn’t been an easy road, the similarities in treatment methods and the commitment of my exceptional team have filled me with optimism. I have learned that even in the face of multiple diagnoses, there is hope for recovery and the opportunity to live a fulfilling life. With the right support, dedication, and a touch of resilience, I believe in the possibility of a brighter future.

What do you consider the biggest misconception about OCD? What about eating disorders?

Ah, let’s break those stigmas and misconceptions once and for all! When it comes to OCD, I believe that the biggest misconception is often the belief that it’s just a quirky personality trait or something enjoyable. Please, let me be clear: OCD is a mental health disorder that can have a profound impact on a person’s life. It’s not a choice, and it’s definitely not something anyone desires or asks for.

Similarly, with eating disorders, there’s a prevalent misconception that they are simply a matter of willpower or a deliberate choice. Nothing could be further from the truth! Eating disorders are serious mental and physical illnesses. In fact, they are known to be one of the most lethal mental health conditions. We must recognize the severity and urgency surrounding these disorders.

It’s time to join forces and challenge these misconceptions head-on. We need to educate ourselves and others, spreading awareness that OCD and eating disorders are not character flaws or choices. They are real, complex, and often devastating conditions that deserve our understanding and support.

Let’s come together as a community to reduce the stigmas that surround these mental health disorders. By sharing accurate information, supporting those affected, and fostering empathy, we can create a more compassionate world where individuals with OCD and eating disorders can feel safe, heard, and understood!

If you could give just one piece of advice to someone with OCD, what would it be?

Oh goodness, only one piece of advice… I’ll try!

First and foremost, I want them to know that they are not alone in this journey. OCD can make you feel isolated and trapped, but there is hope and support out there for you.

My biggest piece of advice would be to seek the right treatment. With the right support and therapy, you can regain control over your life and create a path that aligns with your true values, rather than those dictated by OCD.

Remember, treatment for OCD is not a quick fix, but it is absolutely worth it. Find a therapist who specializes in OCD and ERP, as this evidence-based approach has been shown to be highly effective. Building a strong therapeutic relationship with someone who truly understands your struggles can make a world of difference.

Don’t underestimate the power of support from others who have walked a similar path. Seek out support groups, online communities, or even reach out to mental health organizations specializing in OCD. Connecting with others who truly understand can provide immense comfort and a sense of belonging.

Above all, be kind to yourself. Recovery is a journey, and there will be ups and downs along the way. Embrace your progress, celebrate your victories, and show yourself compassion during the challenging moments. You are stronger than you know, and you have the capacity to reclaim your life from the clutches of OCD!

Help me welcome Brooke Miller, who advocates for awareness of obsessive-compulsive disorder (OCD) and eating disorders, bipolar II, and panic disorder. Brooke has been through many trials and has a lot of wisdom to share, so read on for her story and how she balances it all. Thank you, Brooke!

Can you share a little of your background with us, including your experiences with OCD, an eating disorder, bipolar II, and panic disorder?

Well, buckle up because my mental health journey has been quite a ride!

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Looking back, my first encounter with OCD behaviors happened when I was around 8 to 10 years old. Folding my dirty laundry before tossing it in the hamper became a must-do ritual to avoid any imagined disasters. As I grew older, my OCD manifested in various forms like contamination fears, perfectionism, harm obsessions, “just right” tendencies, and even magical thinking.

Throughout school and college, I had high achievements and appeared flawless on the outside, but inside, anxiety and stress were slowly eating away at me. It took a lot of courage to seek help for the first time, but unfortunately, my initial therapy experience wasn’t fruitful. Undeterred, I tried a couple more therapists who, although well-meaning, didn’t specialize in exposure response prevention (ERP), which is crucial for OCD recovery.

In 2012, after becoming a mom, my OCD took on a whole new dimension, making it nearly unmanageable. It was a wake-up call, and I finally reached out to a local mental health community outreach program. They connected me with a therapist who is an absolute rock star in OCD and ERP. With his guidance, I learned what true OCD treatment and recovery entailed, and together, we dove into the hard work.

Feeling optimistic, I thought I could handle things on my own and took a break from therapy. Little did I know, a relentless form of OCD called “Pure O” struck me, but I kept it hidden, resulting in missed opportunities for treatment. Eventually, I returned to my therapist’s care as I experienced my first panic attack fueled by a brand new OCD subtype—relationship OCD. Intrusive thoughts and images flooded my mind, causing immense shame and convincing me that I was a cheater.

My self-loathing spiraled, leading to significant weight loss, anorexia nervosa, and a dangerous cycle of punishment. It was a turning point when I finally accepted that I needed help. I underwent an intensive treatment program, followed by outpatient therapy with a dedicated treatment team for both OCD and my eating disorder. It was a journey of ups and downs, relapses and recoveries, but I made slow but steady progress.

Just when I thought things were finally falling into place, life threw another curveball. In 2022, I experienced a manic episode and was diagnosed with bipolar II. Balancing the intensity of my OCD exposures while ensuring stability became my new challenge. With the right medication and ongoing therapy, I began to regain my equilibrium and made remarkable strides in my OCD recovery. It felt like I was finally getting a handle on things.

But the surprises weren’t over yet. Fall of 2022 brought yet another diagnosis: Panic disorder. Frequent and intense panic attacks became a daily struggle. For weeks, my treatment team and I worked tirelessly to manage them. Thankfully, a combination of medication and interoceptive exposures began to bring them under control.

And here we are today! I’m doing really well, managing all my mental health disorders and making progress in my recovery every single day. It hasn’t been easy, but my journey has taught me resilience, perseverance, and the incredible strength of the human spirit.

Remember, my story is just one among millions. We all face unique challenges, but we also share the capacity to overcome and thrive. Let’s continue to support each other, break the stigma, and remind ourselves that mental health is a journey worth taking.

You share a lot of your recovery journey on your blog, Smashing Stigmas. What inspired you to start writing about your experiences?

I firmly believe that those with lived experience are the true experts when it comes to mental health. Unless we’ve walked in someone’s shoes, it’s difficult to grasp the challenges of living with a mental health disorder. That’s why I am dedicated to amplifying the conversation about mental health in our society. Through my blog, Smashing Stigmas, I openly share my personal journey of struggles and triumphs on the path to recovery. My goal is to instill hope in others, showing them that with the right support and resources, they too can experience healing. No one should feel alone in their struggles, and by shedding light on mental health, we can create a world where these experiences are openly discussed and embraced. It’s my passion to use my own recovery journey to uplift and inspire others on their own paths toward wellness.

You’re also an IOCDF Advocate! Why did you decide to join this program? What do you hope to achieve in your role?

I am beyond thrilled and deeply honored to be an IOCDF Advocate! My heart’s desire is to make a meaningful impact by raising awareness, shattering stigmas, and ensuring everyone has access to vital mental health resources. Through sharing my personal journey, I aim to empower individuals grappling with OCD and related disorders, offering them hope and reminding them they are not alone. With this role, I aspire to educate the community, ignite passion for advocacy, and foster a world where mental health is embraced and supported by all.

How do your different diagnoses affect each other, if at all? Has it been a challenge to balance different treatment methods and make sure one doesn’t have a negative impact on another?

I was genuinely amazed to discover how interconnected my different diagnoses are and how they can influence one another. Strikingly, the treatment methods for my OCD, anorexia, bipolar II, and panic disorder showed remarkable similarities, which brought a glimmer of hope to my journey towards recovery. One invaluable approach that played a pivotal role was ERP, a technique employed to tackle my OCD, anorexia, and panic disorder. Through this method, I gradually confronted my fears, dismantled obsessive patterns, and reclaimed control over my life.

Medications have also played a crucial role in my healing process. To balance the serotonin levels in my brain, I take a selective serotonin reuptake inhibitor (SSRI), which has been immensely helpful. Additionally, I have utilized a mood stabilizer to minimize the intensity of depressive and manic episodes associated with bipolar II. It’s been a delicate balance, requiring time and perseverance, but finding the right combination has been instrumental in managing my mental health.

In the past, managing one condition often meant the other would spiral out of control. It felt like a relentless game of whack-a-mole, where as soon as I focused on one aspect, the other would worsen. However, the challenges I faced have been mitigated by the unwavering support of my incredible treatment team. Their collaborative efforts and dedication have been nothing short of a lifeline. My therapist, dietitian, psychiatrist, and primary care provider have worked in harmony, ensuring that I receive the best possible holistic care. I am eternally grateful to them for their unwavering support and guidance on this arduous journey.

Today, I stand as a testament to the power of perseverance and the importance of compassionate care. While it hasn’t been an easy road, the similarities in treatment methods and the commitment of my exceptional team have filled me with optimism. I have learned that even in the face of multiple diagnoses, there is hope for recovery and the opportunity to live a fulfilling life. With the right support, dedication, and a touch of resilience, I believe in the possibility of a brighter future.

What do you consider the biggest misconception about OCD? What about eating disorders?

Ah, let’s break those stigmas and misconceptions once and for all! When it comes to OCD, I believe that the biggest misconception is often the belief that it’s just a quirky personality trait or something enjoyable. Please, let me be clear: OCD is a mental health disorder that can have a profound impact on a person’s life. It’s not a choice, and it’s definitely not something anyone desires or asks for.

Similarly, with eating disorders, there’s a prevalent misconception that they are simply a matter of willpower or a deliberate choice. Nothing could be further from the truth! Eating disorders are serious mental and physical illnesses. In fact, they are known to be one of the most lethal mental health conditions. We must recognize the severity and urgency surrounding these disorders.

It’s time to join forces and challenge these misconceptions head-on. We need to educate ourselves and others, spreading awareness that OCD and eating disorders are not character flaws or choices. They are real, complex, and often devastating conditions that deserve our understanding and support.

Let’s come together as a community to reduce the stigmas that surround these mental health disorders. By sharing accurate information, supporting those affected, and fostering empathy, we can create a more compassionate world where individuals with OCD and eating disorders can feel safe, heard, and understood!

If you could give just one piece of advice to someone with OCD, what would it be?

Oh goodness, only one piece of advice… I’ll try!

First and foremost, I want them to know that they are not alone in this journey. OCD can make you feel isolated and trapped, but there is hope and support out there for you.

My biggest piece of advice would be to seek the right treatment. With the right support and therapy, you can regain control over your life and create a path that aligns with your true values, rather than those dictated by OCD.

Remember, treatment for OCD is not a quick fix, but it is absolutely worth it. Find a therapist who specializes in OCD and ERP, as this evidence-based approach has been shown to be highly effective. Building a strong therapeutic relationship with someone who truly understands your struggles can make a world of difference.

Don’t underestimate the power of support from others who have walked a similar path. Seek out support groups, online communities, or even reach out to mental health organizations specializing in OCD. Connecting with others who truly understand can provide immense comfort and a sense of belonging.

Above all, be kind to yourself. Recovery is a journey, and there will be ups and downs along the way. Embrace your progress, celebrate your victories, and show yourself compassion during the challenging moments. You are stronger than you know, and you have the capacity to reclaim your life from the clutches of OCD!

Help me welcome today’s guest, OCD advocate Katy Marciniak! As you’re about to read from Katy herself, she has dipped her toe into different kinds of advocacy and has found ways to spread awareness that work best for her and her life as a busy parent of two. I see so much of my story in Katy’s, and I hope you relate, too, even if your OCD journey has looked a little different. Thank you, Katy!

When were you diagnosed with OCD, and how long did you experience symptoms before you started to get some answers?

My OCD symptoms onset around the age of twelve and I experienced symptoms of varying degrees up until about twenty-three, without having any understanding that I had OCD.

I was terrified to go to therapy. When I was in graduate school I started to realize what I was experiencing may be OCD. I finally found a therapist and was diagnosed and received therapy for a short period of time. Eventually I convinced myself I could handle my OCD without professional support. Years later I started to fall apart, and my OCD really began to infiltrate all aspects of my life. I was resistant to attempting therapy again but I knew I couldn’t cope alone anymore. After a couple failed attempts at finding someone who could effectively treat OCD, at the age of twenty-nine, I finally found myself in the office of a therapist who specialized in OCD. It was the start of a life-changing experience for me. I worked with that therapist for seven years, and it gave me my life back and so much more.

Can you share some of your obsessions and compulsions with us? Did you have any idea they were symptoms of OCD?

As a child my obsessions were often centered around harm, and they onset shortly after seeing media coverage of a school shooting. My mind started to be flooded with these horribly violent thoughts. I had no idea why it was happening, and I was so disturbed and disgusted by it. The more I tried to make it stop, the worse it got. Everything started to be a trigger for the thoughts. I remember feeling so broken and isolated. I would obsess the thoughts meant something awful about me, and I would try to reassure myself that it would be okay through all sorts of compulsions like counting, praying, and eventually just incessantly seeking reassurance from others that I was indeed a “good person.” I had no idea what I was dealing with, and it really felt unbearable so many days. I was too afraid to ask for help, because I didn’t want what I was experiencing to be misinterpreted. That experience as a kid really rocked me, and I tried to cope with it alone for a long time. Eventually the day-to-day intensity of what I was experiencing gradually decreased, but various times as I got older I would have episodes where I would really struggle to cope with triggers. 

Between the onset of my OCD and eventually finding the help I needed at twenty-nine, my OCD went on a world tour of different obsessions and compulsions. I’ve struggled with many subtypes of OCD throughout my journey. Most of the obsessions falling under moral scrupulosity and the general theme of making sure I was doing things “right” and was a “good person.” Until I really found the right support in an OCD therapist I didn’t really see my struggles as OCD, I more or less thought something was just wrong with me. Now at thirty-six I still struggle with my OCD from time to time, but I feel like I’ve acquired the tools I need to cope when I do start to struggle. I’ve been incredibly empowered by the things I’ve learned in therapy over the last few years, and ERP has kind of just become a part of life. I try to follow my values, and learn to sit with the uncertainty that comes up along the way. Regardless if I had OCD or not, I kind of think that’s what it means to go after what you want in life; having OCD just makes that journey a whole lot more rugged at times.

You have two children. Do you feel like your OCD has impacted your parenting journey?

Absolutely. I think one of my most daring exposures was becoming a mom. After getting married I was pretty convinced I couldn’t hack it as a mother, but after working through a lot of my OCD I realized I valued starting a family. It was something I wasn’t willing to give up.

I worked really hard in therapy to address my OCD before I got pregnant, and continued that work through my first pregnancy to really get ahead of what my OCD “might” throw at me, which in turn helped so much once my daughter arrived. I will forever be grateful for the therapy experience I had, that helped support me into and through my first few years of my parenthood journey with both my daughter and son.

There for sure have been challenging moments with my OCD, but it is such a gift to have my children in my life. Having kids is a never-ending exposure. You really never know what they are going to throw at you. Some of those things I’ve handled with ease, and other things took more work to get through. There is so much love, pride, and joy to be found in motherhood, even with your OCD along for the ride. I have found my greatest joy in my children, and not in those picture-perfect moments, but rather in the mundane, simple moments where life seems to move in slow motion and I’m 100 percent present for their joy. Therapy helped me acquire the tools to truly show up for these moments. There is a certain level of joy I don’t think I had ever experienced until I had kids.    

You’re an IOCDF Advocate. What does that entail, and why did you decide to join the advocate program?

I looked into the IOCDF Advocate program when I was trying to expand the way in which I was advocating. I had a blog, been interviewed on podcasts, spoken at the IOCDF conference, and had an Instagram page, but I was trying to find a way to get plugged into other opportunities. At the time a lot of advocacy was focused on social media for me, and I really felt strongly I needed a break from that. Social media can be beneficial, but being unplugged from social media across the board for an extended period of time had an indisputable positive impact on my mental health. I chose to pursue other ways I felt I could make a difference, so I applied to the IOCDF Advocate program and was fortunate enough to be selected. Essentially it’s a group of advocates made up of professionals, sufferers, and family members trying to educate about OCD and raise awareness through different initiatives and projects across different mediums. It has been wonderful to be a part of.

You also have a blog, Navigating Uncertainty. What inspired you to start sharing about your experience in that way? 

I read this question and I had to pause a second, because I actually still can’t believe I ever started a blog. I was pretty convinced I would never share my experience with anyone. . .like no one. Even once I started effective therapy I found it laughable when my therapist suggested I share my writing.

Eventually given some time and progress in therapy, I started to realize that writing was incredibly therapeutic in many ways. I kind of turned to it when I was struggling or I had an insight burst. The more I worked through my OCD I started to wonder if in some way my writing could help someone in their journey. I often thought of the younger version of myself desperate for answers, and the validation and hope that maybe I could provide to someone else started to outweigh the fears and hesitations I had. I was inspired by others sharing their stories and grateful for them doing so (yourself included!). Eventually I just went for it, but honestly it has never felt “easy.” I often write things and am hesitant to post. The OCD shame bug still gets me sometimes. I go through periods where writing comes easier and I want to share, and other times my blog just kind of sits. I’m okay with that though. So really I think the therapy process as a whole inspired me to write.

Do you have advice for someone who’d like to advocate for OCD awareness but doesn’t know where to start?

Any advocacy effort matters, so do what feels right for you, and meet yourself where you are at. You don’t have to share everything, you don’t have to share it in any certain way, and you don’t even have to share your journey. I think it’s so easy to start comparing yourself to other OCD advocates and feel like you aren’t doing enough, so it’s important to remember advocacy looks different for everyone, and all of it makes a difference. I also think it’s important to remember you don’t have to advocate all the time. I’m passionate about advocacy, but I’m also passionate about living the life that I won back from my OCD. Sometimes focusing on advocacy isn’t where I want my mental energy, and I’m realizing that’s also okay.

If you could give just one piece of advice to someone with OCD, what would it be?

Know that it’s going to be okay, and keep showing up for yourself by compassionately holding yourself accountable to doing the work throughout the journey. That doesn’t mean you have to do it all, or do it perfectly, but remember that you deserve to get better, and it starts with showing up for yourself wherever you’re at. That will look different at different phases. I also can’t forget this inspiring quote I once heard in therapy that helps more than you could imagine: “Flick self-judgment away like a booger.”

As often as I’ve lamented the lack of accurate media representation of the other aspects of obsessive-compulsive disorder (OCD)—taboo intrusive thoughts, mental compulsions, less quirkiness and more torment—I’ve also understood it’s hard to capture on film. Today’s guest, Peter Cannon, has managed to do just that in Exposure, his new movie that’s about OCD but not just about OCD.

Let’s hear from Peter on why he made the film and what he hopes viewers will get out of it. Thank you, Peter!

You’ve written and directed a film about OCD called Exposure. Can you tell us about Exposure and what inspired you to create it?

Exposure is mainly the result of having OCD for over a decade.

I’ve made film content that deals with mental health in the past, but it was for school and was “short form” (read as: ten minutes long). It’s kind of a meme at this point that young filmmakers make overly serious movies about mental illness, but it’s the same people joking about that that tell you to write what you know.

The understanding of other mental illnesses in film and TV have come a long way, but OCD never quite got that treatment. Sure, comparatively fewer people have it—but I think a lot of it has to do with the fact that people are more scared to talk about the taboo nature of some of the themes. Maybe it’s a fear of ridicule, or maybe a fear of genuinely causing alarm from the people around them. Either way, the themes of OCD that have seen the light of day have been pretty restricted to contamination obsessions and physical “checking” rituals.

So, after seeing that opportunity, I wrote a script and surrounded myself with a team of filmmakers more skilled than I am. A couple years later, we had a movie.

One thing that really helped is the fact that people with OCD struggle with concepts that are universal when stripped down. Anyone can understand fear, and anyone can understand facing fear is harder than avoiding it. You might notice that we avoid loading up the viewer with all the terminology that we learn with ERP, CBT, and so on—and try to stick to just showing them. That’s on purpose.

Exposure’s protagonist is terrified someone is going to poison him. We see him panicking over a drop of blood, begging a frustrated doctor to help him, avoiding certain foods—he will do seemingly anything to avoid what he considers his fate. And it gets pretty creepy! How did you decide on a psychological thriller to show how OCD invades every part of our lives?

I’m sure you’ve noticed over the decades that OCD has taken on this media identity of being a fun quirk. I’ve even had people suggest it’s helpful in some situations, which is. . .wild to me.

I’m no doctor, but I wanted to show the experience in the way that I do, which is relentless. Terrifying. An assault on the brain. I figured there had to be a couple other people out there that wanted to see an OCD movie like that. So we landed on “psychological thriller” as our genre, and we went from there.

The cast, crew, and I had to walk a bit of a tightrope in making this. We wanted to show the OCD experience from a few different angles, but it’s always been a movie first. Early drafts of the script dug so deep that my (now) wife told me, “This isn’t a movie, this is an essay.” The reality is, when you want to introduce a concept unfamiliar to larger audiences, serving it up in the form of a story just makes it more palatable, and (gasp) enjoyable. The last thing we wanted was for someone to feel like they just attended a lecture.

I did have a therapist look over the representation and give a secondary “thumbs-up” before we made the film, but our job as filmmakers was to introduce and represent this idea via a work of fiction. Actual education and therapy rests in the hands of the professionals.

Let’s talk about the title of the movie, Exposure, and one of the lines from the movie, “Discomfort’s the point.” Imagine my readers don’t know how OCD is treated and explain what this is all about.

I’ll preface this by saying I’m not a therapist, I’m just a filmmaker with OCD. I’ve been saying that a lot these days!

Exposure (or the better term for it, exposure response prevention therapy) is the best tool that exists right now in overcoming obsessions. It’s a practice where the OCD sufferer is placed in some kind of proximity with whatever content spikes their anxiety while resisting a compulsion. If OCD is a cycle, ERP is designed to break that cycle.

To use that contamination obsession example everyone knows about—it could be that someone places their hand on a common doorknob, allowing their anxieties around contamination to be activated. They’d then have to sit with that anxiety, letting the feelings rise, and eventually fall, without giving in to the obsessive urge to wash their hands or use hand sanitizer. That’s essentially a practice of “exposure.”

An old therapist used to tell me that it’s actually quite difficult for the human body to feel anxious about something for long periods of time if you just let it sit. Ironically, what actually feeds the obsession is allowing yourself to avoid that discomfort with a compulsion. So if you can face down the anxiety spikes without running to comfort yourself immediately after, you’ll be stronger for it.

So in that sense, “the discomfort’s the point.” If you see the movie, you’ll see the character take this idea on in more ways than one.

One thing that causes problems for our protagonist is that he thinks ERP is a cure, and that “the more intense he goes, the better he’ll feel.” I’ve felt that way too—I was so full of hope that exposure was my ticket out of OCD forever, and it’s just not that simple.

The tension starts to rack up when he puts himself in more extreme situations, against the advice of the unlicensed therapy group he’d been attending. Our character struggles with learning that exposure is simply a tool to help manage a lifelong condition, and that acceptance is a key part to real mental peace. All of us, including people without OCD, need to accept that our worst fears have some non-zero chance of happening, and that it’s no reason to stop living.

Those of us with OCD can become so focused on how OCD affects us that we sometimes forget the impact it can have on our loved ones. Exposure captures so well how seeking reassurance, avoiding triggering situations, and taking drastic measures to feel safe takes a toll on our relationships. Why was it important to you to show that side of it as well?

None of us live in a vacuum, and many of us have people in our lives that are privy to our struggles with obsession. Some loved ones, partners, spouses, or parents can feel like they’re getting a constant play-by-play of the thought patterns themselves—which makes them the first line of defense for comfort from the mental onslaught. And because the nature of some obsessions are pretty out-there, the list of people to which we feel comfortable telling all this is pretty small.

This isn’t a bad thing by itself, we obviously need people to lean on as we make it through life. However, there are some corrosive side effects to burying yourself into the care of another to avoid each and every anxiety spike.

First off, it’s barely a step away from just being a classic compulsion. Being comforted over and over that “X” won’t happen doesn’t raise your tolerance for anxiety nor take the strength away from the obsession. It feeds it.

Secondly, a relationship is a two-way street, and no human being on the planet is a tireless “care machine.” Being there for someone is work, and this work takes time and emotional energy. Don’t get me wrong, this work is a good thing and necessary in relationships. But so is balance and reciprocation. OCD has a nasty habit of eclipsing the needs of our loved ones, which are just as important. They need care, fun, self-actualization, safety, and health just as much as the one with OCD. I’m going to go out on a limb and guess there are similar situations out there with addictions, other chronic illnesses, and so on.

There’s been a saying bouncing around the internet that goes something like, “Mental illness isn’t your fault, but it is your responsibility.” I think that idea influenced a lot of this movie.

What do you hope people will walk away with after seeing the film?

I sure hope some people change their definitions of OCD, for one. There are several characters in the film we meet with OCD, all with extremely common versions/themes. But rather than say, “Hey, the themes aren’t just contamination! It’s also religion! And sexual orientation! And this one! And that one!”, I think I’d rather people walk away understanding OCD as a cyclical pattern of thoughts, feelings, and actions. The actual content, as that old therapist used to say, is irrelevant.

Apart from that, there are a few smaller points the movie makes that I hope people pick up. OCD’s close relationships with PTSD and substance abuse are in there. The dangers of oversimplifying ERP and not getting information from the right sources are there too.

On top of that, the movie touches on the uncomfortable nature of sexual orientation obsessions, as I’ve seen plenty of discussion on whether or not certain versions of it are informed by homophobia (and if it is, what effect that has on treatment).

It also wouldn’t be an American indie film without some heavy-handed complaints about policing, guns, and inaccessibility to healthcare.

I also want people to have fun watching it, so I hope all this preachiness didn’t take the “thrill” out of “thriller!”

If you could give just one piece of advice to someone with OCD, what would it be?

I’m so far from having this all “figured out,” but I can tell everyone this: more often than not, there’s this threshold of shame and embarrassment about the exact nature of an obsession that stops people from seeking help. OCD thrives on shame. Shame keeps you isolated and performing compulsions for any scrap of comfort rather than dealing with the actual problem, which is the thought pattern.

So, if you are getting help for obsessions, take that leap. Tell the therapist about the exact nature of the obsession. I promise you, reading this, if the therapist is worth their salt then they have heard it before. Yes, even that one. You have to do it if you want to tangibly get better, and I’m telling you, once the work starts, you will.

I personally have good days and bad days with it, but because of a combination of therapy and the right medication, the ratio of good days to bad is looking a lot better to me now.

You don’t deserve to feel this miserable, and if you find the courage to properly deal with it, you won’t have to.

Natasha Daniels has been helping the parents of kids with OCD and anxiety navigate the ups and downs of life, from toddlerhood to the teenage years, for most of her career. Now, following the unexpected death of her husband, she’s writing and talking about grief and how to work through it both as a grieving spouse and the parent of three grieving kids. Natasha has dedicated herself to helping others, and we are lucky to have her in our community! Thank you, Natasha!

Through your resources in AT Parenting Survival, you offer a wealth of support for parents of children with OCD and anxiety: the AT Parenting Survival School, AT Parenting Community, AT Parenting Survival Podcast, and YouTube Channel on Anxiety & OCD. What inspired you to start AT Parenting Survival? What can parents expect when they engage with your resources?

I grew up in a home where my father’s mental health struggles with bipolar and psychosis dominated my childhood. Suicide attempts, psych hospitals, and therapy sessions were all a part of our life. I went into the mental health profession with a hope that I could make an impact in what felt like a broken system.

My own anxiety issues were morphed by the enormity of my father’s struggles. I went to graduate school with the hope of helping other people like my dad, but found myself gravitating toward helping anxious kids, more similar to myself.

I eventually created a child therapy practice solely focused on anxiety and OCD. A few years later I had my own three children who all showed signs of anxiety and OCD.

Ten years after I started my private practice, I stumbled into creating AT Parenting Survival. I had written my first book, How to Parent Your Anxious Toddler. I had gotten an email from the publisher talking about the need for a strong “platform.” I realized very quickly that I didn’t know what a platform was, nor did I have one! So I created a website called Anxious Toddlers.

It was soon afterward that I realized how fulfilling it was to be able to help parents on a global scale. Over the next few years my website shifted from being about toddlers to being about anxiety and OCD for kids and teens. There was such a strong need for parents to get support raising kids with anxiety or OCD. So many parents felt isolated and alone. I got this on a professional and personal level.

I now offer parents raising kids with anxiety or OCD support through my weekly podcast and YouTube videos. The podcast is to support parents and the YouTube videos are to help kids and teens directly.

I also took all the skills I taught in my therapy practice and created easy-to-digest online video courses on anxiety and OCD. After that parents asked if I could create more in-depth support. That is when I developed a membership called the AT Parenting Community. In the AT Parenting Community members get weekly live classes, Zoom support group calls, as well as direct access to my support.

What is the most common question you get from parents with kids who have OCD or anxiety?  

One of the most common questions I get from parents is what is the difference between anxiety and OCD? So many kids with OCD are misdiagnosed with anxiety. As parents start to dive into my resources they also learn about OCD. Sometimes the more they learn, the more they realize their child has been given the wrong diagnosis.

You’ve written several books for kids and teens about anxiety, social skills, kindness, and, most recently, grief. Can you tell us more about The Grief Rock: A Book to Understand Grief and Love? 

In 2021 my husband died suddenly of a blood clot. This turned our world upside down. How do you help kids understand how their dad can be fine one day and gone the next? Besides getting them into a grief group right away, I scoured the internet for the best children’s books on grief. Nothing quite hit the spot.

My kids needed help navigating grief itself. Grief is a beast. It knocks you off your feet when you least expect it. It impacts your ability to eat, sleep, and function. It impacts how others treat you.

My nine-year-old daughter was outwardly struggling. She would unexpectedly burst into tears. She lost several friends who said she wasn’t “fun” anymore. She had a hard time sleeping.

Eventually I started talking to her using rock as a metaphor for grief. I told her that we have this rock in our lives now. Sometimes it crushes us and sometimes it’s a small pebble in our pocket. Sometimes people see the rock and want to run. Sometimes we put so much energy trying to hide the rock, that we get exhausted. We talked about how our rock is so big because our love for their dad was so big. It gave us language to discuss what was happening to us. Eventually it became our shorthand. She would say, “I can’t, Mom. My rock is just too big right now.”

One day I wrote some of the words I was telling her down. When my grief fog started to lift I came across those words again. They were so simple but true. It was a universal description of love and loss. I felt a push to put it out into the world. Even though the publisher wanted to publish it as a children’s book, I saw it as as a simple book that would help anyone trying to navigate the twists and turns of grief.

Is there a relationship between grief and anxiety? Do kids experiencing grief also tend to feel more anxious, maybe about the safety of loved ones or themselves, or fears about death? 

Grief can bring a flood of anxiety with it. Kids can worry about so many things. Depending on how the person died, they might worry that it can happen to them as well.

My daughter continues to worry that she or someone she loves might die in their sleep. Other kids might worry that if they get “sick” they’ll die too.

It can also create fears around stability and change. If it is a death of a parent, they might worry their other parent will die and they’ll be orphaned. If it is a grandparent, they might worry that their other grandparents will die as well.

When kids already have a history of anxiety or OCD it can become an even bigger battle. My youngest has compulsions where she feels she has to say, “I love you” to her brother before bed or something bad will happen to him.

What advice do you have for parents who are   navigating some of these challenges—OCD, anxiety, grief—solo? Conversely, how can parenting partners get on the same page to ensure their child is getting consistent support?

Helping a child with OCD, anxiety, and/or grief alone can be an overwhelming experience. If a parent is dealing with their own struggles, it makes it even harder. I know for me it was important that I found my own support.

It is helpful to remember that you can’t help your kids if you are running on fumes. I had always been the helper, never the one getting help. Even if it makes you uncomfortable, getting your own help and learning self-compassion and self-love is key to helping your kids.

Sometimes it can be equally challenging if you have a partner who is not on the same page. You might be feeling you are rowing in one direction and your partner is rowing in the other.

It can help to tap into each other’s strengths. Often one partner is better at addressing the child’s anxiety or OCD than the other parent. Parents can be successful when they define what roles each parent will do. It might be that one parent is the main source of support for the child with anxiety or OCD, and the other parent picks up additional responsibilities to lighten the load for the other parent. It can also be helpful for parents to periodically have parent-only sessions with their child’s therapist so they are both getting the same information.

If you could give just one piece of advice to someone with OCD, what would it be?

It’s never too late to start working on OCD. There is always hope, even when it feels hopeless. Take one small step toward discomfort. Take one small step to challenge OCD. Those small steps can lead to big change over time.