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Shana Doronn, LCSW, Psy.D. - Guest
Shana Doronn, LCSW, Psy.D. is a licensed Clinical Social Worker and Doctor of Psychology in the UCLA OCD Intensive Treatment Program. She received her MSW at USC and her Psy.D. at University of San Francisco. Dr. Doronn frequently presents on OCD and related disorders in workshops and symposiums throughout the country. She was also a featured therapist on A&E’s reality documentary “Obsessed” from 2008-2010. In addition to her current work in the OCD Intensive Treatment Program, Dr. Doronn also treats patients with OCD and other anxiety disorders in her private practice in Los Angeles and Orange County. |
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W. Keith Sutton, Psy.D. - Host
Dr. Sutton has always had an interest in learning from multiple theoretical perspectives, and keeping up to date on innovations and integrations. He is interested in the development of ideas, and using research to show effectiveness in treatment and refine treatments. In 2009 he started the Institute for the Advancement of Psychotherapy, providing a one-way mirror training in family therapy with James Keim, LCSW. Next, he added a trainer and one-way mirror training in Cognitive Behavioral Therapy, and an additional trainer and mirror in Emotionally Focused Couples Therapy. The participants enjoyed analyzing cases, keeping each other up to date on research, and discussing what they were learning. This focus on integrating and evolving their approaches to helping children, adolescents, families, couples, and individuals lead to the Institute for the Advancement of Psychotherapy's training program for therapists, and its group practice of like-minded clinicians who were dedicated to learning, innovating, and advancing the field of psychotherapy. Our podcast, Therapy on the Cutting Edge, is an extension of this wish to learn, integrate, stay up to date, and share this passion for the advancement of the field with other practitioners. |
Keith Sutton, Psy.D.: (00:22)
Welcome to therapy on the cutting edge, a podcast for therapists who want to be up to date on the latest advancements in the field of psychotherapy. I'm your host, Keith Sutton, Psy.D., a psychologist in the San Francisco Bay Area and the director of the Institute for the Advancement of Psychotherapy. Today, I'll be speaking with Shannon Doran LCSW PsyD, who is a licensed clinical social worker and doctor of psychology at UCLA's OCD Intensive Treatment program. She received her MSW at the University of Southern California and her PsyD at the University of San Francisco. Shana frequently presents on OCD and related disorders in workshops and symposiums throughout the country. She was also a featured therapist on A&E's reality documentary Obsessed from 2008 to 2010. In addition to her current work in the OCD Intensive Treatment program, Dr. Dorin also treats patients with OCD and other anxiety disorders in her private practice in Los Angeles and Orange county. Let's listen to the interview. Hi, Shana. Thank you so much for joining today!
Shana Doronn, LCSW, PsyD: (01:25)
Ah, thank you! It's good to be here. My pleasure!
Keith Sutton, Psy.D.: (01:28)
Yeah! So I know you from the show Obsessed where you were one of the therapists doing Exposure with Response Prevention for clients with OCD. And actually, that show inspired me to go to Philadelphia where I trained at the University of Pennsylvania. I did a three-day workshop with Edna Foa and Exposure with Response Prevention, because, we'll talk about maybe a little later, but there's one client that you worked with a fear of killing someone. And there were some exposures that you did in that. And I was like, I think I need to get some extra training and really understand this before trying this on my own with just a little bit of consultation. I also was mentioning to you on the phone when we talked that I actually use a clip of some of your work from Season 1 Episode 1 with one of the clients when I teach Cognitive Behavioral Therapy and Behavioral exposure techniques.
Keith Sutton, Psy.D.: (02:23)
And also that I show that to clients too. So they can get an understanding of what it looks like to experience anxiety going up and coming down. But first I wanna hear about how you got to doing the work that you're doing and, and you're particularly, and I think yourself, you're a very brave, like in, , really you go for it in the exposure work that you're doing. I'm always so impressed with the shows that I've seen. So yeah, anyway, love to hear about how you got to doing this!
Shana Doronn, LCSW, PsyD: (02:54)
Well, before we get to that did you get to meet Edna Foa?
Keith Sutton, Psy.D.: (02:59)
Yes, I did.
Shana Doronn, LCSW, PsyD: (03:01)
How cool is that?
Keith Sutton, Psy.D.: (03:02)
Yeah, I mean it was great to go like to the source and like learn and hear. And then I actually, I don't know if , Munya Conna at all, but she, I got a consultation with her afterwards. She's a specialist in pediatric OCD, so it was so nice to learn from folks that are, , kind of the experts that did the research and developed this
Shana Doronn, LCSW, PsyD: (03:21)
She's my hero. She doesn't know who I am. I know who she is. Sure. So my evolution, I started as a clinical social worker way long time ago, back in the day. And I always worked on the medical side and I started off in trauma, medical trauma, and then ultimately found my way to HIV, the HIV world before the protease inhibitors, which are already dated. But this was when people were dying indroves. And interestingly enough, back then I was doing Exposure and Response Prevention without even realizing it, because there were people who were afraid to touch others because they had feared giving someone HIV, which shaking someone's hand is not how you get it. But back then, even people with HIV or aids they didn't always feel comfortable, but that's where I started off. Most of my career prior was working in HIV care. Then one of my best friends decided, Phyllis, she decided she's gonna get her doctorate. And I thought, “No.” Yeah, you say nice. I say like, “She can't have her doctorate unless I have my doctorate!” So I had to go back to school, , for all these altruistic and impressive reasons. And I did go back. The program was mostly behavioral and when I was ready to do my postdoc, I had done most of my career at UCLA. Pretty much all of my career at UCLA. So when I was done with my program and finished my dissertation, I saw that there was a job at UCLA and OCD and I applied for it. I didn't really know what it was back then. Seems like something I would enjoy. UCLA takes a while to hire someone, finally got the job. And when I got there, I did my postdoc hours there and everything just clicked. It made sense. It made really good sense and it was stuff that I've been doing in the HIV clinic, and I had some very good training under Dr. Tarlo and I stayed there for a while, took a brief exit to Illinois, but I'm a California girl and came back. And so I've been work working in OCD since about 2008. No, no, that's a lie: 2003.
Keith Sutton, Psy.D.: (06:07)
Well, that's great. And you're still at UCLA today?
Shana Doronn, LCSW, PsyD: (06:12)
Yes. I've been back, back at UCLA I have tinsey tiny private practice, but I tend to stay away from that. Which is silly. I know.
Keith Sutton, Psy.D.: (06:24)
Well, that's wonderful. It sounds like you're doing wonderful work. Tell me about.. Could you tell me a little bit about, for some folks that clinicians that are listening to this, I'm sure they've heard of exposure and exposure for OCD, but I would love to hear your kind of thoughts on it.
Shana Doronn, LCSW, PsyD: (06:44)
I think for people who, are just trying to get a feel for OCD sometimes the treatment can seem barbaric or there were a few people when I was on the show Obsessed, few therapists not many, that wrote in and said, “This , this is horrible. What are you doing to these people?” And that, of course, I was wondering what are they doing with their patients. So how are they - they must be making them worse if they're trying to give them reassurance all the time.
Keith Sutton, Psy.D.: (07:19)
Yeah.
Shana Doronn, LCSW, PsyD: (07:19)
But, but I didn't let on my negative thoughts and feelings. The process is not barbaric. It can be demoralizing but because we're working oftentimes with highly intelligent people and the most important thing to realize is that insight/intelligence is pretty much worthless in treating emotions, especially when your brain is hijacked with anxiety and fear. You can't tap into your emotions. And it's so easy to kind of, try to get into just the cognitive aspect of treatment. And so in that sense, it could be demoralizing, especially when we as clinicians get excited because someone didn't wash their hands and they touched their face. We go “Yay!” And then we have to remember, “Oh, no, this is an attorney.” This is a physician. This is just anyone.
Keith Sutton, Psy.D.: (08:21)
Well, I think it's so counterintuitive for so many people, especially therapists going into try to relieve suffering or anxiety or pain or difficult feelings to actually evoke those. And I know like when I first was doing one of the first exposures, it, with one of my clients, this was more around PTSD and doing some agoraphobia stuff. I was getting anxious that he was getting anxious and I was like, “Oh, do some deep breathing” because I was kind of like, “oh no, like what am I doing here?” And it really wasn't until I actually saw that show and then did the training. And actually that's something I'd suggest to many therapists is to actually go and watch this series to actually see somebody experiencing anxiety and see how the therapist sits with them. And, because it's, I think it's hard when you don't have that confidence cause you haven't had the experience of seeing somebody's anxiety going up so high and then coming down again.
Shana Doronn, LCSW, PsyD: (09:20)
Oh it is. It's so difficult. It's just as a new clinician in the field. It's just as much exposure for the clinician initially as it is for the client or patient. Every once in a while, I'll watch someone’s anxiety go up and I think “This better work, this is gonna work.” It seems like it's been forever and their anxiety hasn't come down and you're sweating a little yourself, but eventually you could see almost like a fever breaking. They give a sigh and they take a deep breath on their own and you don't have to tell anyone to take a deep breath cause they'd probably punch you out.
Keith Sutton, Psy.D.: (10:00)
Heheh Sure!
Shana Doronn, LCSW, PsyD: (10:02)
And you could see the anxiety coming down, but what goes up has to come down or at least lead to tolerable, that's for sure.
Keith Sutton, Psy.D.: (10:11)
Yeah. How do you kind of explain it to clients? Cause I think that's the other piece is that, , that's the last thing somebody with anxiety wants to do is actually evoke anxiety or go towards it or sit with it.
Shana Doronn, LCSW, PsyD: (10:27)
Well, the people that come to see me through the university, they all know what they're getting themselves into. When I did more private practice and people would just call from out in the community. Before I would work with them, if I didn't think that they had a clue as to what this treatment was about, I would have them go to the OC foundation and look at questions to ask a therapist. Because people with anxiety they want the therapist to POOF! Fix! and they don't appreciate the suffering aspect of it. And that could lead to a horrible experience in care. So I think people have to be really informed, but I've never been someone to do a big private practice. So that's why it's like, nah, I'm not gonna take the chance if they still wanna work with me.
Keith Sutton, Psy.D.: (11:25)
Coming in kind of knowing what they're getting when they come in. Cause I feel like that piece of that psychoeducation, the client really understanding what helps with anxiety, helps to get on board. And if you don't have that you can't really kind of make that movement forward. Otherwise they end up feeling like, “oh, what are you doing?” And if the therapist has trained others or supervised others, as they're trying to maybe pull them along into doing exposures, but the client doesn't really understand what's kind of going on, it can end up feeling bad or outta control and the therapist really needs to kind of rewind go back and kind of get on the same page with the client right before actually moving forward to get any success in kind of what they're doing together,
Shana Doronn, LCSW, PsyD: (12:13)
People I think are much better informed now, but there's still some people that are completely unaware.
Keith Sutton, Psy.D.: (12:22)
Maybe we could talk about one of the videos actually that I saw that was pretty impactful for me when you were working with a woman and part of her OCD was fear of hurting someone or killing someone, harm to others OCD and particularly she would avoid knives,she would avoid going places with knives and these kinds of things. And so when you built up to one of the big exposures, you actually asked her in your office to hold a knife and you had all these kind of big knives laid out and actually had her hold the knife to your throat. And she was really anxious and kind of shaky and scared to do it, and her anxiety I think was like at a 10.
And you were like, “can you feel the cartilage on my neck?” I was just interested about your thoughts on that and I mean, again, somebody from another perspective, or maybe doesn't do this work, they think “like, oh God, what if the client was gonna really kill you or something like that.” And they think that that's another piece of OCD work is that oftentimes folks with OCD are actually the safest. But I think for clinicians that don't know this work as much, I'm wondering if you could speak to that a little bit.
Shana Doronn, LCSW, PsyD: (13:41)
Yes. So when we were filming the staff, they were really pretty anxious, I've been working with Trina for about nine or ten weeks so we gradually build up to that point. What you saw on TV is actually what I really do. I didn't have to do - well I can't really act so I didn't do any acting I was just me. So we started off with using a script. I do like to use a lot of script work even for nonviolent non-sexual stuff just to give us an entree into exposure therapy. And we slowly gradually built our way up. And we started with a plastic knife. I think when we first got to
Keith Sutton, Psy.D.: (14:35)
Can you actually explain script for people that might not know what a script is in exposure therapy?
Shana Doronn, LCSW, PsyD: (14:40)
Yes. I use basically an imaginal exposure in writing, or you could put it on tape, but in writing I will start with I and the letter K and build up to I kill and I killed so and so, and when we do the script, we're building up to the worst case scenario and my scripts tend to be like a paragraph long, right. When they get too long, it's like, what are they getting habituating to. So the script is used to trigger anxiety, and it's facing the worst case scenario without any caveats it's done.
Keith Sutton, Psy.D.: (15:23)
I remember like writing out - I did this with one client where I “wake up in the middle of the night, I grab a knife, I kill my roommate and”, kind of going through of the worst fears of these things that would happen again, against her will or something or something would snap one day. And then the client reads it over and over to kind of habituate to that story, those words, those thoughts and so on.,
Shana Doronn, LCSW, PsyD: (15:45)
And the script should ultimately be about it covers all bases and it's fine in all documents. It's a working document, but I also use this script when someone's doing the exposure work, just to keep them focused, because what I have found a lot is - I say patients because I'm hospital based but - when people are - patients are - are learning how to do exposure, there's the tendency to what I call, “jumping ship.” Like they'll face their fear on this and sometimes their anxiety when it peaks, it comes down and they'll get bombarded with other thoughts that seem so much more important. So, if someone fears that they're dying of this illness, anxiety starts to come down, then they say,”oh, no, that doesn't bother me, I'm afraid of THIS illness.” I keep 'em focused on the task at hand because if they're jumping ship, they're not really habituating to it very much.
Keith Sutton, Psy.D.: (16:46)
Then they're doing multiple exposures at the same time, rather than staying with one.
Shana Doronn, LCSW, PsyD: (16:50)
Yes. So the script is helpful to focus.
Keith Sutton, Psy.D.: (16:54)
Then uou worked up to plastic knives?
Shana Doronn, LCSW, PsyD: (16:59)
Plastic knives, butter knives, any dull type of knife and then all the others. I think she picked a serrated, which is surprising, it's not the sharpest. But it does look violent.
Keith Sutton, Psy.D.: (17:18)
There are different camps that even have different opinions on how high you really have to go. Do you actually need to hold the knife to your hand? Or do you need to put your hand in the toilet water and rub it in your hair or something like, or do you need to take the donut and put it on the sidewalk and kind of eat it off the ground or so on? What, what are your thoughts on kind of the necessity or the options about whether you need to go to that highest kind of level on the hierarchy?
Shana Doronn, LCSW, PsyD: (17:49)
I think, well, I wouldn't have someone do something I wouldn't do. So I get to take a lot of steps and don't have to take the elevator. I don't like taking that, but if I have to, I do. I'm not about dunking toilet water on somebody's head. There's not a lot of utility to put your hands on a toilet seat and not freak out. Fine. I'm not gonna go put my hand on a peed on obvious, like it's overtly peed on. I'll put my hands on a toilet seat. I'll normalize if needed. I think it depends on the person, but I don't think for people afraid of throwing up that I need to have them stick their finger down their throat and vomit. For the knife thing, that's a perfectly fine exposure as far as I'm concerned. And I've done it a long time ago, I did it with someone who was a boxer. But I wasn't scared. They're scared. They're like shaking.
Keith Sutton, Psy.D.: (18:55)
Sure.
Shana Doronn, LCSW, PsyD: (18:57)
But with certain things, I just don't think there's a lot of utility to go - it's okay to go extreme, but at some point it's ridiculous. Like where's the utility - and maybe I've softened a, a bit as I've gotten older - but, I've never been about “putting the donut in the gutter and eating it.” I'm not gonna do that. That's gross.
Keith Sutton, Psy.D.: (19:20)
For sure. Yeah.
Shana Doronn, LCSW, PsyD: (19:21)
If they want to they can but I'm not gonna, I'm not gonna encourage someone to do so.
Keith Sutton, Psy.D.: (19:28)
Yeah.
Shana Doronn, LCSW, PsyD: (19:30)
Do you have any thoughts on that? How far?
Keith Sutton, Psy.D.: (19:33)
Yeah, I tend to think about it - I guess oftentimes I feel like there is this kind of tipping point, oftentimes with the exposures where the person has had multiple successes and they start really getting it. And then they start doing it on our own and start kind of - they come in and they say, “oh, I did this and this, this week”, like things we hadn't even quite like - they're getting it so much that there's actually almost this shift in where they start actually seeking out their own exposures and doing exposures in the moment and really kind of going towards anxiety. And I think that that is really often times what I'm looking for. And so if there is still a part of them, that's like, “I don't wanna do that” then we would, , go up. But again, we're only gonna do something that makes sense or something. Not too gross or things like that, but again, it depends on I guess what the worries are, what the OCD is telling. But I think definitely wouldn't do anything that I wouldn't do. Sometimes I'm participating with my clients in exposure. Sometimes it's uncomfortable for me to be doing it. But again that's part of the work and kind of doing it together and that collaboration.
Shana Doronn, LCSW, PsyD: (20:52)
Now you're working in private practice primarily. I work with moderate to severe OCD and I see people every day. So there are people, that we see with germ contamination - their skin is really for falling off their hands. They're showering four hours a day. Everything's gonna feel extreme for them. But we take it slowly. We're not trying to annihilate the patient, but of course it's building the skillset - well, let me backtrack. When people call me they ask me, “so what are the tools in dealing with OCD?” And I think, well to tolerate the anxiety and not engage in the compulsion. And for some reason that doesn't click, it's like, “no, no, but the tools.”
Keith Sutton, Psy.D.: (21:47)
Yeah.
Shana Doronn, LCSW, PsyD: (21:48)
It's to experience the anxiety and not do anything about it. I guess people still wanna know what the magic formula is. And I'm always to this day - I'm scratching my head. Am I missing something? They're supposed to not engage in the compulsion, tolerate the anxiety and then normalize. Live their life, presumably based in their values, what is important to them.
Keith Sutton, Psy.D.: (22:14)
Yeah.
Shana Doronn, LCSW, PsyD: (22:15)
Do you ever get that?
Keith Sutton, Psy.D.: (22:17)
Yeah, I think that's definitely the piece and I think that's - I like in Acceptance commitment therapy, the kind of idea of the emotional avoidance and like trying to get rid of, and I think that that's part of another attempt to get rid of - just gimme the tool to get rid of this - versus like really kind of shifting and moving towards the anxiety. And like you are mentioning going towards your values, despite the discomfort and being willing to go towards the discomfort.
Shana Doronn, LCSW, PsyD: (22:48)
I think -we use ACT in the sense that there's a values based behavior. And when I think of ACT, I could always say, “well, exposure therapy is part of ACT. You gotta go into it to get out of it.” Right. And that would be - what is it called? Where you're kind of deep?
Keith Sutton, Psy.D.: (23:09)
Cognitive diffusion?
Shana Doronn, LCSW, PsyD: (23:10)
Yea diffusion. But the only way to diffuse it is to go into it. You just can't watch it on a leaf. If people could watch whatever their thoughts or their scary whatever's-going-on, their unwanted thoughts, images, sensations, just go on a leaf and leave, they would. They wouldn't need us.
Keith Sutton, Psy.D.: (23:26)
Yeah.
Shana Doronn, LCSW, PsyD: (23:28)
But exposure therapy will ultimately diffuse the fear. And I don't know about you, when I remember learning about behavioral therapy in school, and every time they talked about reinforcement, the non -I still get whatever those questions on a test wrong, because it's sure positive and negative - but the classical conditioning with the Pavlov’s dog, we're kind of doing an element to that, but we're ringing the bell and trying to get them to not salivate or not have them feel the anxiety. And ultimately the anxiety is not so bad. I never thought I would've ended up doing that kind of work. And then in doing this work, all the developmental theories that I could remember popped into mind, because you could see where people get kind of stuck. The moral development comes in just as a conceptualization to where people are. So we're treating their anxiety of course and the OCD. But I always refer to them needing to get growed up. There's like this slice in their life, which oftentimes interferes in relationships, whatever that is, where they're just not grown up. They're still waiting for the knight or knightess in shining armor and they're waiting for the fantasy and everybody will live happily ever after. So it's not - when the OCD starts to stabilize, it's getting them growed up.
Keith Sutton, Psy.D.: (24:59)
Yeah. Say more about that. The growed up - you mean like that they're kind of waiting for something. They're not necessarily taking the direction in their lifeor so on? Or feeling in control of their life? Or kind of waiting for someone to come to fix things?
Shana Doronn, LCSW, PsyD: (25:15)
So, depending on when their anxiety started and what their home life is, because everybody is in the context of their environment, presumably family life. We're all learning different things for the better or for the worse. But people tend to have what I call adult temper tantrums.
Keith Sutton, Psy.D.: (25:38)
Uhhuh.
Shana Doronn, LCSW, PsyD: (25:38)
Like, you can't just stomp your feet. That's not okay. It's like the crossing their arms and stomping their feet. You can't act like that. Adults don't act like that. Not that I was so adult like back in the day - I’m a little better now - but there's still some naive notions of “life is fair” and “everybody else's life is perfect” and there's also the “I don't wanna be a bad person or a good person” which correlates with a five to eight year old in there, world development? And so as adults we get to see situations from a broader perspective and certain aspects of someone's life is a little thwarted. And it could also come in relationships - like “I didn't feel like they love me” - which always makes - well, I don't have any hair of my arm, but it would stick up if it could stand. Because we're teaching people not to use their feelings, emotions, whatever you wanna call them, to guide them. So if they don't feel like someone loves them, that's not a feeling as soon as the word “Like” comes in. I feel like it's like, “Uhuh, that's a thought. I don't know how you feel, but say this thought.” And they kind of confuse themselves - actually language, which I struggle to speak sometimes, is so much a part of the work that we do. People with anxiety love to glum on to ambiguity as though it's the absolute truth, which is great fodder for the OCD like - “Oh, I'm a pedophile. When I read up on pedophilia, it said, pedophiles have morals. I have morals. Therefore I'm a pedophile.” Like, what!? No, you're cutting up. How do you are? “Well, I feel it to be true.” Like what!? Either ya you are or ya aren’t. They're confusing themselves with this imprecise language. So I tend to be a stickler between “that's a thought” and “that's a feeling”. And teach people about how ambiguous words will trip them up. Like “love”can be so ill defined. “Happiness” is something that comes up quite a bit. “I don't feel happy.” Well, I'm - okay this is where act can be very helpful. They're looking to these thoughts to be feelings and feelings to be thoughts. And they're kind of messing themselves up. I know I get confused now, which doesn't bode well at parties. Whenever someone says, “oh, I can't stop” - I know people say this, and this is just something. Ugh. - “I can't stop obsessing.” I'm like, no. They mean “compulsions.”D
Keith Sutton, Psy.D.: (28:17)
Yeah. Yeah.
Shana Doronn, LCSW, PsyD: (28:18)
But that doesn't sound good at a party. “Oh, I can't stop compulsing.” That doesn't bode well for my social life if I have to talk about that. But really, because obsessions are not a choice, I tell them, “oh, obsessions are not a verb.”
Keith Sutton, Psy.D.: (28:31)
Yeah, I think that's confusing for a lot of people too. I've had clients say, “Oh, it's pure OCD because I'm obsessing.” But then when we look at it, it's actually they're compulsively checking or kind of thinking about it and things in this way and because they're thinking about: am I pedophile or am I gonna kill somebody or so on? But we have to look at: what is the thing that that is trying to help or prevent or so on. What's the bad thing. “Oh, well, I don't wanna do this. So I think about it all the time.” And so kind of that understanding of connecting. But I do think that language is important in being able to understand where's the obsession, where's the compulsion and particular to -
Shana Doronn, LCSW, PsyD: (29:12)
A vocabulary for them by the way. But go ahead, go ahead. I'll tell you later.
Keith Sutton, Psy.D.: (29:17)
Yeah, exactly just like you're saying. Like creating that vocabulary to be able to have a common language in being able to work on the OCD.
Shana Doronn, LCSW, PsyD: (29:25)
I oftentimes will show a 35 second clip of Family Guy, which covers the Yale/Brown Obsessive Compulsive Scale beautifully. You just watch 10 episodes, you've covered everything. Or South park. Or watch Quentin Tarantino. But I refer - there's a clip if people wanna watch - called “Meg in low rider jeans”
Keith Sutton, Psy.D.: (29:46)
Okay.
Shana Doronn, LCSW, PsyD: (29:48)
Lois is talking to me, “I'm gonna take you to the store and we'll get you some cute low rider jeans to show off that cute butt” or whatever. And Stewey says, “Ugh, low rider jeans” and he gets an image- a popping as I call it- a popping image of Meg, and he says, “Go away, damn it. Go away.” And then it keeps popping in. And eventually he takes a rolling pin out and starts to beat it. And I'll tell people, which is the obsession, the N1 of thought, image impulse, urge sensation, these are poppings.. And I refer to the compulsive thought process as thunking because people get it so confused. Like, anything related to the obsession you're thunking about - “well, how do I know I really did that?” “I walked two inches to the right and maybe I swerved a little and I might have touched the person inappropriately.” - And it's all this analyzing or mass talk. That is what I call it. But just to distinguish the obsession from the compulsion.
Keith Sutton, Psy.D.: (30:43)
Yeah, definitely. And the other particular piece that I think is like - you're talking about the developmental piece. I mean I think a lot of therapists that maybe aren't as familiar with exposure with response prevention get drawn to the content of what it means and what is this - that he had this thought of his sister or something like that and so on. And I think that - what is your thought or take on that? And also, I think on the other aspect of that, there is oftentimes an aspect of connection to life stressors and then the almost like kind of manifesting and kind of then the mind then going towards the OCD as kind of a unhealthy kind of coping and so on. But yeah, I would love to get your thoughts on that.
Shana Doronn, LCSW, PsyD: (31:31)
Okay. What was the first part?
Keith Sutton, Psy.D.: (31:32)
So the one is on content and about therapists that say, “Oh, well, maybe he's thinking about something with his sister or he's got issues with his sister or family or so on and kind of - do you look at the aspects of the content or even like, that one person with the knife, the worry is that she's going to kill someone, be in jail, go to hell and bad and so on or I alone or whatever it might be.
Shana Doronn, LCSW, PsyD: (32:01)
Well, of course, in an assessment, I'll get some of the background information just to make sure that we're not dealing with PTSD or something other than OCD but the content may or may not have anything to do with what's going on at home. Could be a trigger! who knows. I don't spend a lot of time but it's interesting. But with Trina, with most people, I don't do a lot of that. It comes up because by the time people have gotten to me in therapy, they've done so much psychoanalysis and theorizing and philosophizing and who knows what. Yeah, it could be because of the family life. It may not be, I don't know, but I acknowledge it. I constantly bear in mind, that the people we work with are intelligent. So there is kind of a, like a perk to, to see if there's any kind of meaning.
Keith Sutton, Psy.D.: (33:08)
Sure.
Shana Doronn, LCSW, PsyD: (33:10)
I know I'm kind of shifting here, but the family stuff is still very important. Oftentimes parent will aid in abet, or the family dynamic will be quite chaotic. I went to a couple of lectures, or it must have been CEUs, on parental alienation syndrome, which I know is just veering off to something different.
Keith Sutton, Psy.D.: (33:36)
Yeah. I actually just posted a podcast this week about it interview an expert in that area
Shana Doronn, LCSW, PsyD: (33:41)
Love. I mean, no, it's horrible. What happens, but what happens is maybe since you already have a podcast on it, I started asking patients, or zeroing in a bit more, if the parents are divorced? Are you allowed to talk with the other parent? What is that relationship like? And with parental alienation of course the, if the person was younger - I only work with adults in the OCD program, but I have worked with children - but with adults, it's still important to find out what a divorce and custody was like. And if someone comes from a family where the other parent was talked about inappropriately, it's usually the narcissistic or borderline type of parent. And when that child, or even young adult tries to veer away from that parent and causes some kind of narcissistic, some kind of wound, the wrath shall befall them. So they learn to doubt themselves. They have to follow what the parent says. So if there's the propensity for a disorder for OCD, that could definitely spark that trajectory for sure.
Keith Sutton, Psy.D.: (34:59)
Well, that's interesting. Is there any research on that at all? That'd be, that would be interesting if that because that whole diathesis stress model of the genetics and then kind of what happens in the environment that leads it to manifest. That - definitely at least that family stress - would be one potential aspect.
Shana Doronn, LCSW, PsyD: (35:19)
Yeah. I don't know if there's research because you're the only other therapist that I know that's heard of it and you just did a podcast on it. So you're, you're aware of it, but I, I heard of these things, of course, parental alienation can happen in any family, but a few of my friends went through that. I knew them pre and post, so it's a horrible situation, but the stress of it of course is triggering and any kind of chaotic home is triggering. And sometimes you just have someone who had kind of like an ideal - if there is such a thing - household and theystill have of OCD.
Keith Sutton, Psy.D.: (35:58)
Yeah, yeah, definitely. When I think too, that the aspects are - I know that with OCD some of the research has found that for children: higher rates of relapse when there's a lot of family difficulties and the correlation between the high EE or the expressed emotion in the family system and relapse and symptoms and so on. So oftentimes those systemic aspects are so important to look at because they may be - maybe just the family stress that might be increasing it. I know that with some clients that - while they've also maybe got stress going on at home or work or something like that - sometimes their OCD of course flares up. And it's almost kind of -not that they're trying to cope in that way - but it can almost kind of exacerbate the distress and then that almost gets channeled or funneled into the OCD and then treating the OCD and also treating the stressors that are going on in life at the same time are oftentimes needed
Shana Doronn, LCSW, PsyD: (37:07)
For relapse prevention in our program, we do talk a lot about triggers. And when people are in our program, they're kind of in this safe zone in terms of triggers. So I mean the safe distressing mode, but they get to feel comfortable with it. And when they are interacting - even though hopefully we're having family meetings - but interacting with family, and they're not in the program, that's a trigger. When they go back to work, they socialize with friends, they go to the bank: all of these points can be triggers for a lapse or relapse. You had mentioned something about the - well, my interpretation was the themes of OCD - where had I have seen a theme play out for people who have a history of being, abused sexually, emotionally, physically. I've seen quite a bit where their themes might not be exactly that, but it's harm to others as well. So it may not be the same kind of harm. So with that - people who have been abused, could fear harming others.
Keith Sutton, Psy.D.: (38:13)
Yeah. Sometimes that - it kind of manifests in that way, because it - OCD from my understanding of it kind of really draws on those worst fears, those taboo things, those and everybody has weird thoughts. But then with somebody with OCD, they think, “oh no, I had this weird thought: and it gets stuck and then kind of becomes like that mental hiccup. Sometimes I use the example of like - everybody's had the experience of going to the bathroom in a public bathroom or something that maybe as gross. And they're like, “oh, that's kind of gross” as they leave. But then they don't think about it after, whatever five minutes. And then later on they're eating lunch or something, maybe they wash their hands or not. But for someone with OCD it's the same thought, that everybody has these weird thoughts, but it just gets so stuck-, and so it's not so far out of the realm of the usual, it's just kind of those weird, odd thoughts that kind of get stuck.
Shana Doronn, LCSW, PsyD: (39:05)
Yes. And I call OCD brains, sticky brains or anxious brains, sticky brains, because whatever themes, it just sticks. And it wreaks havoc. Something - random thought, but I have many - I don't know if you use - I use a distress meter in session. And when I try to teach people is the higher their distress - or the 10 of 10, there's almost like an inverse relationship. There is an inverse relationship with insight. So a 10 outta 10, you're a murderer. And as the anxiety symptoms go down, the insight pops back up. And I think that's something important, that we do in our program, whether it be a high, medium, or low or zero to 10, I think that rating is important and that just popped into my head. So I thought I would share that.
Keith Sutton, Psy.D.: (40:05)
So like you're kind of assessing like how much do they like - a 10 they totally believe they're a murderer that it's like, ego cystonic, and like - zero they have a thought that they're a murderer, but they know they're not so it's like ego dystonic. Like they know that it's like separate - you also rate that to kind of get where they are in kind of their insight to whatever the OCD is or the fears are?
Shana Doronn, LCSW, PsyD: (40:31)
Yes. I use that quite a bit and I've also - well when I get into treatment, but before I even get into it, I want people to know their symptoms of anxiety or distress, whatever they wanna call it. And I'll often pull from the panic worksheet, just the sensory, the sensation aspect of it,. The thoughts we already know, it will come out because they'll say I'm afraid of. And so when we do our first exposure, well, I'll start with an interoceptive. So if they get rapid heartbeat, which is always the easiest to deal with, if I like that one, I'll have people run up a flight of stairs and put their hand on their heart, have it regulate. I might have them do it again and feel their heart rate go back to baseline when they're at the height of their 10, 9, 8, or until they're able to tolerate it. I don't allow a lot of talking and distracting. I keep them focused. And I started to use that, for any emotion, including crying .So my sister, who's not a therapist, said to me, I hope you're not a tissue pusher to your patients. I hadn't really thought that much about it. So now, when I start a session, I'll tell people, or when I meet someone for the first time, “Here are the tissues. If you cry, I'm not gonna push them to you. I don't wanna break your tears. You'll stop crying when you're ready and no talking when you're hysterically crying. One, I can't understand you. And two, I don't want to break that emotion because we're - when we think of laughter, we don't punch ourselves in the stomach or head to stop laughing unless we're in school and somebody starts busting up laughing. And if we're trying to teach people the temporary ephemeral nature of our experiences, emotions - I use feelings and emotions inter interchangeably. I know they're not, but for the purpose of discussion. So when someone's laughing, we want them to enjoy it. So if someone's sad or they're grieving, there's a lot of grief in OCD, of lost time or family dynamics. I don't want to stop them; and the same thing for anxiety. They learn that everything's temporary. Unless they try to block the emotion and then with a compulsion, then it's forever.
Keith Sutton, Psy.D.: (42:49)
I think that's a great - yeah, I love that. That's a great point of like: we don't try to stop ourselves from laughing. So why stop yourselves from crying? Really to experience that wave of emotion and as it kind of goes through - I was interested too, on the way you think about, or your thoughts on,as a CBT therapist, doing exposure with response prevention, you have to be very directive and particularly there's times in the video where you're like “put your hands on the tampon residue” or whatever it is, it was the the first episode which is great. You had used the restroom and watched your hands and dried them on a towel, clean towel. But his OCD was saying it was all bad and there was something disgusting or so on, but you were kind of saying like, put your hands on it and really kind of guiding and directing. And I was wondering, how do you, how do you think about, or how do you deal with when somebody is kind of like, “no, no, I don't wanna do this. And kind of walking that line of saying like, no, no, you need to do this. Or that line of like, okay, wait, this is now a little too much. And I wanna make sure I'm not taking away as agency or her agency?
Shana Doronn, LCSW, PsyD: (44:06)
Right. And I don't want to, I don't want to, I want them to have some control over something. It's, it's what we talk about. So I like, I don't really do unexpected or real life, especially in the beginning of exposure therapy. I like everything to be controlled. I know it's not, mimicking real life yet, but, we have a discussion. Let's go with this. Of course, when push comes to shove and we get to this point, people don't wanna do it, but I do wanna know if you think you could take the chance great, if not, it will be something that we do need to get to
Shana Doronn, LCSW, PsyD: (44:45)
But we will be getting to it. So we'll push and an old boss once said to me, what's the, I didn't make this up. Okay. What's the difference between a pit bull and an OCD therapist? And I don't know, I never heard the original joke that had to do with whatever. And he said the, the pit bull, eventually let's go. So we're there to push. But again, I am working in an intensive program. We've got 30 days to make that reduction in symptoms, but I don't wanna be barbaric any more than the treatment lends itself to that. So they should have some agency and if they're consistently not doing something, it's okay, what's this roadblock what's going on here? How could we break everything thing into manageable parts and try to tackle this? And some people are willing to go for it over time. Some people don't, they're just not ready.
Keith Sutton, Psy.D.: (45:42)
Yeah. Yeah. And I think that it also depends on the therapist's confidence because when what the person needs to do, you are confident that that's kind of the way we need to go about it. And then when they're like, I don't wanna do that then, looking at yeah. What are your thoughts about what's getting in the way, because I think this is what's needed to help us get through you. I sometimes I'll tell clients, you don't have to do this right now. , we can talk about these other things, but I know you wanna do this because - And that at video that I show the clip of you, the person is doing that OCD treatment, because he wants a closer relationship with his partner and to move his partner in and you kind of remind him again of his values and why he's doing this to get that closer, better relationship. And that kind of is something that, and is motivating. So oftentimes I bring it back to the person saying, I know you wanna do it, this to get there. And so it's up to you really, but I think you should do this. And oftentimes the client is able to muster it up and do it and takethat leap, that chance. Yes, it's hard. We're asking to do hard stuff.
Shana Doronn, LCSW, PsyD: (46:48)
Heck yeah. It's not easy. And it’s different, I would've gather in private practice because you're seeing people weekly maybe twice, maybe three times a week and so there is that gap in time. And so with the gap in time, it's almost like an avoidance. So the brain perceive things as a compulsion. So going into some big exposure in private practice is always tricky and pacing is really important, but it's what you do. And hopefully most of the people in private practice are not at the high, severe as the norm because there's only so much you could do.
Keith Sutton, Psy.D.: (47:38)
Yeah, exactly. Or some at times some people need an intensive outpatient or some people need an inpatient. From your experience of folks that maybe do have the hardest time, making progress in a, say a 30 day program or relapsing afterwards or, or so on. Are there any factors that you at least either from research or from your program or from your own experience that you notice that are helpful to kind of think about?
Shana Doronn, LCSW, PsyD: (48:12)
Um, It seems that, well, I have my theories, I work on campus. The pain thresholds for people seems to be a lot less. Everything's supposed to be for, and I'm not saying we don't strive for fairness in society. We don't do our best to advocate for others, but the notion of offending comes up a lot and can actually be an aspect of OCD. And so, because people are growing up with this notion of fairness, we're not supposed to suffer, anxiety is bad. Things can be a bit trickier. So, it's harder to push people. It's harder to push someone to go say something, what they would deem offensive.
Keith Sutton, Psy.D.: (49:10)
Yeah you mean like, so you've maybe got somebody, particularly, a young adult or student or something like that. And their OCD is worried about saying something offensive. And, and so part of the exposure is to actually say something that's offensive, but they're kind of tolerance for it is very low or they, they they're too scared to, or worried or..
Shana Doronn, LCSW, PsyD: (49:33)
Saying something. Or, when the Kavanaugh trial was going on, there seemed to be an influx of people who were terrified to walk on campus. They wanted their arms like this, their books in their hand, because what if they touched someone inappropriately? They didn't know. And 10 years later they're gonna be sued. So…
Keith Sutton, Psy.D.: (49:59)
Oh, like, okay. So like if...
Shana Doronn, LCSW, PsyD: (50:01)
For touching appropriately, like what if I rape someone..
Keith Sutton, Psy.D.: (50:04)
Like a, Me Too kind of, like where somebody, yeah. Years later talked about having felt, treated unjustly sexually or touched physically or something like, like that or abused or, or so on. So…
Shana Doronn, LCSW, PsyD: (50:18)
Just because they used their arms down and they might have inadvertently hit someone, sorry, that's the rest of the thought. And that came up a lot. Offending comes up a lot and that you have to be careful. Right. Treating OCD, OCD is offensive.
Keith Sutton, Psy.D.: (50:33)
Yeah.
Shana Doronn, LCSW, PsyD: (50:34)
However, getting someone to buy into some of the exposures, it can be tricky. Yeah not that I want people to purposely go offend someone, but try not walking on eggshells. Just, how about that for starters and yeah.
Keith Sutton, Psy.D.: (50:53)
Yeah.
Shana Doronn, LCSW, PsyD: (50:54)
You're always gonna offend someone at some point and of course people with OCD, as you know, can have this hyper sense of responsibility. So if they unknowingly offend someone, it's like, now that's the crime of the century and they wanna go to jail and go, yeah.
Keith Sutton, Psy.D.: (51:14)
Yeah. So that, so it's another, in that realm of the harm to others kind of category that they're going to say something or do something or bump into someone, and then their OCD tells them that it's gonna, this is all these negative things that are gonna happen just again. Like, and again, I think another piece for people that don't necessarily know a lot about OCD or this treatment, is that again, the person with OCD is usually the less least likely person to be doing something offensive or hurting somebody or so on because they're so terrified of it, or like that client about the murder or something like that. She's probably like the least likely to hurt someone, even though she's terrified that she's going to, whatever, a knife is gonna being in her proximity is gonna lead her to hurt or murder or somebody or something like that.
Shana Doronn, LCSW, PsyD: (52:04)
It, it gets tricky. I don't, I don't know if most of your podcasts are about OCD, but just in case, not all of 'em are just as a reminder, an obsession is a bothersome, intrusive, unwanted thought image, impulse urge, or sensation - that sensation seems to get lost on people. and I don't know if you've been seeing a spike in that…
Keith Sutton, Psy.D.: (52:29)
I haven't so much yeah. Say more about that. We kind of cover lots of different topics all over. You're actually the first person that I've really talked to very focused on OCD. Can you say more about the sensation piece?
Shana Doronn, LCSW, PsyD: (52:44)
Yeah.This comes up for people who are fearful of being a pedophile or what if they wanted to sleep with their pet, they could hold their cat, on their lap and people will report, “Well I have sensations down there.” Well, I would gather if the cat's puring you're gonna fill something, but the way that the cat you're gonna fill something, but they there's the leap too. “I think therefore I shall do” that thought-action fusion. It's like, no, no, no, no. When I think in thunk, my quote, therefore you shall do when you analyze it, you shall do. But just the sensation is indicative of being some kind of perve and there's such a misread on that or the same if you're changing a diaper and you, “oh, there's a child's genitals.” Oh, that's a penis, penis, penis, and sex have nothing to do with the kid. But if they start thinking about sex, they might notice something and boom, now they're a pedophile, which of course what gets lost on them. And I've had this happen before people who are afraid of being a pedophile, they will vomit. I've had people vomit in my office. They're so horrified that gets lost on them, but the sensations and what do you deal with them? And that's where they're gonna feel their anxiety. People who are afraid. What if I cheated on my spouse? What if I had an erection?
Keith Sutton, Psy.D.: (54:10)
But there's also, people worry that what if I all of a sudden become gay, or, lesbian or so on. And that these are also an, another piece of OCD. comes up. And of course you need to evaluate for, if the person is kind of is having those feelings and then rejecting them or so, or if this is more of an OCD that they have a good sense of who they are, but they're fearful. And again, it's not, again, like you're saying that disconnect of that insight, zero to 10, I'm a murder or something with that 10 totally / zero none at all that thought. but then that connected to that emotion or that feeling
Shana Doronn, LCSW, PsyD: (54:51)
With the gay. And now we ask, in the Y box to the Yale Brown Obsessive compulsive scale, if they're being transgender, it's not lack, it's not about not gender affirming. Of course, gender affirming is what we want to do. What it's usually what I've seen fear of being gay, or I've worked with someone who identified as bisexual, who was fearful of being transgender. And it's people who aren't necessarily homophobic that all my friends are gay, but it's dealing with the - it's the intolerance of the uncertainty and being able to live with the doubt that happens. And so something that gets kind of tricky and you probably see this there's facing the fear that something bad's gonna happen. And then there's also, I'm not certain that I did and I'll never know. And I'll never these thoughts outta my head. So what looks like I'm afraid of being a pedophile. They know they're not gonna cause harm or it's disturbing, but they don't know how to get the thoughts out of their head. And it doesn't matter what the thought is. A few people who are afraid that the earth is flat. They know the earth is not flat. They have this fear of falling off it and it's associated with anxiety and they know they're not gonna fall off the insights there, but how do I get the thought outta my head? And that gets kind of tricky because it's easy to focus on falling off the earth and not delve into: I'll never get these thoughts outta my head. And having to go into the thoughts. I always be thinking this, I'll never stop thinking that. And what happens if you sit with a bad exposure long enough or deal with that exposure, eventually their anxiety comes down, “Hey, it's time to eat. Do you think that can go to the bathroom first?” And then they start to realize, oh, you mean I will get other thoughts. Yeah, real life kicks in when the anxiety comes down. But a fear of not getting out of one's head is pretty common.
Keith Sutton, Psy.D.: (56:44)
Yeah, definitely. Well, we're near the end of our time here and I really appreciate this conversation. And I really appreciate the work that you and the other clinicians and especially the clients / the patients did through that Obsessed TV show, which, you can still get it on. iTunes or like Amazon prime, to download. And I actually recommend to lots of therapists that, , watch those to see. And actually I just, one of my supervisees, I just had watch and she came in supervision next week. I said, how'd you go? She's like, I had to do exposure to watching other people do exposure because she was with her clients, I kind of noticed she kept trying to get help them to cope and calm down and breathing and so on and it was reinforcing the avoidance and a lot of therapists don't and I still even - figuring out how do you balance that helping somebody cope with an emotion and at the same time, how do you learn how to sit with it and ride that wave? Because if we're trying to always give all those coping skills and things like that, it can actually reinforce avoidance. And like you're saying that, really we, we need to help clients to be able to sit and experience those emotions kind of as they pass through those thoughts and also really embrace uncertainty because anxiety want’s certainty and you can't have it.
Shana Doronn, LCSW, PsyD: (58:07)
We don't get it. NFL writes a great article about staying in the exposure long enough. And I think it's for, OCD and trauma and make, so the therapist has to learn or at least fake it until you make it to stay with the person until the anxiety does stabilize and not bail out too soon.
Keith Sutton, Psy.D.: (58:28)
Yeah, definitely. Well, thank you so much for your time. I really appreciate it. Thanks for coming.
Shana Doronn, LCSW, PsyD: (58:33)
Thank you so much.
Keith Sutton, Psy.D.: (58:35)
Take care. Bye-bye
Shana Doronn, LCSW, PsyD: (58:36)
You too byebye.
Keith Sutton, Psy.D.: (58:38)
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Welcome to therapy on the cutting edge, a podcast for therapists who want to be up to date on the latest advancements in the field of psychotherapy. I'm your host, Keith Sutton, Psy.D., a psychologist in the San Francisco Bay Area and the director of the Institute for the Advancement of Psychotherapy. Today, I'll be speaking with Shannon Doran LCSW PsyD, who is a licensed clinical social worker and doctor of psychology at UCLA's OCD Intensive Treatment program. She received her MSW at the University of Southern California and her PsyD at the University of San Francisco. Shana frequently presents on OCD and related disorders in workshops and symposiums throughout the country. She was also a featured therapist on A&E's reality documentary Obsessed from 2008 to 2010. In addition to her current work in the OCD Intensive Treatment program, Dr. Dorin also treats patients with OCD and other anxiety disorders in her private practice in Los Angeles and Orange county. Let's listen to the interview. Hi, Shana. Thank you so much for joining today!
Shana Doronn, LCSW, PsyD: (01:25)
Ah, thank you! It's good to be here. My pleasure!
Keith Sutton, Psy.D.: (01:28)
Yeah! So I know you from the show Obsessed where you were one of the therapists doing Exposure with Response Prevention for clients with OCD. And actually, that show inspired me to go to Philadelphia where I trained at the University of Pennsylvania. I did a three-day workshop with Edna Foa and Exposure with Response Prevention, because, we'll talk about maybe a little later, but there's one client that you worked with a fear of killing someone. And there were some exposures that you did in that. And I was like, I think I need to get some extra training and really understand this before trying this on my own with just a little bit of consultation. I also was mentioning to you on the phone when we talked that I actually use a clip of some of your work from Season 1 Episode 1 with one of the clients when I teach Cognitive Behavioral Therapy and Behavioral exposure techniques.
Keith Sutton, Psy.D.: (02:23)
And also that I show that to clients too. So they can get an understanding of what it looks like to experience anxiety going up and coming down. But first I wanna hear about how you got to doing the work that you're doing and, and you're particularly, and I think yourself, you're a very brave, like in, , really you go for it in the exposure work that you're doing. I'm always so impressed with the shows that I've seen. So yeah, anyway, love to hear about how you got to doing this!
Shana Doronn, LCSW, PsyD: (02:54)
Well, before we get to that did you get to meet Edna Foa?
Keith Sutton, Psy.D.: (02:59)
Yes, I did.
Shana Doronn, LCSW, PsyD: (03:01)
How cool is that?
Keith Sutton, Psy.D.: (03:02)
Yeah, I mean it was great to go like to the source and like learn and hear. And then I actually, I don't know if , Munya Conna at all, but she, I got a consultation with her afterwards. She's a specialist in pediatric OCD, so it was so nice to learn from folks that are, , kind of the experts that did the research and developed this
Shana Doronn, LCSW, PsyD: (03:21)
She's my hero. She doesn't know who I am. I know who she is. Sure. So my evolution, I started as a clinical social worker way long time ago, back in the day. And I always worked on the medical side and I started off in trauma, medical trauma, and then ultimately found my way to HIV, the HIV world before the protease inhibitors, which are already dated. But this was when people were dying indroves. And interestingly enough, back then I was doing Exposure and Response Prevention without even realizing it, because there were people who were afraid to touch others because they had feared giving someone HIV, which shaking someone's hand is not how you get it. But back then, even people with HIV or aids they didn't always feel comfortable, but that's where I started off. Most of my career prior was working in HIV care. Then one of my best friends decided, Phyllis, she decided she's gonna get her doctorate. And I thought, “No.” Yeah, you say nice. I say like, “She can't have her doctorate unless I have my doctorate!” So I had to go back to school, , for all these altruistic and impressive reasons. And I did go back. The program was mostly behavioral and when I was ready to do my postdoc, I had done most of my career at UCLA. Pretty much all of my career at UCLA. So when I was done with my program and finished my dissertation, I saw that there was a job at UCLA and OCD and I applied for it. I didn't really know what it was back then. Seems like something I would enjoy. UCLA takes a while to hire someone, finally got the job. And when I got there, I did my postdoc hours there and everything just clicked. It made sense. It made really good sense and it was stuff that I've been doing in the HIV clinic, and I had some very good training under Dr. Tarlo and I stayed there for a while, took a brief exit to Illinois, but I'm a California girl and came back. And so I've been work working in OCD since about 2008. No, no, that's a lie: 2003.
Keith Sutton, Psy.D.: (06:07)
Well, that's great. And you're still at UCLA today?
Shana Doronn, LCSW, PsyD: (06:12)
Yes. I've been back, back at UCLA I have tinsey tiny private practice, but I tend to stay away from that. Which is silly. I know.
Keith Sutton, Psy.D.: (06:24)
Well, that's wonderful. It sounds like you're doing wonderful work. Tell me about.. Could you tell me a little bit about, for some folks that clinicians that are listening to this, I'm sure they've heard of exposure and exposure for OCD, but I would love to hear your kind of thoughts on it.
Shana Doronn, LCSW, PsyD: (06:44)
I think for people who, are just trying to get a feel for OCD sometimes the treatment can seem barbaric or there were a few people when I was on the show Obsessed, few therapists not many, that wrote in and said, “This , this is horrible. What are you doing to these people?” And that, of course, I was wondering what are they doing with their patients. So how are they - they must be making them worse if they're trying to give them reassurance all the time.
Keith Sutton, Psy.D.: (07:19)
Yeah.
Shana Doronn, LCSW, PsyD: (07:19)
But, but I didn't let on my negative thoughts and feelings. The process is not barbaric. It can be demoralizing but because we're working oftentimes with highly intelligent people and the most important thing to realize is that insight/intelligence is pretty much worthless in treating emotions, especially when your brain is hijacked with anxiety and fear. You can't tap into your emotions. And it's so easy to kind of, try to get into just the cognitive aspect of treatment. And so in that sense, it could be demoralizing, especially when we as clinicians get excited because someone didn't wash their hands and they touched their face. We go “Yay!” And then we have to remember, “Oh, no, this is an attorney.” This is a physician. This is just anyone.
Keith Sutton, Psy.D.: (08:21)
Well, I think it's so counterintuitive for so many people, especially therapists going into try to relieve suffering or anxiety or pain or difficult feelings to actually evoke those. And I know like when I first was doing one of the first exposures, it, with one of my clients, this was more around PTSD and doing some agoraphobia stuff. I was getting anxious that he was getting anxious and I was like, “Oh, do some deep breathing” because I was kind of like, “oh no, like what am I doing here?” And it really wasn't until I actually saw that show and then did the training. And actually that's something I'd suggest to many therapists is to actually go and watch this series to actually see somebody experiencing anxiety and see how the therapist sits with them. And, because it's, I think it's hard when you don't have that confidence cause you haven't had the experience of seeing somebody's anxiety going up so high and then coming down again.
Shana Doronn, LCSW, PsyD: (09:20)
Oh it is. It's so difficult. It's just as a new clinician in the field. It's just as much exposure for the clinician initially as it is for the client or patient. Every once in a while, I'll watch someone’s anxiety go up and I think “This better work, this is gonna work.” It seems like it's been forever and their anxiety hasn't come down and you're sweating a little yourself, but eventually you could see almost like a fever breaking. They give a sigh and they take a deep breath on their own and you don't have to tell anyone to take a deep breath cause they'd probably punch you out.
Keith Sutton, Psy.D.: (10:00)
Heheh Sure!
Shana Doronn, LCSW, PsyD: (10:02)
And you could see the anxiety coming down, but what goes up has to come down or at least lead to tolerable, that's for sure.
Keith Sutton, Psy.D.: (10:11)
Yeah. How do you kind of explain it to clients? Cause I think that's the other piece is that, , that's the last thing somebody with anxiety wants to do is actually evoke anxiety or go towards it or sit with it.
Shana Doronn, LCSW, PsyD: (10:27)
Well, the people that come to see me through the university, they all know what they're getting themselves into. When I did more private practice and people would just call from out in the community. Before I would work with them, if I didn't think that they had a clue as to what this treatment was about, I would have them go to the OC foundation and look at questions to ask a therapist. Because people with anxiety they want the therapist to POOF! Fix! and they don't appreciate the suffering aspect of it. And that could lead to a horrible experience in care. So I think people have to be really informed, but I've never been someone to do a big private practice. So that's why it's like, nah, I'm not gonna take the chance if they still wanna work with me.
Keith Sutton, Psy.D.: (11:25)
Coming in kind of knowing what they're getting when they come in. Cause I feel like that piece of that psychoeducation, the client really understanding what helps with anxiety, helps to get on board. And if you don't have that you can't really kind of make that movement forward. Otherwise they end up feeling like, “oh, what are you doing?” And if the therapist has trained others or supervised others, as they're trying to maybe pull them along into doing exposures, but the client doesn't really understand what's kind of going on, it can end up feeling bad or outta control and the therapist really needs to kind of rewind go back and kind of get on the same page with the client right before actually moving forward to get any success in kind of what they're doing together,
Shana Doronn, LCSW, PsyD: (12:13)
People I think are much better informed now, but there's still some people that are completely unaware.
Keith Sutton, Psy.D.: (12:22)
Maybe we could talk about one of the videos actually that I saw that was pretty impactful for me when you were working with a woman and part of her OCD was fear of hurting someone or killing someone, harm to others OCD and particularly she would avoid knives,she would avoid going places with knives and these kinds of things. And so when you built up to one of the big exposures, you actually asked her in your office to hold a knife and you had all these kind of big knives laid out and actually had her hold the knife to your throat. And she was really anxious and kind of shaky and scared to do it, and her anxiety I think was like at a 10.
And you were like, “can you feel the cartilage on my neck?” I was just interested about your thoughts on that and I mean, again, somebody from another perspective, or maybe doesn't do this work, they think “like, oh God, what if the client was gonna really kill you or something like that.” And they think that that's another piece of OCD work is that oftentimes folks with OCD are actually the safest. But I think for clinicians that don't know this work as much, I'm wondering if you could speak to that a little bit.
Shana Doronn, LCSW, PsyD: (13:41)
Yes. So when we were filming the staff, they were really pretty anxious, I've been working with Trina for about nine or ten weeks so we gradually build up to that point. What you saw on TV is actually what I really do. I didn't have to do - well I can't really act so I didn't do any acting I was just me. So we started off with using a script. I do like to use a lot of script work even for nonviolent non-sexual stuff just to give us an entree into exposure therapy. And we slowly gradually built our way up. And we started with a plastic knife. I think when we first got to
Keith Sutton, Psy.D.: (14:35)
Can you actually explain script for people that might not know what a script is in exposure therapy?
Shana Doronn, LCSW, PsyD: (14:40)
Yes. I use basically an imaginal exposure in writing, or you could put it on tape, but in writing I will start with I and the letter K and build up to I kill and I killed so and so, and when we do the script, we're building up to the worst case scenario and my scripts tend to be like a paragraph long, right. When they get too long, it's like, what are they getting habituating to. So the script is used to trigger anxiety, and it's facing the worst case scenario without any caveats it's done.
Keith Sutton, Psy.D.: (15:23)
I remember like writing out - I did this with one client where I “wake up in the middle of the night, I grab a knife, I kill my roommate and”, kind of going through of the worst fears of these things that would happen again, against her will or something or something would snap one day. And then the client reads it over and over to kind of habituate to that story, those words, those thoughts and so on.,
Shana Doronn, LCSW, PsyD: (15:45)
And the script should ultimately be about it covers all bases and it's fine in all documents. It's a working document, but I also use this script when someone's doing the exposure work, just to keep them focused, because what I have found a lot is - I say patients because I'm hospital based but - when people are - patients are - are learning how to do exposure, there's the tendency to what I call, “jumping ship.” Like they'll face their fear on this and sometimes their anxiety when it peaks, it comes down and they'll get bombarded with other thoughts that seem so much more important. So, if someone fears that they're dying of this illness, anxiety starts to come down, then they say,”oh, no, that doesn't bother me, I'm afraid of THIS illness.” I keep 'em focused on the task at hand because if they're jumping ship, they're not really habituating to it very much.
Keith Sutton, Psy.D.: (16:46)
Then they're doing multiple exposures at the same time, rather than staying with one.
Shana Doronn, LCSW, PsyD: (16:50)
Yes. So the script is helpful to focus.
Keith Sutton, Psy.D.: (16:54)
Then uou worked up to plastic knives?
Shana Doronn, LCSW, PsyD: (16:59)
Plastic knives, butter knives, any dull type of knife and then all the others. I think she picked a serrated, which is surprising, it's not the sharpest. But it does look violent.
Keith Sutton, Psy.D.: (17:18)
There are different camps that even have different opinions on how high you really have to go. Do you actually need to hold the knife to your hand? Or do you need to put your hand in the toilet water and rub it in your hair or something like, or do you need to take the donut and put it on the sidewalk and kind of eat it off the ground or so on? What, what are your thoughts on kind of the necessity or the options about whether you need to go to that highest kind of level on the hierarchy?
Shana Doronn, LCSW, PsyD: (17:49)
I think, well, I wouldn't have someone do something I wouldn't do. So I get to take a lot of steps and don't have to take the elevator. I don't like taking that, but if I have to, I do. I'm not about dunking toilet water on somebody's head. There's not a lot of utility to put your hands on a toilet seat and not freak out. Fine. I'm not gonna go put my hand on a peed on obvious, like it's overtly peed on. I'll put my hands on a toilet seat. I'll normalize if needed. I think it depends on the person, but I don't think for people afraid of throwing up that I need to have them stick their finger down their throat and vomit. For the knife thing, that's a perfectly fine exposure as far as I'm concerned. And I've done it a long time ago, I did it with someone who was a boxer. But I wasn't scared. They're scared. They're like shaking.
Keith Sutton, Psy.D.: (18:55)
Sure.
Shana Doronn, LCSW, PsyD: (18:57)
But with certain things, I just don't think there's a lot of utility to go - it's okay to go extreme, but at some point it's ridiculous. Like where's the utility - and maybe I've softened a, a bit as I've gotten older - but, I've never been about “putting the donut in the gutter and eating it.” I'm not gonna do that. That's gross.
Keith Sutton, Psy.D.: (19:20)
For sure. Yeah.
Shana Doronn, LCSW, PsyD: (19:21)
If they want to they can but I'm not gonna, I'm not gonna encourage someone to do so.
Keith Sutton, Psy.D.: (19:28)
Yeah.
Shana Doronn, LCSW, PsyD: (19:30)
Do you have any thoughts on that? How far?
Keith Sutton, Psy.D.: (19:33)
Yeah, I tend to think about it - I guess oftentimes I feel like there is this kind of tipping point, oftentimes with the exposures where the person has had multiple successes and they start really getting it. And then they start doing it on our own and start kind of - they come in and they say, “oh, I did this and this, this week”, like things we hadn't even quite like - they're getting it so much that there's actually almost this shift in where they start actually seeking out their own exposures and doing exposures in the moment and really kind of going towards anxiety. And I think that that is really often times what I'm looking for. And so if there is still a part of them, that's like, “I don't wanna do that” then we would, , go up. But again, we're only gonna do something that makes sense or something. Not too gross or things like that, but again, it depends on I guess what the worries are, what the OCD is telling. But I think definitely wouldn't do anything that I wouldn't do. Sometimes I'm participating with my clients in exposure. Sometimes it's uncomfortable for me to be doing it. But again that's part of the work and kind of doing it together and that collaboration.
Shana Doronn, LCSW, PsyD: (20:52)
Now you're working in private practice primarily. I work with moderate to severe OCD and I see people every day. So there are people, that we see with germ contamination - their skin is really for falling off their hands. They're showering four hours a day. Everything's gonna feel extreme for them. But we take it slowly. We're not trying to annihilate the patient, but of course it's building the skillset - well, let me backtrack. When people call me they ask me, “so what are the tools in dealing with OCD?” And I think, well to tolerate the anxiety and not engage in the compulsion. And for some reason that doesn't click, it's like, “no, no, but the tools.”
Keith Sutton, Psy.D.: (21:47)
Yeah.
Shana Doronn, LCSW, PsyD: (21:48)
It's to experience the anxiety and not do anything about it. I guess people still wanna know what the magic formula is. And I'm always to this day - I'm scratching my head. Am I missing something? They're supposed to not engage in the compulsion, tolerate the anxiety and then normalize. Live their life, presumably based in their values, what is important to them.
Keith Sutton, Psy.D.: (22:14)
Yeah.
Shana Doronn, LCSW, PsyD: (22:15)
Do you ever get that?
Keith Sutton, Psy.D.: (22:17)
Yeah, I think that's definitely the piece and I think that's - I like in Acceptance commitment therapy, the kind of idea of the emotional avoidance and like trying to get rid of, and I think that that's part of another attempt to get rid of - just gimme the tool to get rid of this - versus like really kind of shifting and moving towards the anxiety. And like you are mentioning going towards your values, despite the discomfort and being willing to go towards the discomfort.
Shana Doronn, LCSW, PsyD: (22:48)
I think -we use ACT in the sense that there's a values based behavior. And when I think of ACT, I could always say, “well, exposure therapy is part of ACT. You gotta go into it to get out of it.” Right. And that would be - what is it called? Where you're kind of deep?
Keith Sutton, Psy.D.: (23:09)
Cognitive diffusion?
Shana Doronn, LCSW, PsyD: (23:10)
Yea diffusion. But the only way to diffuse it is to go into it. You just can't watch it on a leaf. If people could watch whatever their thoughts or their scary whatever's-going-on, their unwanted thoughts, images, sensations, just go on a leaf and leave, they would. They wouldn't need us.
Keith Sutton, Psy.D.: (23:26)
Yeah.
Shana Doronn, LCSW, PsyD: (23:28)
But exposure therapy will ultimately diffuse the fear. And I don't know about you, when I remember learning about behavioral therapy in school, and every time they talked about reinforcement, the non -I still get whatever those questions on a test wrong, because it's sure positive and negative - but the classical conditioning with the Pavlov’s dog, we're kind of doing an element to that, but we're ringing the bell and trying to get them to not salivate or not have them feel the anxiety. And ultimately the anxiety is not so bad. I never thought I would've ended up doing that kind of work. And then in doing this work, all the developmental theories that I could remember popped into mind, because you could see where people get kind of stuck. The moral development comes in just as a conceptualization to where people are. So we're treating their anxiety of course and the OCD. But I always refer to them needing to get growed up. There's like this slice in their life, which oftentimes interferes in relationships, whatever that is, where they're just not grown up. They're still waiting for the knight or knightess in shining armor and they're waiting for the fantasy and everybody will live happily ever after. So it's not - when the OCD starts to stabilize, it's getting them growed up.
Keith Sutton, Psy.D.: (24:59)
Yeah. Say more about that. The growed up - you mean like that they're kind of waiting for something. They're not necessarily taking the direction in their lifeor so on? Or feeling in control of their life? Or kind of waiting for someone to come to fix things?
Shana Doronn, LCSW, PsyD: (25:15)
So, depending on when their anxiety started and what their home life is, because everybody is in the context of their environment, presumably family life. We're all learning different things for the better or for the worse. But people tend to have what I call adult temper tantrums.
Keith Sutton, Psy.D.: (25:38)
Uhhuh.
Shana Doronn, LCSW, PsyD: (25:38)
Like, you can't just stomp your feet. That's not okay. It's like the crossing their arms and stomping their feet. You can't act like that. Adults don't act like that. Not that I was so adult like back in the day - I’m a little better now - but there's still some naive notions of “life is fair” and “everybody else's life is perfect” and there's also the “I don't wanna be a bad person or a good person” which correlates with a five to eight year old in there, world development? And so as adults we get to see situations from a broader perspective and certain aspects of someone's life is a little thwarted. And it could also come in relationships - like “I didn't feel like they love me” - which always makes - well, I don't have any hair of my arm, but it would stick up if it could stand. Because we're teaching people not to use their feelings, emotions, whatever you wanna call them, to guide them. So if they don't feel like someone loves them, that's not a feeling as soon as the word “Like” comes in. I feel like it's like, “Uhuh, that's a thought. I don't know how you feel, but say this thought.” And they kind of confuse themselves - actually language, which I struggle to speak sometimes, is so much a part of the work that we do. People with anxiety love to glum on to ambiguity as though it's the absolute truth, which is great fodder for the OCD like - “Oh, I'm a pedophile. When I read up on pedophilia, it said, pedophiles have morals. I have morals. Therefore I'm a pedophile.” Like, what!? No, you're cutting up. How do you are? “Well, I feel it to be true.” Like what!? Either ya you are or ya aren’t. They're confusing themselves with this imprecise language. So I tend to be a stickler between “that's a thought” and “that's a feeling”. And teach people about how ambiguous words will trip them up. Like “love”can be so ill defined. “Happiness” is something that comes up quite a bit. “I don't feel happy.” Well, I'm - okay this is where act can be very helpful. They're looking to these thoughts to be feelings and feelings to be thoughts. And they're kind of messing themselves up. I know I get confused now, which doesn't bode well at parties. Whenever someone says, “oh, I can't stop” - I know people say this, and this is just something. Ugh. - “I can't stop obsessing.” I'm like, no. They mean “compulsions.”D
Keith Sutton, Psy.D.: (28:17)
Yeah. Yeah.
Shana Doronn, LCSW, PsyD: (28:18)
But that doesn't sound good at a party. “Oh, I can't stop compulsing.” That doesn't bode well for my social life if I have to talk about that. But really, because obsessions are not a choice, I tell them, “oh, obsessions are not a verb.”
Keith Sutton, Psy.D.: (28:31)
Yeah, I think that's confusing for a lot of people too. I've had clients say, “Oh, it's pure OCD because I'm obsessing.” But then when we look at it, it's actually they're compulsively checking or kind of thinking about it and things in this way and because they're thinking about: am I pedophile or am I gonna kill somebody or so on? But we have to look at: what is the thing that that is trying to help or prevent or so on. What's the bad thing. “Oh, well, I don't wanna do this. So I think about it all the time.” And so kind of that understanding of connecting. But I do think that language is important in being able to understand where's the obsession, where's the compulsion and particular to -
Shana Doronn, LCSW, PsyD: (29:12)
A vocabulary for them by the way. But go ahead, go ahead. I'll tell you later.
Keith Sutton, Psy.D.: (29:17)
Yeah, exactly just like you're saying. Like creating that vocabulary to be able to have a common language in being able to work on the OCD.
Shana Doronn, LCSW, PsyD: (29:25)
I oftentimes will show a 35 second clip of Family Guy, which covers the Yale/Brown Obsessive Compulsive Scale beautifully. You just watch 10 episodes, you've covered everything. Or South park. Or watch Quentin Tarantino. But I refer - there's a clip if people wanna watch - called “Meg in low rider jeans”
Keith Sutton, Psy.D.: (29:46)
Okay.
Shana Doronn, LCSW, PsyD: (29:48)
Lois is talking to me, “I'm gonna take you to the store and we'll get you some cute low rider jeans to show off that cute butt” or whatever. And Stewey says, “Ugh, low rider jeans” and he gets an image- a popping as I call it- a popping image of Meg, and he says, “Go away, damn it. Go away.” And then it keeps popping in. And eventually he takes a rolling pin out and starts to beat it. And I'll tell people, which is the obsession, the N1 of thought, image impulse, urge sensation, these are poppings.. And I refer to the compulsive thought process as thunking because people get it so confused. Like, anything related to the obsession you're thunking about - “well, how do I know I really did that?” “I walked two inches to the right and maybe I swerved a little and I might have touched the person inappropriately.” - And it's all this analyzing or mass talk. That is what I call it. But just to distinguish the obsession from the compulsion.
Keith Sutton, Psy.D.: (30:43)
Yeah, definitely. And the other particular piece that I think is like - you're talking about the developmental piece. I mean I think a lot of therapists that maybe aren't as familiar with exposure with response prevention get drawn to the content of what it means and what is this - that he had this thought of his sister or something like that and so on. And I think that - what is your thought or take on that? And also, I think on the other aspect of that, there is oftentimes an aspect of connection to life stressors and then the almost like kind of manifesting and kind of then the mind then going towards the OCD as kind of a unhealthy kind of coping and so on. But yeah, I would love to get your thoughts on that.
Shana Doronn, LCSW, PsyD: (31:31)
Okay. What was the first part?
Keith Sutton, Psy.D.: (31:32)
So the one is on content and about therapists that say, “Oh, well, maybe he's thinking about something with his sister or he's got issues with his sister or family or so on and kind of - do you look at the aspects of the content or even like, that one person with the knife, the worry is that she's going to kill someone, be in jail, go to hell and bad and so on or I alone or whatever it might be.
Shana Doronn, LCSW, PsyD: (32:01)
Well, of course, in an assessment, I'll get some of the background information just to make sure that we're not dealing with PTSD or something other than OCD but the content may or may not have anything to do with what's going on at home. Could be a trigger! who knows. I don't spend a lot of time but it's interesting. But with Trina, with most people, I don't do a lot of that. It comes up because by the time people have gotten to me in therapy, they've done so much psychoanalysis and theorizing and philosophizing and who knows what. Yeah, it could be because of the family life. It may not be, I don't know, but I acknowledge it. I constantly bear in mind, that the people we work with are intelligent. So there is kind of a, like a perk to, to see if there's any kind of meaning.
Keith Sutton, Psy.D.: (33:08)
Sure.
Shana Doronn, LCSW, PsyD: (33:10)
I know I'm kind of shifting here, but the family stuff is still very important. Oftentimes parent will aid in abet, or the family dynamic will be quite chaotic. I went to a couple of lectures, or it must have been CEUs, on parental alienation syndrome, which I know is just veering off to something different.
Keith Sutton, Psy.D.: (33:36)
Yeah. I actually just posted a podcast this week about it interview an expert in that area
Shana Doronn, LCSW, PsyD: (33:41)
Love. I mean, no, it's horrible. What happens, but what happens is maybe since you already have a podcast on it, I started asking patients, or zeroing in a bit more, if the parents are divorced? Are you allowed to talk with the other parent? What is that relationship like? And with parental alienation of course the, if the person was younger - I only work with adults in the OCD program, but I have worked with children - but with adults, it's still important to find out what a divorce and custody was like. And if someone comes from a family where the other parent was talked about inappropriately, it's usually the narcissistic or borderline type of parent. And when that child, or even young adult tries to veer away from that parent and causes some kind of narcissistic, some kind of wound, the wrath shall befall them. So they learn to doubt themselves. They have to follow what the parent says. So if there's the propensity for a disorder for OCD, that could definitely spark that trajectory for sure.
Keith Sutton, Psy.D.: (34:59)
Well, that's interesting. Is there any research on that at all? That'd be, that would be interesting if that because that whole diathesis stress model of the genetics and then kind of what happens in the environment that leads it to manifest. That - definitely at least that family stress - would be one potential aspect.
Shana Doronn, LCSW, PsyD: (35:19)
Yeah. I don't know if there's research because you're the only other therapist that I know that's heard of it and you just did a podcast on it. So you're, you're aware of it, but I, I heard of these things, of course, parental alienation can happen in any family, but a few of my friends went through that. I knew them pre and post, so it's a horrible situation, but the stress of it of course is triggering and any kind of chaotic home is triggering. And sometimes you just have someone who had kind of like an ideal - if there is such a thing - household and theystill have of OCD.
Keith Sutton, Psy.D.: (35:58)
Yeah, yeah, definitely. When I think too, that the aspects are - I know that with OCD some of the research has found that for children: higher rates of relapse when there's a lot of family difficulties and the correlation between the high EE or the expressed emotion in the family system and relapse and symptoms and so on. So oftentimes those systemic aspects are so important to look at because they may be - maybe just the family stress that might be increasing it. I know that with some clients that - while they've also maybe got stress going on at home or work or something like that - sometimes their OCD of course flares up. And it's almost kind of -not that they're trying to cope in that way - but it can almost kind of exacerbate the distress and then that almost gets channeled or funneled into the OCD and then treating the OCD and also treating the stressors that are going on in life at the same time are oftentimes needed
Shana Doronn, LCSW, PsyD: (37:07)
For relapse prevention in our program, we do talk a lot about triggers. And when people are in our program, they're kind of in this safe zone in terms of triggers. So I mean the safe distressing mode, but they get to feel comfortable with it. And when they are interacting - even though hopefully we're having family meetings - but interacting with family, and they're not in the program, that's a trigger. When they go back to work, they socialize with friends, they go to the bank: all of these points can be triggers for a lapse or relapse. You had mentioned something about the - well, my interpretation was the themes of OCD - where had I have seen a theme play out for people who have a history of being, abused sexually, emotionally, physically. I've seen quite a bit where their themes might not be exactly that, but it's harm to others as well. So it may not be the same kind of harm. So with that - people who have been abused, could fear harming others.
Keith Sutton, Psy.D.: (38:13)
Yeah. Sometimes that - it kind of manifests in that way, because it - OCD from my understanding of it kind of really draws on those worst fears, those taboo things, those and everybody has weird thoughts. But then with somebody with OCD, they think, “oh no, I had this weird thought: and it gets stuck and then kind of becomes like that mental hiccup. Sometimes I use the example of like - everybody's had the experience of going to the bathroom in a public bathroom or something that maybe as gross. And they're like, “oh, that's kind of gross” as they leave. But then they don't think about it after, whatever five minutes. And then later on they're eating lunch or something, maybe they wash their hands or not. But for someone with OCD it's the same thought, that everybody has these weird thoughts, but it just gets so stuck-, and so it's not so far out of the realm of the usual, it's just kind of those weird, odd thoughts that kind of get stuck.
Shana Doronn, LCSW, PsyD: (39:05)
Yes. And I call OCD brains, sticky brains or anxious brains, sticky brains, because whatever themes, it just sticks. And it wreaks havoc. Something - random thought, but I have many - I don't know if you use - I use a distress meter in session. And when I try to teach people is the higher their distress - or the 10 of 10, there's almost like an inverse relationship. There is an inverse relationship with insight. So a 10 outta 10, you're a murderer. And as the anxiety symptoms go down, the insight pops back up. And I think that's something important, that we do in our program, whether it be a high, medium, or low or zero to 10, I think that rating is important and that just popped into my head. So I thought I would share that.
Keith Sutton, Psy.D.: (40:05)
So like you're kind of assessing like how much do they like - a 10 they totally believe they're a murderer that it's like, ego cystonic, and like - zero they have a thought that they're a murderer, but they know they're not so it's like ego dystonic. Like they know that it's like separate - you also rate that to kind of get where they are in kind of their insight to whatever the OCD is or the fears are?
Shana Doronn, LCSW, PsyD: (40:31)
Yes. I use that quite a bit and I've also - well when I get into treatment, but before I even get into it, I want people to know their symptoms of anxiety or distress, whatever they wanna call it. And I'll often pull from the panic worksheet, just the sensory, the sensation aspect of it,. The thoughts we already know, it will come out because they'll say I'm afraid of. And so when we do our first exposure, well, I'll start with an interoceptive. So if they get rapid heartbeat, which is always the easiest to deal with, if I like that one, I'll have people run up a flight of stairs and put their hand on their heart, have it regulate. I might have them do it again and feel their heart rate go back to baseline when they're at the height of their 10, 9, 8, or until they're able to tolerate it. I don't allow a lot of talking and distracting. I keep them focused. And I started to use that, for any emotion, including crying .So my sister, who's not a therapist, said to me, I hope you're not a tissue pusher to your patients. I hadn't really thought that much about it. So now, when I start a session, I'll tell people, or when I meet someone for the first time, “Here are the tissues. If you cry, I'm not gonna push them to you. I don't wanna break your tears. You'll stop crying when you're ready and no talking when you're hysterically crying. One, I can't understand you. And two, I don't want to break that emotion because we're - when we think of laughter, we don't punch ourselves in the stomach or head to stop laughing unless we're in school and somebody starts busting up laughing. And if we're trying to teach people the temporary ephemeral nature of our experiences, emotions - I use feelings and emotions inter interchangeably. I know they're not, but for the purpose of discussion. So when someone's laughing, we want them to enjoy it. So if someone's sad or they're grieving, there's a lot of grief in OCD, of lost time or family dynamics. I don't want to stop them; and the same thing for anxiety. They learn that everything's temporary. Unless they try to block the emotion and then with a compulsion, then it's forever.
Keith Sutton, Psy.D.: (42:49)
I think that's a great - yeah, I love that. That's a great point of like: we don't try to stop ourselves from laughing. So why stop yourselves from crying? Really to experience that wave of emotion and as it kind of goes through - I was interested too, on the way you think about, or your thoughts on,as a CBT therapist, doing exposure with response prevention, you have to be very directive and particularly there's times in the video where you're like “put your hands on the tampon residue” or whatever it is, it was the the first episode which is great. You had used the restroom and watched your hands and dried them on a towel, clean towel. But his OCD was saying it was all bad and there was something disgusting or so on, but you were kind of saying like, put your hands on it and really kind of guiding and directing. And I was wondering, how do you, how do you think about, or how do you deal with when somebody is kind of like, “no, no, I don't wanna do this. And kind of walking that line of saying like, no, no, you need to do this. Or that line of like, okay, wait, this is now a little too much. And I wanna make sure I'm not taking away as agency or her agency?
Shana Doronn, LCSW, PsyD: (44:06)
Right. And I don't want to, I don't want to, I want them to have some control over something. It's, it's what we talk about. So I like, I don't really do unexpected or real life, especially in the beginning of exposure therapy. I like everything to be controlled. I know it's not, mimicking real life yet, but, we have a discussion. Let's go with this. Of course, when push comes to shove and we get to this point, people don't wanna do it, but I do wanna know if you think you could take the chance great, if not, it will be something that we do need to get to
Shana Doronn, LCSW, PsyD: (44:45)
But we will be getting to it. So we'll push and an old boss once said to me, what's the, I didn't make this up. Okay. What's the difference between a pit bull and an OCD therapist? And I don't know, I never heard the original joke that had to do with whatever. And he said the, the pit bull, eventually let's go. So we're there to push. But again, I am working in an intensive program. We've got 30 days to make that reduction in symptoms, but I don't wanna be barbaric any more than the treatment lends itself to that. So they should have some agency and if they're consistently not doing something, it's okay, what's this roadblock what's going on here? How could we break everything thing into manageable parts and try to tackle this? And some people are willing to go for it over time. Some people don't, they're just not ready.
Keith Sutton, Psy.D.: (45:42)
Yeah. Yeah. And I think that it also depends on the therapist's confidence because when what the person needs to do, you are confident that that's kind of the way we need to go about it. And then when they're like, I don't wanna do that then, looking at yeah. What are your thoughts about what's getting in the way, because I think this is what's needed to help us get through you. I sometimes I'll tell clients, you don't have to do this right now. , we can talk about these other things, but I know you wanna do this because - And that at video that I show the clip of you, the person is doing that OCD treatment, because he wants a closer relationship with his partner and to move his partner in and you kind of remind him again of his values and why he's doing this to get that closer, better relationship. And that kind of is something that, and is motivating. So oftentimes I bring it back to the person saying, I know you wanna do it, this to get there. And so it's up to you really, but I think you should do this. And oftentimes the client is able to muster it up and do it and takethat leap, that chance. Yes, it's hard. We're asking to do hard stuff.
Shana Doronn, LCSW, PsyD: (46:48)
Heck yeah. It's not easy. And it’s different, I would've gather in private practice because you're seeing people weekly maybe twice, maybe three times a week and so there is that gap in time. And so with the gap in time, it's almost like an avoidance. So the brain perceive things as a compulsion. So going into some big exposure in private practice is always tricky and pacing is really important, but it's what you do. And hopefully most of the people in private practice are not at the high, severe as the norm because there's only so much you could do.
Keith Sutton, Psy.D.: (47:38)
Yeah, exactly. Or some at times some people need an intensive outpatient or some people need an inpatient. From your experience of folks that maybe do have the hardest time, making progress in a, say a 30 day program or relapsing afterwards or, or so on. Are there any factors that you at least either from research or from your program or from your own experience that you notice that are helpful to kind of think about?
Shana Doronn, LCSW, PsyD: (48:12)
Um, It seems that, well, I have my theories, I work on campus. The pain thresholds for people seems to be a lot less. Everything's supposed to be for, and I'm not saying we don't strive for fairness in society. We don't do our best to advocate for others, but the notion of offending comes up a lot and can actually be an aspect of OCD. And so, because people are growing up with this notion of fairness, we're not supposed to suffer, anxiety is bad. Things can be a bit trickier. So, it's harder to push people. It's harder to push someone to go say something, what they would deem offensive.
Keith Sutton, Psy.D.: (49:10)
Yeah you mean like, so you've maybe got somebody, particularly, a young adult or student or something like that. And their OCD is worried about saying something offensive. And, and so part of the exposure is to actually say something that's offensive, but they're kind of tolerance for it is very low or they, they they're too scared to, or worried or..
Shana Doronn, LCSW, PsyD: (49:33)
Saying something. Or, when the Kavanaugh trial was going on, there seemed to be an influx of people who were terrified to walk on campus. They wanted their arms like this, their books in their hand, because what if they touched someone inappropriately? They didn't know. And 10 years later they're gonna be sued. So…
Keith Sutton, Psy.D.: (49:59)
Oh, like, okay. So like if...
Shana Doronn, LCSW, PsyD: (50:01)
For touching appropriately, like what if I rape someone..
Keith Sutton, Psy.D.: (50:04)
Like a, Me Too kind of, like where somebody, yeah. Years later talked about having felt, treated unjustly sexually or touched physically or something like, like that or abused or, or so on. So…
Shana Doronn, LCSW, PsyD: (50:18)
Just because they used their arms down and they might have inadvertently hit someone, sorry, that's the rest of the thought. And that came up a lot. Offending comes up a lot and that you have to be careful. Right. Treating OCD, OCD is offensive.
Keith Sutton, Psy.D.: (50:33)
Yeah.
Shana Doronn, LCSW, PsyD: (50:34)
However, getting someone to buy into some of the exposures, it can be tricky. Yeah not that I want people to purposely go offend someone, but try not walking on eggshells. Just, how about that for starters and yeah.
Keith Sutton, Psy.D.: (50:53)
Yeah.
Shana Doronn, LCSW, PsyD: (50:54)
You're always gonna offend someone at some point and of course people with OCD, as you know, can have this hyper sense of responsibility. So if they unknowingly offend someone, it's like, now that's the crime of the century and they wanna go to jail and go, yeah.
Keith Sutton, Psy.D.: (51:14)
Yeah. So that, so it's another, in that realm of the harm to others kind of category that they're going to say something or do something or bump into someone, and then their OCD tells them that it's gonna, this is all these negative things that are gonna happen just again. Like, and again, I think another piece for people that don't necessarily know a lot about OCD or this treatment, is that again, the person with OCD is usually the less least likely person to be doing something offensive or hurting somebody or so on because they're so terrified of it, or like that client about the murder or something like that. She's probably like the least likely to hurt someone, even though she's terrified that she's going to, whatever, a knife is gonna being in her proximity is gonna lead her to hurt or murder or somebody or something like that.
Shana Doronn, LCSW, PsyD: (52:04)
It, it gets tricky. I don't, I don't know if most of your podcasts are about OCD, but just in case, not all of 'em are just as a reminder, an obsession is a bothersome, intrusive, unwanted thought image, impulse urge, or sensation - that sensation seems to get lost on people. and I don't know if you've been seeing a spike in that…
Keith Sutton, Psy.D.: (52:29)
I haven't so much yeah. Say more about that. We kind of cover lots of different topics all over. You're actually the first person that I've really talked to very focused on OCD. Can you say more about the sensation piece?
Shana Doronn, LCSW, PsyD: (52:44)
Yeah.This comes up for people who are fearful of being a pedophile or what if they wanted to sleep with their pet, they could hold their cat, on their lap and people will report, “Well I have sensations down there.” Well, I would gather if the cat's puring you're gonna fill something, but the way that the cat you're gonna fill something, but they there's the leap too. “I think therefore I shall do” that thought-action fusion. It's like, no, no, no, no. When I think in thunk, my quote, therefore you shall do when you analyze it, you shall do. But just the sensation is indicative of being some kind of perve and there's such a misread on that or the same if you're changing a diaper and you, “oh, there's a child's genitals.” Oh, that's a penis, penis, penis, and sex have nothing to do with the kid. But if they start thinking about sex, they might notice something and boom, now they're a pedophile, which of course what gets lost on them. And I've had this happen before people who are afraid of being a pedophile, they will vomit. I've had people vomit in my office. They're so horrified that gets lost on them, but the sensations and what do you deal with them? And that's where they're gonna feel their anxiety. People who are afraid. What if I cheated on my spouse? What if I had an erection?
Keith Sutton, Psy.D.: (54:10)
But there's also, people worry that what if I all of a sudden become gay, or, lesbian or so on. And that these are also an, another piece of OCD. comes up. And of course you need to evaluate for, if the person is kind of is having those feelings and then rejecting them or so, or if this is more of an OCD that they have a good sense of who they are, but they're fearful. And again, it's not, again, like you're saying that disconnect of that insight, zero to 10, I'm a murder or something with that 10 totally / zero none at all that thought. but then that connected to that emotion or that feeling
Shana Doronn, LCSW, PsyD: (54:51)
With the gay. And now we ask, in the Y box to the Yale Brown Obsessive compulsive scale, if they're being transgender, it's not lack, it's not about not gender affirming. Of course, gender affirming is what we want to do. What it's usually what I've seen fear of being gay, or I've worked with someone who identified as bisexual, who was fearful of being transgender. And it's people who aren't necessarily homophobic that all my friends are gay, but it's dealing with the - it's the intolerance of the uncertainty and being able to live with the doubt that happens. And so something that gets kind of tricky and you probably see this there's facing the fear that something bad's gonna happen. And then there's also, I'm not certain that I did and I'll never know. And I'll never these thoughts outta my head. So what looks like I'm afraid of being a pedophile. They know they're not gonna cause harm or it's disturbing, but they don't know how to get the thoughts out of their head. And it doesn't matter what the thought is. A few people who are afraid that the earth is flat. They know the earth is not flat. They have this fear of falling off it and it's associated with anxiety and they know they're not gonna fall off the insights there, but how do I get the thought outta my head? And that gets kind of tricky because it's easy to focus on falling off the earth and not delve into: I'll never get these thoughts outta my head. And having to go into the thoughts. I always be thinking this, I'll never stop thinking that. And what happens if you sit with a bad exposure long enough or deal with that exposure, eventually their anxiety comes down, “Hey, it's time to eat. Do you think that can go to the bathroom first?” And then they start to realize, oh, you mean I will get other thoughts. Yeah, real life kicks in when the anxiety comes down. But a fear of not getting out of one's head is pretty common.
Keith Sutton, Psy.D.: (56:44)
Yeah, definitely. Well, we're near the end of our time here and I really appreciate this conversation. And I really appreciate the work that you and the other clinicians and especially the clients / the patients did through that Obsessed TV show, which, you can still get it on. iTunes or like Amazon prime, to download. And I actually recommend to lots of therapists that, , watch those to see. And actually I just, one of my supervisees, I just had watch and she came in supervision next week. I said, how'd you go? She's like, I had to do exposure to watching other people do exposure because she was with her clients, I kind of noticed she kept trying to get help them to cope and calm down and breathing and so on and it was reinforcing the avoidance and a lot of therapists don't and I still even - figuring out how do you balance that helping somebody cope with an emotion and at the same time, how do you learn how to sit with it and ride that wave? Because if we're trying to always give all those coping skills and things like that, it can actually reinforce avoidance. And like you're saying that, really we, we need to help clients to be able to sit and experience those emotions kind of as they pass through those thoughts and also really embrace uncertainty because anxiety want’s certainty and you can't have it.
Shana Doronn, LCSW, PsyD: (58:07)
We don't get it. NFL writes a great article about staying in the exposure long enough. And I think it's for, OCD and trauma and make, so the therapist has to learn or at least fake it until you make it to stay with the person until the anxiety does stabilize and not bail out too soon.
Keith Sutton, Psy.D.: (58:28)
Yeah, definitely. Well, thank you so much for your time. I really appreciate it. Thanks for coming.
Shana Doronn, LCSW, PsyD: (58:33)
Thank you so much.
Keith Sutton, Psy.D.: (58:35)
Take care. Bye-bye
Shana Doronn, LCSW, PsyD: (58:36)
You too byebye.
Keith Sutton, Psy.D.: (58:38)
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