Episode 27: OCD, An Expert’s Inside Perspective with Dr. Elizabeth McIngvale

At 12 years old, Dr. Elizabeth McIngvale was diagnosed with obsessive-compulsive disorder (OCD). By age 17, she found success in evidence-based treatment and became a national spokesperson for patients. Now, 20 years later, she treats OCD patients of her own, while still advocating to end stigma and misconceptions about OCD and perfectionism.  

Dive into this episode of The Menninger Clinic’s Mind Dive Podcast with hosts Dr. Kerry Horrell and Dr. Bob Boland for an expert’s insider journey of OCD. Also explored are the contrasts of OCD and obsessive compulsive personality disorder (OCPD) and how doctors can improve patient treatment by recognizing and acknowledging the differences.  

Elizabeth McIngvale, PhD, LCSW, is the director of McLean OCD Institute at Houston. She currently serves on the faculty at Harvard Medical School and has founded the Peace of Mind Foundation and OCDChallenge.com, both now within the International OCD Foundation. 

“My message to patients is that we are going to get them back to functioning, but we should really be fighting for freedom from their illness,” said Dr. McIngvale. “We are fighting to get them to a life where they can make decisions for themselves and live by their values, not their diagnosis.” 

Follow The Menninger Clinic on Twitter, Facebook, Instagram and LinkedIn to never miss an episode of Mind Dive. To submit a topic for discussion, email podcast@menninger.edu. 

Visit www.menningerclinic.org to learn more about The Menninger Clinic’s research and leadership role in mental health. 

Listen to Episode 26: Bridging Faith & Mental Health Care with Dr. Marcy Verduin

Resources mentioned in this episode: 

Episode 21: OCD From the Front Lines with Dr. Wayne Goodman, Dr. Eric Storch 

Follow The Menninger Clinic on Twitter, Facebook, Instagram and LinkedIn to stay up to date on new Mind Dive episodes. To submit a topic for discussion, email podcast@menninger.edu. If you are a new or regular listener, please leave us a review on your favorite listening platform!

Visit The Menninger Clinic website to learn more about The Menninger Clinic’s research and leadership role in mental health.

Transcript

Episode 27: OCD, An Expert’s Inside Perspective with Dr. Elizabeth McIngvale

00:02

Welcome to the Mind Dive podcast brought to you by the Menninger Clinic, a national leader in mental health care. We're your hosts, Dr. Bob Boland,

00:11

and Dr. Kerry Horrell. twice monthly, we dive into mental health topics that fascinate us as clinical professionals, and we explore those unexpected dilemmas that arise while treating patients. Join us for all of this, plus the latest research and perspectives in the minds of distinguished colleagues near and far. Let's dive in.

00:42

We are thrilled to be joined today by Dr. Elizabeth McIngvale. She's the director of the McLean OCD Institute at Houston, diagnosed with OCD herself at 12 years old. She now serves on faculty at Harvard Medical School and has founded the Peace of Mind Foundation and OCDchallenge.com, both now within the International OCD Foundation, where she also serves as a board member and national advocate. Welcome, welcome.

01:10

Thank you. Thank you for having me. I'm excited to be here. Yeah. And

01:13

again, I think this was a just a very short introduction. But I would absolutely highlight you are a real national figure in not only advocating for understanding OCD, from the perspective of a treater and as a person who's had it, but also really like lowering stigma for mental health in general. So thank you, we're so thrilled to get to speak with you.

01:35

Thank you. Thank you. Likewise,

01:37

as I just mentioned, in your work, you've been an advocate for really understanding and educating others about what OCD is, and also about what OCD isn't. And that's some of what we're going to talk about today about the difference between OCD and perfectionism. But kind of as we're getting started, you know, you've been really open about your own journey with OCD. Would you mind sharing with us a little bit about your career so far, and how you've kind of developed an interest in of course, OCD, but also reducing stigma and increasing access to care?

02:07

Totally, you know, so I grew up here in Houston, Texas, and right where, obviously Menninger Clinic is now located. And we I live in Houston, right? We live in a city that has the best and biggest medical center in the world, and really great medical treatment across the board. We've always been known for that. But when I was diagnosed with OCD, I was about 12 or 13, when I started to have symptoms and received a diagnosis 15 Before I was able to get good treatment. But what happened is I spent, my family spent quite a few years searching for good care and trying to find treatment and we continued to hit roadblocks, we continued to get treatment and care that wasn't evidence based. And that really made me worse in different ways. Not only did it not help my OCD, but it also made me believe treatment when it worked for me that I couldn't learn to manage my symptoms, and stigma and everything else just actually became more profound, right, I started to fit more and more into societal stereotypes of mental health. And I started to believe them to be true in different ways. And so for me my journey to appropriate treatment, but then receiving it and being able to apply it to my life really propelled everything I do today, whether it's advocacy from a stigma perspective, or my career, which is now treating individuals with OCD. It's all rooted in my own personal journey and my own personal experience. And I always share that because I think that advocacy work, stigma work, even clinical work, right? It is really tough. It's tough work. It's exhausting. And there's a lot of burnout in our field. But I've never been close to burnout in my life. And the reason for that is because I feel very passionately, that this is a mission that was kind of given to me and that this is what I'm intended to be doing because of my own background versus something I'm choosing to do. So let's talk about how the field and the mission around advocacy chose me. I didn't really choose it. Hmm.

03:57

Gosh, I mean, well, you share this with us that your motto is fight for freedom not functioning. Yeah. And then you know, I mean, to a typical clinician, like myself, I mean that that's a little bit counterintuitive. I mean, often while we talked about his functioning, and stuff, can you say a little bit about this and what it means?

04:17

Yeah, you know, so when I was 15, I actually was a patient at the Menninger Clinic when it was in Topeka, Kansas. And that's where I first received treatment. And at that point, I really had this

04:27

so that would be the effective treatment. You got no,

04:29

the wonderful treatment that Oh, good. Okay. Yeah. It was the first time I had access to really good evidence based treatment. It was when Menninger used to have an OCD program and yeah, and I went to it in Topeka. And what happened is, is before I went to treatment, I really didn't believe I could be functioning right. I didn't think graduating high school is a possibility. I didn't even know that living was a possibility. And so for me, just having my eyes open to the fact that treatment and resources were available that could allow me to live reproductive life was something I was. So I don't know if I'm the right word, but like, shocked that that was possible that that could exist. And so my first step in treatment was that I really believed that if I can just function, then I'm winning, right? Like that means treatment was successful, that was a good treatment outcome. But what I've learned, 20 plus years later, is that actually, like, you can have really bad OCD and I can still really be suffering and functioning, right, I actually could function at a really high level, but be suffering, right, we see this with with addiction, we see this across the board. 

05:35

And so my message is that, yes, we're going to get you back to functioning. But we really should be fighting for freedom from your illness, we should be fighting that we can get you to a life, where you get to make decisions for yourself that you get to live by your values, not by how your diagnosis, you know, explains or dictates your life or your life decisions. And so functioning is a part of freedom, right? It's the first step. But the reality that I want people to hear is that you can be struggling a lot in functioning. And this is actually an important piece for stigma, right? Because I'll never forget, when I first became the national spokesperson for OCD, I was 17. And I became kind of the poster child for OCD, and was talking a lot about it. And I did a ton of news stations, articles, blah, blah, blah, you name it. And I'll never forget this one media interview that they called me, they were doing an interview, I was driving in my car, it was on 1960 This road in Houston. Like it's profound to me. And I remember the person saying, Well, I'm looking at your picture. And I'm feeling really confused, because you don't look like someone who has a mental illness. Right. And it struck me in so many ways, but it was so hurtful for me to think that, "Because I look like I'm functioning or because I'm in school. And that means I can't be suffering." And the reality is, is that, until it can't be, mental illness often is silent. We function, we push through, but we hide it right. And we kind of suppress it because we don't want society to see it, talk about it, acknowledge, you know, us to have to acknowledge it, because we don't know what that means. And so I think a big piece of stigma is this understanding that people can be functioning but really suffering, because I think that old Texas saying, "Pull yourself up by your bootstraps." So some of us need help to be able to do that. And for some of us, you think I have pulled myself up? You think I'm functioning, but I'm struggling a lot on the inside.

05:43

Reflecting on that, we hear that a lot from patients, don't we? Yeah, you know, like my family, other people see me look fine, I can smile when I go to things and like, you know, quote, act normal, but, you know, they don't realize how much I'm suffering. And it kind of hurts them. I think that that's the case.

07:40

And it tends to be again, I think a real limitation in values and work of psychiatry and psychology that we focus on getting people back. Like, if there's baseline, and then there's people there, you know, just the lack of functioning, we get you back to functioning. and that's sort of the goal. And it's one of the reasons why I'm super interested in positive psychology and the experience of, we don't want to just get you to just be able to have a job and just be functioning and whatever we want you to be able to have a life that's thriving, that's based on your values that's based on things that bring you joy. And so I love your motto. I also think, in doing a I was I was deep diving on your Instagram in preparation, just to be real about my snooping. But one of the things that--you have a lot of really wonderful layperson, easy to digest ideas around this, one of the things you were talking about is uncertainty. And how in the fight for freedom, especially from OCD, there's this piece about uncertainty. And I wonder if you can speak to that connection?

08:46

Absolutely. You know, so what we know with OCD is that it's the doubting disease. And when you think about at the core of anyone who's living with OCD, you are trying to achieve certainty, which isn't possible. Therefore, you get stuck in the doubt, right. And so, for example, right, I have a trigger. If I touch that doorknob, my hands are contaminated, and I might get someone sick or cause harm to someone I love. And so I start trying to figure out how to be sure that I'm not going to get someone sick, or how to be sure that I'm not going to finalist contaminated. And I end up engaging in behaviors like hand washing, or avoidance behaviors, not touching doorknobs, that sort of thing, because it's all rooted really, in the search for certainty. OCD gives you this kind of fear or doubt that then you start trying to figure out how can I be sure something bad won't happen, there won't be this negative outcome, whatever the feared consequences. And so the treatment as a whole, right, like the component core concept of OCD treatment is we want to teach you how to change your relationship with anxiety and OCD. We want to teach you how to quit responding to the false alarms right? So OCD sending that false alarm that you need to be sure, and we actually want you to respond with like, I don't really need to be sure. And I'm going to accept the uncertainty that exists in that choice and choose to move on with My life because the other choice of trying to have certainty, I will continue to get stuck. And OCD will come bigger and it will never feel appeased. Like, no matter how many rituals we do, we never actually achieved certainty because it's not a real thing to achieve, right? You can achieve a feeling of certainty, but actually achieving certainty. There's not many things in life that are certain right, maybe death and taxes. But again, the reality is, is that everything we do, there's uncertainty. And so a lot of people kind of cringe when they hear this because they think, you know, well, Liz, like, that just seems really extreme. Like, why do we need to lean into things like someone without OCD doesn't lean into all this uncertainty, right? They don't have to lean into like, why might not get sick, I might get sick, and I might cause harm to someone I love. And the reality is, is that actually they do Lean into all those things every day of their life, they just don't have to lean into it in a way that's like big, and they're acknowledging it, because it's just how they function, right? You and I function every day you take a risk that you might get someone sick, you know, by the way you interact with them, you could be carrying an underlying unless you have no idea. But with OCD, if we have OCD around that, we don't get the option to be ignorant, because our OCD is throwing all these thoughts around us already around certainty. So we have to lean in and approach it in a louder way, if that makes sense. And so we're just really we're trying to teach you how to live with uncertainty, right? How across the board. That doesn't mean we have to accept our worst case fears as truth. I think a lot of people think that they think, Oh, well, I have to just accept that I'm going to get people sick, that I'm going to be this bad person. It's like, Absolutely not. Why would you want to do the treatment, if that's what you had to accept, when these are things that are really important to you, what we want you to do is we want you to be able to live in the middle ground, like you and I do every day of our life. So quick example is, you know, I assigned, I agreed to do this podcast with you guys. And, you know, you added it to my calendar for 1pm. On Wednesday, I had every intention that I would be here. When I committed right, I said no problem. It's in my calendar, I had no reason to believe that I wouldn't be able to attend this podcast, a million things could have happened that would have made me not be able to attend today, right? My daughter's second day of school, I could have gotten a call from them, there's so many things that could have made it where I couldn't attend. But for all intents and purposes, I agree that oh, yeah, I'll be there. And I felt pretty certain about it. But really, I accepted a ton of uncertainty in that decision. I just didn't have to outwardly acknowledge the uncertainty because it wasn't in my face. Yet. When you get in your car, you're risking a lot of things right every time you drive a car, but you don't when you walk to your car, sit there and ruminate. But you're not ruminating around all the things when you walk to your car that could go wrong. If you were, you probably wouldn't drive your car. And so we all accept uncertainty in everything we do. It's a part of living our life. And patients with OCD really struggle with that. And so that's what we're trying to get them to be able to do.

12:51

No, I agree. But I do want to be accepted if we just generally don't think about it.

12:56

That's right. I think that's the distinction is it's like it sounds like people who don't struggle with this. It's easy to do. We know it's not

13:02

making a decision every time I get into my car, I

13:05

know, just getting in your car. And people with OCD do that as well, for things that aren't triggering for them. But whatever is currently a trigger, they are not able to just ignore it, right? They anxiety, the distress is overwhelming. And so the way we have to teach you to ignore it is we have to intentionally lean into uncertainty.

13:23

I think just in the last episode we recorded I brought this one up again, too. But one of my favorite episodes we've ever done was with a researcher out of UC San Diego, Dr. Jeste, who studies wisdom and being able to measure wisdom. And one of the things he talks about as one of the key components of wisdom is a tolerance for uncertainty. Right. And that's related to again, part of being able to the tolerating of it is so important. So I love that that's like this, we're all still working on it.

13:52

It's a work in progress, right? We all have it. That's what COVID taught us, right? COVID allowed people to kind of see into the life of individuals with anxiety and OCD because so many of us when COVID first happened, right? The anxiety around COVID For a lot of people became crippling became debilitating. And the reality is, it was the first time people couldn't just accept uncertainty, right? They had to intentionally accept it. They didn't know how and but we are all accepting uncertainty still around COVID. And for some people, it's still significantly harder than others. But you know, we all have to face it in different ways.

14:24

Well, yeah, I mean, there's still people who don't travel and that's totally understandable given that you know, it's the pandemics not over.

14:31

I write when I was right when the pandemic hit, I was working with a patient on the young adults unit who was recovering from OCD had actually had there was a childhood illness and most here for a different reason, but had a significant resurgence in their OCD symptoms because of their their primary obsessiveness was around getting other sick and around handwashing. And this was, again, COVID. Just really I think we saw a lot of that

14:57

COVID must be incredibly reinforcing for anyone who had any kind of germ concerning stuff in different

15:02

ways. You know, we see it happen across the board the Ebola outbreak COVID, it doesn't matter, right, OCD is gonna latch on to anything it can. So it's when it's in the news, if it's something that is a trigger for you, yeah, it can stick. And it certainly has for a lot of people

15:15

makes sense. Let's talk a lot about perfectionism. Because I know you've heard about that a lot. And in the type A personality patterns, can you talk a little about these areas of functioning? And you know, and how are they similar but distinct?

15:29

Yeah, very similar and very distinct in different ways. So let's kind of break them down. So first of all, let's talk about perfectionism in an OCD lens. So there can be OCD, perfectionism, I'll give an example. But when I was a kid, I would write and erase and write and erase over and over again, on my homework, there'd be holes in my homework, from all the erasing this is old school before we used computers for homework, I'm sure, right? But because I was so worried about if my letters didn't look a certain way, or it wasn't perfect, and it was rooted in this fear that like something bad would happen, or for some people, perfectionism can be rooted in like the teachers gonna think I'm sloppy, or that I don't care or that you know, I'm not. And so perfectionism can be very de disabling it can be very distressing, right? We can see individuals, you know, get stuck straightening their hair for hours, because it needs to be perfect. If it's not perfect, how will I be perceived? And that may or may not be OCD could have more of a social anxiety component can take perfectionism can take kind of different forms. Like, we really need to know what's the root fear that's making it triggering? Am is the fear more rooted in OCD, unwanted intrusive thoughts? Is the fear more rooted in social anxiety, right? So we want to understand that to be able to appropriately treat it, but also perfectionism can be personality based, right? When we think about what we call obsessive compulsive personality disorder, I always say that OCPD is what society thinks OCD is. Yeah, so years ago, my sister's creative. I'm not I used to I was sitting around the table when we were making some T shirts and slogans for peace of mind. And I was like, I need some slogans for OCD for us to use. And she said, Okay, my favorite slogan is OCD is not an adjective. And it became this incredible slogan that stuck is really stuck and everyone uses but it's a perfect way to help us describe that. If you are describing OCD as an adjective, that is not OCD. But that may be OCPD. So when you are saying, oh, you should see my coworkers desk, she's so OCD, you should see my mother in law's kitchen. She is so OCD. That is not OCD. That is typically a preference, right? That is typically part of someone's personality, right? It's obsessive compulsive personality disorder. And so the big difference here that we have to think about is what function does the behavior serve? And where does the distress lie, right for individuals with OCD, they have unwanted intrusive thoughts and they engage in engage in repetitive behaviors to try to feel better from that thought. They do not like the thought they do not like the behavior, they do it because they feel like they have to OCD rituals do not bring us pleasure or joy. They simply reduce the distress from the obsession. And so we get stuck doing them because we feel like it's the only way we can get better get relief. OCPD is actually functional in different ways. Right? I 100% have some OCPD tendencies, right? About 20% of people or more with OCD also have OCPD if you come to my house and open my fridge on any given day, you're gonna be like, Oh, this is like, organized. So great. I love it. Right? My closet organized and color coded in a certain way. I love that. Like, I love opening my fridge and feeling like it's organized. I know where everything is. I love it. Because it's a system for me that like, oh, yeah, I can easily see when we're getting low on something and I need to order it from the grocery store. It's functional, it's helpful. There are no OCD behaviors that are functional are helpful. They are destructive, and they're debilitating. And so oftentimes, I always say when OCD is being used as an adjective, we're often talking more about OCPD

19:06

So, we recently had on doctors Storch and Goodman talking about OCD as well. And one of the things that he used, the phrase was OCD is more ego dystonic it sounds like when we're thinking about perfectionism, and which perfectionism can of course get pathological as well or get in a way that that impacts people's life. But it tells me more ego syntonic tone where it's a

19:29

fancy words describe what you just kind of said Yes, right. Yeah, right.

19:33

Is it something that you actually like? I had a consult once where one of the patients had their phones super organized and like okay, so part of this treatment for OCD, you're gonna make me unorganized all my phone, right? And it was like, Well, is it disruptive to you to have your phone organized are like no, I like it like this. It's like, well, then why would we address why would we fix that? Like, why would we if it's not disruptive to your life, if you like it and you enjoy it, that's not your OCD. Your OCD is things that are disruptive to your life, right? So yes, perfectionism, if you send an email to your boss, and you are double checking it and triple checking it, and you can't sleep at night, and you're reading the center inbox, and you're making sure that you wrote what you said, and that you didn't say something wrong, or you're doing that with a text message, that's probably more OCD, right, you're not enjoying those behaviors, you're doing them because you feel like you have to You're really anxious, they're distressing. But if you're a surgeon, and when you walk into the surgical room, you like your instruments laid out in a certain way and handed to you a certain way. And that's how it helps you function. And that's kind of your like particularities or your your personality. It's functional, and it serves a purpose, even if it could be kind of annoying to other people who have to follow the rules. I'm glad

20:41

you brought surgeons because they're my reflection. Is that like in medical school? Yeah, people, people either were perfectionist or wish they were, yeah, pretty much because it's, you know, it's a survival tactic to get you through all the material.

20:55

And that's the key thing, right, is that people will talk about how this perfect, that type of perfectionism serves a purpose for them, it helps them right, it serves in so that's the big piece that doesn't mean OCPD doesn't sometimes need to be treated. Because it can get to a point where you feel like your systems make sense. But other people can't live like that. Right? So we do definitely still see where the person might say, well, I don't think it's a big deal for the family to have to change clothes when they first get home or for the certain things to happen. And like that's how I am. And that's the rules they should follow. But they might say, well, that's not how I want to live. And so you may still need to work on it, even if it may or may not right. So it can still be problematic. I don't want to, I don't I also don't want to send the message like OCPD is always helpful for you and always good, it can still cause a lot of problems, especially in relationships and functioning.

21:43

That's helpful. Only because it helps to sort of address the boundaries. And notice, because often when you describe this to people, they either they say, Well, I'm kind of like that. And I don't see how that's a bad thing. And so like understanding what's what's quote, normal, what's sort of more personality? What's more pathology of this of a disease, right? Is, it's often confusing for people.

22:08

And I was gonna say that was you, you already answered our next question. But I'm still gonna ask you, do you have other any other thoughts to add on it, but that, especially perfectionism that's coming from a more personality functioning lens, as in, it's coming from a place maybe of shame, having to do with our sense of self and worthiness? It's impacting relationships? What are some of the psychological and or social consequences of that perfectionistic behavior? And when do we know that it's something we need to treat?

22:39

So I mean, I think typically, if we're talking about OCPD, which is the only one I feel like I can semi-talk to, even though I want to be candid, right, OCD is my specialty over OCPD. Most patients with OCPD, don't show up to my offices, right? Because they don't really find it to be problematic. When we do see them, it tends to be because their family members are bringing them in, right? The family members are saying like, I can't live like this anymore, like this, these systems, these protocols like this is we I can't do it, right? We have kids now or whatever the reasoning is. And so that's what we want to look at just like with anything else, is it disruptive to your functioning, right? And it may not be disruptive to your own functioning, but if it's disruptive to your relationship, or it's disruptive to your kids, or it's disruptive to your household, then it still needs to be addressed. If you're willing to address it right now, of course, they have to have the motivation and buy in. But really what we want to know is like is it impacting functioning, and if it's not impacting your functioning, but it's impacting other people's that is still going to impact your functioning as well.

23:35

Are there different interventions for folks with perfectionism even as it relates to OCD? Or are kind of the same kind of gold standard treatment for OCD used for perfectionism?

23:49

Yeah, so while we're talking about perfectionism in an OCD lens, right, not OCPD. So like, what I was talking about earlier of erasing, and rewriting, or maybe, you know, excessively straightening our hair to perfection, but you know, or something like that, if it's an OCD behavior around or something like rooted more than an OCD fear that something bad may or may not happen, treatment is going to be the same exposure response prevention is going to still be our gold standard behavioral intervention for OCD, if it's rooted more in social anxiety, right? So I feel like I have to have, you know, my clothes can't have wrinkles on them. Because if they do, then people might think I'm sloppy, and they're not going to respect me. And they may think poorly of me. And it's more this kind of social anxiety or even Generalized Anxiety Disorder, we're going to do more CBT work, right, so more or less ERP, which is specific to OCD, and more specific cognitive behavioral therapy, which is the evidence based intervention for social anxiety disorder. And so again, we really want to know when you see symptoms, as a therapist, we shouldn't be treating the symptom. We need to figure out what is causing that person to engage in those behaviors, right. So we're not treating you the fact that you hand wash. We're yes, we're going to remove the hand washing but we need to understand why are you here? Watching what is the trigger? What is the core fear that then elicits the handwashing response? It's the same with perfectionism, right? We really need to understand what is causing these perfectionistic behaviors and target that as well.

25:14

Yeah, so many achievements are geared I think more towards kind of, as you said, the symptoms or the functioning, how do you how do you get to that freedom part in your treatment?

25:22

So that's the difference is that treatment has to go beyond symptomology. Right? So for me, when I've, throughout my life with OCD, I've had a million different compulsions, right? Whether it's going in and out through thresholds, whether it's praying, whether it's hand washing, what it doesn't matter, right, reassurance seeking, confessing, avoidance behaviors, you name it, if we were only treating my symptoms, so like reducing my hand washing and just having me touch more things, that would be helpful to an extent. But what happens is patients like myself, talk about how that treatment kind of created this place in our life where we were just playing this game of Whack-a-Mole, we were like addressing one thing, and a new thing pops up and addressing another thing, and another thing pops up. And it just felt like this constant, like, I'm just having to survive to be able to function, right? I'm just having to, like, constantly fight my OCD so that I can function. If you are doing OCD treatment, and you're going to therapy weeks after week after week after week, and every single week, you're talking about your triggers from that week and addressing the triggers for the week in the next week. It's the triggers from that week. That's a problem. You shouldn't have to constantly be fighting triggers, we need to be addressing why the triggers are coming up. And we need to be focusing on the core fears, right? For many people, they think, Oh, well, if you have contamination, OCD, you're afraid of getting sick, I was never afraid of getting sick. My fear was that if I got sick, I could get someone else sick. And if I cause harm to someone else, how could I live with myself? That was my core fear. So we actually have to address that core fear while we're doing the OCD work, because then what happens is the same thing that happens when you pull a weed, give and take a weed whacker. And like it'll make your yard look good for a few days, but it's gonna grow back. Or instead, we can pull the weed and make sure we see the root and get that feeling of satisfaction that like that weeds not coming back. We need to address what our core fears are. Because when we address those, we're able to get freedom. And that isn't just OCD. That's really life. Yeah, when you have relationship issues, right, you can end that relationship and start a new one. And we often find some of our same patterns follow us, because we're not actually addressing what's causing those relationship issues. Instead, we're just kind of trying to like move past them, ignore them or start over.

27:35

Again, I still appreciate that because it's it reminds me of you know, big focus, the work we do here. And I think especially on the--not especially, but I work on the compass program. So I think about it regularly, but that we focus on of course diagnostic clarity, we want to get people diagnostic clarity, but we're way more interested in what we call core issues, the things that are happening under the surface that are leading to this repetition of symptoms and these conflicts. So I again, I really

28:02

appreciate you. Yeah, so with OCD, right, we can target the symptoms at face value, or we can target what causes the symptoms. So a lot of my patients will say, well, Liz, how do I stop ruminating? Well, it's not by just working all day to try to not ruminate, right, that's miserable. That treatment, I've done it, it is miserable to spend your day trying to not ruminate, we need to address the core fear that causes you to ruminate. So that the urge to ruminate goes away. I don't want you to try to not ruminate, I want you to not even have the urge to ruminate.

28:34

Yeah, I think that that, to me, that's where like, in the long side of the focus on exposure, and, you know, avoidance, there's that depth oriented piece that can be so important for fears. This is a kind of final question we wanted to ask you is, there's just coming back to your work around reducing stigma. And I wonder, you know, our podcast tends to gear towards clinicians and people who are treating mental illness, any thoughts you have for reducing stigma, especially in regard to these anxiety based disorders that you'd want to share with clinicians?

29:04

You know, I think obviously, the more we can neutralize the thoughts and you know, with OCD, for example, there's a lot of what we would call like, extra stigmatizing subtypes, right? Sexual orientation, OCD, sexual intrusive thoughts, where we have these unwanted sexual intrusive thoughts, harm and violent, intrusive thoughts, right, that feel much more stigmatizing at times than something like contamination that seems to be talked about on a much more mainstream, you know, kind of level or basis. And so I think as a clinician, it's really important for us to feel comfortable talking about all the subtypes and creating a safe space. And a lot of that is going to be b by also encouraging our patients to talk about it in a neutral way. Right if our patients are talking about it in the scary way, and we're responding as if Oh my gosh, that's so scary and hard versus like, hey, let's talk about that again. And like let's relax and let's, let's talk about it in a more neutral stance. That's, that's really important. The second piece to me is all about evidence based care. If you are a clinician and you are not engaging in evidence based treatment for your patients diagnosis, it's really important ethically, for you to refer them out. And it is really important for you to understand what are the evidence based interventions for your patients diagnosis, because the reality is, is that stigma will always be worse, if we don't believe we can get better. And if we're not getting the right treatment that can help us, of course, we're going to think we're doomed. We're never going to be able to be a part of society, people can't help us treatment doesn't work for me, right, I can't get better. The stigma is perpetuated. And so one of the best ways you can reduce stigma as a clinician, is by helping your patients get access to evidence based care or by of course, engaging in it yourself with them. And then of course, engaging in advocacy. And you know, all that's just so important. You know, I think so many times we think it has to be this like big platform, but it's if you have a kid at a school offered to do a talk at your kids school and the things that you you're knowledgeable in, because you wouldn't believe how many teachers and counselors want and are hungry for those resources and that education or your church or your faith based community, right, there's just lots of ways for us to be de stigmatizing mental health.

31:11

Wow. So that sounds quite a helpful, hopeful and helpful note to end on. And thank thanks so much.

31:17

And, again, I just want to say you know Dr. McIngvale, so appreciate you talking to us about this. And again, having followed your work for a bit just so appreciate your passion and your vulnerability and sharing your story and using your story as a way to continue to share about this disorder and help people really understand it. So thank you so much for talking with us today.

31:37

Well, yeah, thanks so much. You're listening to Elizabeth McIngvale, the director of the McLean OCD Institute in Houston. We're your host, I'm Bob Boland.

31:46

I'm Kerry Horrell, and thanks for diving in. The Mind Dive podcast is presented by the Menninger Clinic. If you're curious about the professional experiences of mental health clinicians, make sure to subscribe wherever you listen.

32:00

For more episodes like this, visit www.menningerclinic.org.

32:05

To submit a topic for discussion, send us an email at podcast@menninger.edu