Debra Dalton Stein, MFT, of the OCD Center of Los Angeles describes her journey as a psychotherapist from working primarily with eating disorders, to becoming an OCD specialist.
branch of the OCD Center of Los Angeles
One of the greatest barriers to effective therapy for Obsessive Compulsive Disorder (OCD) is the lack of mental health treatment providers trained in the treatment of this condition. Most graduate school programs provide a broad overview of the counseling process, without offering much in the way of specialized training for specific conditions such as OCD. As a result, most psychotherapists have a limited understanding of OCD and its appropriate treatment.
Prior to 2013, like so many other therapists, I didn’t know a lot about OCD or its treatment. I was aware that people with OCD had compulsions such as excessive hand washing, and checking doors and stove knobs, but that was about it. Up until that point, I had spent much of my career – over 20 years – working at various treatment programs that focused on other diagnoses, and specializing in the treatment of eating disorders in my private practice. I’d had an eating disorder myself in my 20s, and like all eating disorders, it was a nightmare. And just like so many people struggling with OCD, I found it extremely difficult to find appropriate help (that is, once I finally gave up trying to do it myself).
Like many people with OCD, my first efforts to get treatment for my eating disorder were not successful. I was not emaciated or overweight, and so I didn’t “look” like I had an eating disorder. My experience was not unlike so many people with OCD who do not excessively wash their hands or check doors and locks, and thus are often misdiagnosed by untrained mental health treatment professionals.
My entryway to learning about OCD came unexpectedly from a long-term client I had been treating for anorexia nervosa. I had come to know Sara* and most of her family over the course of the three years that I worked with her. I knew Sara well and she was a wonderful person. One day towards the end of treatment, Sara looked very uncomfortable and anxious during our therapy session together. She told me she needed to tell me something she had never told anyone – not even her mother with whom she was very close. I could see that Sara feared my judgment, and so I told her nothing she could tell me would change the way I saw or felt about her.
Sara proceeded to tell me that since the age of five, she had been experiencing horrible images of herself harming her mother whom she dearly loved. I told her I was sorry she had been going through this all alone for so many years (she was 22 at the time), and that I didn’t know what these images meant. I let her know she was not “crazy” as was her fear, and wondered to myself, “Why don’t I know about this?”
Sara intuitively knew the images and thoughts were not a reflection of who she was or ever wanted to be. She had no history of violence or harming anyone in any way in her life. But she didn’t understand why she repeatedly experienced these mental images, and was deeply ashamed of them and of herself. At the time she was nearly fully recovered from her eating disorder, and worked in a demanding career that was her passion.
I asked Sara if she would allow her mom to join us in our next session so I could support her in telling her mother about what she had been dealing with alone for so many years. Sara agreed, and when she told her mother about the unwanted images, her mother hugged her and told her she was not afraid that Sara was going to hurt her in any way.
After that session, I contacted a local therapist who specialized in anxiety disorders. In discussing Sara with this specialized treatment provider I learned that OCD comes in many forms, and that it was treatable using some very specific techniques. I referred Sara to the OCD specialist for treatment, while I continued to work with her in support of her eating disorder recovery.
That experience of recognizing my limited knowledge of OCD led me to become very interested in learning more about the condition. I made a point of reading numerous books about OCD treatment, and over time began to identify its symptoms in many of the clients I was treating for eating disorders. One of the many things I learned was that a 2004 study had found that 64% of individuals with eating disorders have at least one anxiety disorder and that 41% of these people have OCD [1].
I began to research how I could competently and effectively be trained to treat OCD. I discovered the website of the International OCD Foundation (IOCDF), where I learned about their Behavior Therapy Training Institute (BTTI). This is a specialized training program that the IOCDF offers periodically across the country. The next training was scheduled in Pasadena, California, about a two-hour drive from where I lived. I was told by an IOCDF representative that getting into the training was competitive, and that there was a designated time to call and reserve a spot in the program. I planned ahead, called at the time given, and was excited to be accepted into their training program.
The two and a half day training was an immersion into all things OCD. It was during that weekend program that I learned about treating OCD with a specific type of Cognitive Behavioral Therapy (CBT) called Exposure and Response Prevention (ERP). Experts took turns presenting, and to be honest, I was overwhelmed with all of the information that was so new to me. At the end of the weekend I was assigned to continue my training by working with a local licensed psychologist who specialized in treating OCD as my clinical supervisor.
Soon thereafter, I went to the 2014 IOCDF Conference in Los Angeles. This was another excellent learning experience, as I attended numerous seminars and workshops on OCD and its treatment. The many books I had read about OCD, combined with the BTTI training, had laid a strong foundation upon which the conference would build. In addition, I took an online certification course focused specifically on the treatment of OCD and Anxiety.
Through several of the conference workshops that I had attended, I had learned how to structure OCD treatment focusing on three core techniques:
- Cognitive Restructuring – This is the “C” part of CBT, and it focuses on helping clients learn how to more effectively respond to their intrusive OCD thoughts. By learning how to “restructure” their thoughts, clients with OCD learn to challenge their irrational thinking patterns with more realistic thoughts that are based on objective reality rather than fear.
- Exposure and Response Prevention (ERP) – This is the “B” part of CBT, and it focuses on helping the client directly face their fears. This is done via specific behavioral “exposures” that are done in session and as take-home assignments. These exposures target the client’s behavioral symptoms in a structured, systematic, and concrete way through which the client becomes less anxious in response to their unwanted thoughts. CBT with an emphasis on ERP is the evidence-based treatment for OCD. Simply put, ERP works, and there are literally scores of research studies that prove that it is the most effective treatment for OCD.
- Mindfulness Training – The goal of mindfulness training is to learn how to change our relationship to our unwanted thoughts, feelings, sensations and urges, and to respond to them in a different way. Mindfulness teaches us to allow and accept these uncomfortable internal experiences without judgment, and to instead let them move through our minds without engaging with them. We can then more effectively use ERP to practice tolerating them. When integrating mindfulness with ERP, we learn that these experiences are bearable, and will often go away on their own eventually.
After the IOCDF conference, and after completing the online certification, I felt much more confident in my ability to treat OCD. But there was one small problem: I still needed a client with OCD! So I posted on a local therapist email list that I was looking to treat an individual with OCD using CBT/ERP. I offered to work for a low fee or, if necessary, for free. I also became a professional member of the IOCDF and posted my bio on the website.
Within a few weeks, I received a call from a newly graduated high-school student who had also attended the same conference. She was just as excited as I was to commence treatment, and we worked together for a couple of months before she had to leave for college. She was highly motivated, did her exposure homework, and made steady progress. She would need follow-up care, but she now had a better understanding of her OCD and knew how to effectively do ERP on her own. Happily, she felt much better and I was really proud of her hard work.
After being supervised with this client I was formally certified as a BTTI graduate. I continued to build experience working with OCD, and after a few months I gained employment at the OCD Center of Los Angeles. There, I received more training before I began seeing clients at their Santa Barbara office location, where I continue to work today.
Like treating eating disorders, working with OCD is an extremely rewarding experience. Helping clients understand their symptoms and supporting them through the hard work of ERP is a privilege. I have worked for the OCD Center of Los Angeles since 2015 and remain thankful to Sara, who may never know that her courage to be vulnerable with me in one session could help so many others.
• Debra Dalton Stein, MFT, is a psychotherapist at the Santa Barbara branch of the OCD Center of Los Angeles, a private, outpatient clinic specializing in Cognitive-Behavioral Therapy (CBT) for the treatment of OCD and related anxiety-based conditions. In addition to individual therapy, the center offers five weekly therapy groups, as well as online therapy, telephone therapy, home visits, and intensive outpatient treatment. To contact the OCD Center of Los Angeles, click here.
* Names and identifying details have been changed to protect the privacy of individuals.
[1] Kaye, et. Al. Relationship between Anorexia Nervosa and Obsessive and Compulsive Behaviors. Psychiatric Annals, 1993. (23):365-373.
10 Comments
Thank you for sharing your journey. I loved how you discovered your passion in such a unique way.
This also made me realise an important point that if it wasn’t for the bravery of a few people like Sara in sharing these thoughts which cause them so much shame, not as much attention would be given to this disease and perhaps that would mean less research and treatments. Thankful for those people!
Lubna,
Thank you for your kind words.
I agree that sharing difficult thoughts and feelings with one’s therapist can be an act of bravery, especially when it comes to OCD. It also speaks to the importance of specialized training for therapists so when clients do share these thoughts, the therapist is able to recognize what it is and treat it effectively.
Hi,
I have suffered with HOCD for many years and at times it was crippling. I had CBT and my therapist was not aware of my anxiety disorder. I searched the internet and eventually found others who had the same symptoms as myself and I cried with relief. It is something that people do not like to talk about but I urge you to become a specialist in this particular form of OCD as it is the most debilitating condition imaginable. Please help others like myself.
I have this condition under control with the help of medication.
I applaud you for the work you are doing and urge you to continue supporting others like me!
Katherine,
Thank you for your kind words. I am glad to know you were able to identify what was going on for you. I have heard many clients report how getting the correct diagnosis was a huge relief and made them feel they were not alone.
All of the therapists at the OCD Center of Los Angeles specialize in treating all forms of OCD, including HOCD. It is actually a very common subtype of OCD and like all forms of OCD can be treated effectively with Cognitive Behavioral Therapy (CBT), with an emphasis on a specific CBT technique called Exposure and Response Prevention (ERP).
I’ve struggled with OCD for over 50 years. During the past two decades I was fortunate to receive excellent psychiatric counseling and the meds I was prescribed substantially reduced my symptoms, but the OCD persisted in the background with periodic flares that were overwhelming. Over time I often found myself increasingly in a state of high alert/anxiety, obsessively scanning my thoughts and feelings for signs of the next crushing outbreak- a toxic vigilance.
About a year ago I began exploring with Debra new ways of working with this disorder. Through practice of the techniques outlined in this article and with Debra’s guidance and support, I’ve come to a new relationship with OCD. The OCD is not gone. Rather my response has shifted from reflexive avoidance and fear to an acknowledgement and compassion that provides the space to choose my actions- an empowerment that builds upon itself.
The work isn’t over. For me, I doubt it ever will be. But I am no longer stuck being a victim of OCD. I’m getting better at creatively engaging with the world- noting my OCD but no longer enslaved by it, I’m thankful for the freedom to choose actions consistent with my values.
Steve,
It is heartening to hear how well you are doing and your continued willingness to apply the tools to manage OCD effectively and live your valued life. Thank you for sharing your experience!
I found this article very interesting and quite informative at the same time. The world needs more people like you!
SCS,
I’m glad you found the article both interesting and informative. And thank you for your kind words!
I have OCD, I am 33 years old and was diagnosed with this at 15. I found this article interesting and yet at the same time found that it lacked some information and explanation when it came to the 3rd to last paragraph about the newly graduated student and her OCD. As I read it, it seemed to be all great and grand with her experience with OCD. That she had done her exposure homework, and had some follow up appointments and it was all great. I am glad though that you pursued the field of OCD. I live in a small town and there are few people who work with people with OCD. Thank you for your service.
Lacey,
Due to reasons of confidentiality, I purposely did not provide many details about the client I referred to in the article. Like most, this client had a number of therapy sessions to complete her treatment. Once in treatment, most clients feel better when they understand the disorder, how it works, and how doing ERP improves their symptoms.
I understand it can be difficult finding OCD specialists in a small town. Depending on where you live, we may be able to provide you with online therapy.