At the Forefront of OCD Treatment: Sally Winston

Since I was diagnosed with obsessive-compulsive disorder (OCD) in 2006, resources on the disorder have seemed to explode—and that wasn’t that long ago! My guest today, Dr. Sally Winston, has contributed to our current understanding of OCD and its treatment, and I’m honored to learn more about her and her career! We talk a little about my favorite topic, unwanted and scary intrusive thoughts (yes, I said favorite!). Thank you, Dr. Winston, for being here.

How long have you treated OCD? Why did you decide to focus on anxiety and stress disorders?

In 1975, I became the first postdoctoral fellow in psychology at Sheppard Pratt Hospital in Baltimore, and then stayed on staff for seventeen years. I was identified early on as a heretic from the prevailing psychoanalytic model and in 1978, after encountering the work of Claire Weekes and spending some time with Diane Chambless and Alan Goldstein, who were pioneering a CBT model of direct exposure-based treatment of panic and phobias, I was drafted to run something we called the Agoraphobia Clinic. This was DSM II time, when there was no panic disorder classification and the idea of specialization in psychiatry was treated with skepticism. We developed our understanding of anxiety disorders and OCD (then still classified as an anxiety disorder) along the way. I was very involved in the Anxiety and Depression Association of America (ADAA), where I interacted with and learned from the researchers and clinicians who were developing the field. In 1992, the Anxiety and Stress Disorders Institute (ASDI) became an independent institute, still located on the hospital grounds. During the 1990s, our understanding of OCD gradually grew, as we realized it was neither rare nor untreatable nor difficult to diagnose if you knew what you were looking for. We now have over twenty therapists and trainees.

Of course we know that people who don’t have OCD often have misconceptions about it, that it’s all about being organized or having a germ phobia. Have you also had to dispel misconceptions held by people who have OCD? If so, would you consider this part of the treatment process?

Yes, misconceptions remain, not only in the general population but also in the vast majority of therapists in practice. Getting the word out that OCD is not just being afraid of germs (misnamed germophobia) or being detail-oriented—or having a bizarre preoccupation with something—is a critical issue. Much of my career has focused on educating clinicians about OCD and anxiety disorders, as many people believe they know how to treat these disorders but lack the training they need to do it effectively, so that leaves many people seeing well-meaning therapists who participate unwittingly in co-compulsing therapies or uninformed “face your fears” suggestions that ultimately make things worse.

And because so many compulsions are actually hidden, cognitive attempts to “cope” with obsessions, such as self-reassurance, ruminative analysis, trying to replace negative thoughts with positive or rational ones, and avoidances of every kind, most people who have OCD do not know it. They may think of themselves as being worriers or perfectionists or quirky or having shameful bad thoughts, but they do not know to seek the right kind of help.

Your book Overcoming Unwanted Intrusive Thoughts addresses disturbing and frightening obsessions, what Lee Baer referred to as “taboo” thoughts. What inspired you to write this book? Why is it important to focus on this type of intrusive thoughts?

The inspiration for the book Marty Seif and I wrote came from the unbelievable attention one page on intrusive thoughts on his website received in 2016. He was getting tens of thousands of hits a month. Most of these people did not know to Google OCD because they did not know they had it. They were trying to find help for thoughts they did not want. It was clear that there was a gap in the self-help literature that needed to be filled. He began a monthly newsletter on unwanted intrusive thoughts, but that was not meeting the need, so we collaborated on our second book and called it Overcoming Unwanted Intrusive Thoughts, consciously leaving out the word “OCD” in the title.

Initially, our plan was to present the inner self-perpetuating struggles and loops of OCD as dialogues between Oscar (Obsession), Cassandra (Compulsion), and David (Observer), but our editors wisely redirected us to call our characters Worried Voice, False Comfort, and Wise Mind in order to present our metacognitive model more clearly. (These same characters appear in our third book, Needing to Know for Sure, on compulsive checking and reassurance seeking and our fourth, in progress, on anticipatory anxiety and chronic indecisivenesss.)

While most of us have never lived through a pandemic before, those of us with OCD have definitely had to deal with uncertainty! Do you think the general public could benefit from some of the principles of OCD treatment?

It is true that people who have learned to tolerate uncertainty, can accept that what we can imagine is not factual, and that worries or intrusive thoughts are not red flags demanding urgent action can fare better in uncertain times such as now. Distinguishing between real danger (COVID-19), discomfort, distress, and reasonable and unreasonable risk are all part of negotiating the health and safety of ourselves and those around us. Washing your hands when you come into the house from outside because you are following CDC guidelines is different from rewashing your hands thirty minutes later because you had a thought that maybe you did not wash well enough. People who have been treated for OCD and done well understand these distinctions. And they know that living a meaningful and joyful life requires accepting that there are no guarantees, no flawless decision-making, no risk-free living, and frequently no answer to unanswerable questions like “when will this be over and things back to normal?”

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

Thoughts are just thoughts. Feelings are feelings. They have no power on their own. You have a choice in the relationship you have with them.