If you have obsessive-compulsive disorder (OCD) or a related disorder, you’ve probably heard how helpful it can be to see a therapist trained in cognitive behavioral therapy (CBT), particularly exposure and response prevention (ERP). But what about working with a therapist and your partner so you can take your treatment even further at home—and work through some issues OCD can cause in relationships? Therapist Emily Risinger has worked with parents of children with OCD and partners of people with OCD as well as those people with OCD themselves, using CBT, mindfulness techniques, and art therapy. I learned so much from chatting with her on a video call, and got some good book recommendations too! Thank you, Emily, for sharing your insights with such passion.
Tell me more about your podcast, Brave Me: A Podcast Built for Brave People.
I started it February last year, before the pandemic was in full swing and we kind of just had whispers of it. I was thinking “I want to do something different, that challenges the things that scare the crap out of me but that I can do.” Public speaking scares me, articulating myself really well is challenging for me, so I wanted to do that. So I started off with just a couple really small episodes and then I was kind of absent from it because of all of the chaos in the world, but now I’ve been doing it more consistently and it feels really good, really empowering. I also like tailoring episodes to what I’m searching for to recommend to my clients. I really want to cut out the clutter of “click here, here’s some ads, or here’s a 25-minute mindfulness thing.” I just wanted something quick, easy, accessible for them to use, and then a way to challenge myself as well so I could kind of conceptualize this whole idea of what it was to do some guided meditation and mindfulness practice but also practice using those skills myself and challenging myself. It’s been fun, kind of scary, but I’ve really enjoyed it.
The first couple ones were very basic, just deep breathing and muscle relaxation. I wanted something where someone was guiding the breathing, and where you can hear the breathing more, because I wasn’t finding that from other meditation scripts I was looking for, and I really wanted something that was accessible for people who were trying to practice more of that deep breathing, and I wanted progressive muscle relaxation because I also work with Tourette’s and body-focused repetitive behaviors [BFRBs], to loosen up those muscles when they’re feeling the urge. Those were the first ones I did and then I moved into more guided meditations that had more themes like canoeing down a river or finding gratitude in your home or things like that that helped with grounding exercises and finding some more calming visualizations.
Cool, that sounds great. I find that I’m intimidated by the word “meditation” and that sounds really nice to me. So, sounds like you don’t just treat OCD but OCD and related disorders—how did you decide to focus on that?
I was seeing a lot of folks who had OCD and they’d say, “Oh, I also do this other thing that I haven’t really talked about, and it’s not a big deal, but it bothers me.” I’d say, “Okay, what’s this other thing?” and it would be skin picking or hair pulling, some mild to moderate cases. I did some research on it and I found out how often it happens with folks, where they might have skin picking or hair pulling and OCD and how it was treated in the past like sister disorders and now it’s more like far distant cousins. I kind of went down this path of researching it a bit and I found this really great program from the TLC Foundation for Body-Focused Repetitive Behaviors. [Emily holds up a book by Charles Mansueto, Overcoming Body-Focused Repetitive Behaviors: A Comprehensive Behavioral Treatment for Hair Pulling and Skin Picking.] I did this program with them to learn more about CBT and how it’s used with BFRBs. I found it really fascinating how there’s an overlap with different repetitive behaviors. They’re on different neural circuits, but they’re very similar, and I really liked what these folks wrote about body-focused repetitive behaviors. It was very individualized and targeted therapy and cut out the muck, just here’s the solution, let’s work toward it and tailor it to your needs and put it into play and adapt as needed.
You said they used to be more like sisters and now they’re more like distant cousins. So basically with more research they’ve figured out they’re not that similar and then how are they treated differently? It’s CBT for both of them?
Yeah, it is CBT for both of them, and mindfulness is a big part for both of them. With BFRBs it hits more of the sensory aspects of things, so our bodies are looking for sensory information throughout the day and with BFRBs it’s trying to meet that need but it’s getting into pulling hair and feeling with the fingertips or the scalp. There’s some kind of sensory information our bodies are looking for. How that differs from OCD is it’s on more of a pleasure circuit versus an anxiety circuit.
Interesting! I’m learning new things all the time. How long have you been in practice, and how long have you been treating OCD? Did you always know you would treat OCD? What was your inspiration?
Did I always know I would treat it? No, I originally went to grad school for art therapy, but I always knew I wanted to stay within the cognitive behavioral therapy realm of things, but I felt like something was missing, the self-expression aspect of it. I thought art therapy would be where I wanted to go, but a series of life events happened as it often does, and I was living in Wisconsin after grad school with my son and my partner and we decided to move back to Minnesota. I was living in Minnesota for a while and Rogers opened up in Eden Prairie, which was close to where I was living, and I’d worked with Rogers before when I lived in Milwaukee, and I thought, that’s interesting, I want to hear more about that. I went in for an interview and thought this could work. I launched the IOP [intensive outpatient program] there in the child and adolescent unit, and that was a whole adventure, but I got to learn more about ERP because I worked with therapists who were exposure therapists. I loved how effective it was, I loved how I could sit with people in their fears and watch them become more empowered, and I really loved how person-centered it was and how it hit not only the behaviors and thinking but also their feelings and the essence of themselves and getting back to their values. After that I was like, yes, this is where I was supposed to be. It was a really cool moment.
What misconceptions do people have about OCD? And how do you think we can work to fix it?
Everybody has intrusive thoughts, and I think that’s something that people are like “What? Yeah, I guess I do have weird thoughts, and I never really thought about that before.” I did a lot of work with parents before the pandemic and I had to take sort of a side break from it because of my own kids’ needs, but I used to do a lot of treating parents and how to support their kids and I remember working with parents and saying, “Just pay attention to your thoughts, when you have that weird feeling when you’re cutting carrots or something and you’re like, ‘What if I cut my finger off?'” Later they would say, “Emily, you know that thing about my thoughts? I totally had some weird stuff like what if the oven blows up, what if I put the cat in the fridge?” Yeah, I know! You just don’t have OCD so your brain doesn’t get stuck on it.
So you’re saying that it’s a big misconception that only people with OCD have intrusive thoughts?
Yep. The other thing is I would say anybody can have OCD. It doesn’t matter who you are, it doesn’t matter where you’re from, it doesn’t matter how you were brought up, it doesn’t matter who your parents were, you can have OCD. And you can live a fulfilling life with OCD.
What would you tell someone who says that their goal is to never have an intrusive thought again, knowing that they will?
I like to be really open, honest, and transparent about the information I know from the research that’s available, so with a kid I’d say it’s not so much about not having scary thoughts, it’s more about what perspective you can take with the scary thoughts, how you can work with the scary thoughts. Scary thoughts happen. I think that goes back to everybody has intrusive thoughts. One of my favorite books I just got, because I’m starting to do more parent-oriented OCD, maternal and paternal stuff, is Good Moms Have Scary Thoughts. The fun thing about it is it’s just about two moms sitting on a bench and one’s like “Oh, I should breastfeed, why don’t I breastfeed, because formula is poisonous?” and the other mom is like “I’m breastfeeding, what am I doing, I’m exhausted, am I a bad mom?” What you’re thinking about in the moment can change just from taking a different perspective on it.
You mentioned that before the pandemic you were doing coaching with parents. Can you say more about that and why it’s important to get the family involved?
I currently do more coaching with partners. I think it’s really important to find somebody who will work with accommodations and reassurance with parents and also train parents on okay, yeah, your kid is doing these things, but it’s not so much from your kid, it’s from this OCD thing in their brain. So if you were working with your child on insulin control, it wouldn’t be so much about your child and their inability to manage their sugar levels, it’s more that they have this disorder that they need help with. I really liked working with parents and identifying, like, let’s watch language and track when you are accommodating. There can be a lot of “Oh, I do this for them all the time,” so I say let’s monitor that and see what “all the time” really looks like. I help them use tools like validation or urge surfing techniques or keeping up with the pep talk, like “You can do this, I know it’s tough but let’s work on it together, what kind of exposures can we set up for each other?” So I really did enjoy that and I really enjoy that for partners as well and working through a lot of the turmoil that can accompany having OCD and having a partner. Sometimes one partner ends up being more in charge of the day-to-day things or scheduling changes in the household because of OCD.
What is urge surfing?
I use it a lot more for kids; I don’t use it much for adults. It’s like, “Okay, let’s wait and see what happens.” I got it from The Complete OCD Workbook. I use it with kids. I really love this book because I feel like it’s just a quick down and dirty book about what OCD is all about in the outpatient world, but urge surfing for kids can help them be like “there’s a scary thing that’s going to happen” and sometimes kids know what it is and sometimes not so much, but let’s wait and see, let’s sit together and wait and see what happens.
I love using humor in my practice. You know, it is a serious thing and it is very distressing, but finding that place where you can laugh with your partner, parents, people around you, about these quirky things that happen—I feel like it just helps you work with your OCD. I also like to take OCD as it’s a part of your brain still, it’s kind of like that aunt you never really want to invite to the holidays but you do anyway because they’re your aunt. I like to treat it more like that. There’s some quirky things you can laugh about but they’re still here with us.
I was just thinking about that—you know how people without OCD will make a joke, and it’s like, “It’s not even a good OCD joke, though.” There are funny things about OCD—I laugh about OCD all the time, but sometimes people who don’t have it don’t know how to joke about it so they think I’m offended, and it’s like, “I’m actually not, though, it’s not offensive, it’s just not a very good one.” It’s better when it almost makes you mad—
Ugh, I’m so mad because it’s true!
I would love to work with you if I were in that space right now because it helps so much to have levity. It seems weird to have one thing that’s the serious thing, don’t laugh about this.
Right, you know, I think it’s just part of being human. Even the deepest, darkest parts of ourselves we have to find some humor in it, not so much as a defense mechanism but it’s kind of like that judgmental/nonjudgmental stance or radical acceptance. Yeah, this is daunting, this is scary, but I’m not gonna give it more power by being afraid of it and thinking I have to treat it so factual and observational. It’s more like, yeah, it is scary and it’s scaring the shit out of a lot of people.
I think treating it super seriously like that, for me, would make it worse because then I would overanalyze it and think, “This is a dark, serious topic, why is this happening?” Where, like, that’s fricking hilarious that that’s what you thought, that’s where your brain took you? I know there are times when you shouldn’t laugh, but when you can get to that moment it’s such a powerful thing. When you can think, “No, that was truly ridiculous that I ever thought that.”
That’s where I really like to bring in the art therapy side of things, too, with thought defusion strategies. Saying it out loud, it can just sound so ridiculous, and whether it’s a singsong voice or you’re using your Oprah voice or just saying it louder with your friend, you’re transferring their power. It’s still you confronting OCD, but you’re taking away the power it thinks it has over you.
I love that. What other art therapy techniques would you use for OCD?
Cross-stitching for BFRBs can be really empowering because it’s a tactile thing; it’s also super sensual. I ran a women’s group for women and women-identified individuals with OCD and did some thought defusion, self-care, and creating a profile for what your OCD looks like: when it is strong/loud, what its weaknesses were, what it attacked, where it lived, and making a comic book or a graphic novel page out of it.
If you could give someone with OCD just one piece of advice, what would it be?
I had two that suddenly came to mind. The first one is that you’re not alone and the second was that you have what you need inside you.