Help me welcome the amazing Amy Mariaskin! When our beagles were both 15.5 years old we introduced them to each other on a Zoom call—they didn’t seem to know what was going on, but the point is that we tried to foster a connection, and that’s what Amy is all about. Whether she’s working with clients at her Nashville OCD practice, sharing tips in her new book, Thriving in Relationships When You Have OCD: How to Keep Obsessions and Compulsions from Sabotaging Love, Friendships, and Family Connections, or speaking at a conference, Amy leads with compassion and the belief that we can love our lives even with OCD, and she wants to help make that a reality.
Not only are you an OCD therapist at Nashville OCD & Anxiety Treatment Center, you founded the center! This brings up so many questions. For starters, why did you choose to focus on OCD and anxiety, and what led you to opening NOATC?
Like many others in this field, I have personal experience with OCD. Despite developing symptoms in early childhood, I wasn’t diagnosed until I was in my early 20s and studying clinical psychology in a PhD program. I was floored by how much relief I got just from getting a diagnosis. I switched my focus in school and decided to devote my career to helping others with OCD find early intervention and effective care.
My graduate program was tailored more toward research than therapy, but after working with my first client with OCD, I was hooked on being a therapist. It seemed like the perfect combination of science and art and afforded me the opportunity to work with brilliant clients and families. What could be better? I began seeing clients part-time in 2011 in a tiny, poorly lit office, and within six months I had left my other full-time job to be in private practice five days a week! It was clear how much the Nashville community needed specialty care. After a stint as a clinical director at Rogers Behavioral Health Nashville, I wanted to return to providing direct therapy with clients, but I loved working with colleagues. My solution was to open up the NOATC in June 2018. While the first year was a lot of work, late nights, and tears, I feel like we’ve built something really special for Tennessee over the past four and a half years. I’m so honored and privileged to work alongside my awesome colleagues. They make me a better person.
Let’s say someone approaches you and says, “I have OCD but I’ve been told there’s no cure. Should I try therapy anyway?”
Oh, yes—this is such a common question. When people ask it, there’s usually something else lurking underneath it. There might be an underlying fear that if therapy fails to help, it will “prove” to the person that they are truly broken (you’re not!). Or it may be an acknowledgment that therapy is financially and emotionally taxing, and the person is evaluating the pros and cons of taking on this work without the promise of an outcome. It could be that the outcome itself is being portrayed as a black or white situation (cured vs. sick) instead of recognizing the gradations in improvement that can affect one’s life.
Therefore, before I rush to provide a resounding YES, I like to help people explore the meaning behind this question. What does cured mean? What does symptom reduction mean? What if you don’t need total symptom elimination to have a meaningful life? I like to honor people where they are but also acknowledge that if they’ve made it to the therapy room, they are at least therapy-curious, if not completely bought in. Overall, I want to instill hope that therapy can be helpful while empowering people to decide for themselves about how therapy fits into their plan.
You have a new book out, Thriving in Relationships When You Have OCD: How to Keep Obsessions and Compulsions from Sabotaging Love, Friendships, and Family Connections. What an important topic! I think sometimes we focus so much on simply surviving with OCD we forget we also deserve to thrive. What are some tools readers will gain?
It was a deliberate choice to use positive language in the title instead of only talking about how OCD can sabotage us. I wanted for the people with OCD to be centered and to show that we can all thrive above and beyond just managing our symptoms. My goal with this book was to highlight the ways in which OCD can infiltrate our connections with others and how to center our relationship values to create the connections we want. The tools and exercises in the book range from audio clips (like a self-compassion meditation) to structured worksheets (such as one to help track reassurance) to behavioral exercises (like one to increase intimacy). I enjoyed not feeling constrained by any one therapeutic modality. That is, even though all of the strategies are from evidence-based treatments, they are not solely from one treatment method. I had the freedom to write a book the way that I practice with my clients, which is integrative of different techniques.
I hope that people who read this book get the following from it: (1) a sense of validation and connection to others who have struggled with similar things, (2) clarification of their interpersonal goals in different relationships like friendships and partnerships, and (3) tools to reduce the impact of OCD on these relationships. I also tried my best to infuse the book with humor, and even though I feel like some of my best one-liners were removed by the editor, I hope that humor still shines through. Humor is a great way to take the wind out of OCD’s sails and encourages “cognitive defusion,” an acceptance and commitment therapy (ACT) term for creating distance between thoughts/emotions and their impact. I wish I could insert an effective joke here to give you an example, but maybe you’ll just have to get the book!
A statement I often see about OCD is that it doesn’t discriminate, and I agree. However, while anyone can get OCD, not everyone has access to effective treatment. How can some barriers to treatment be dismantled?
Financial barriers are probably the biggest one people face. Therapy is expensive, and insurance reimbursement rates are painfully low, discouraging therapists from accepting insurance. If you can’t find someone who has specialty training and takes your insurance, finding clinics that have intern rates is one way to address this. The Open Path Collective is another resource for finding services offered at sliding scale rates. Others may live in geographical areas with few or no trained providers. In some places this has been alleviated by the uptick in virtual therapy services. But depending on licensing laws it can still be near impossible to find care in certain areas of the world. I know that Beyond Borders CBT is working on increasing services across country lines.
Finally, therapy, like many other healthcare fields, has a checkered past in the United States. Sexual and gender minorities were pathologized for years as having mental disorders, and research in the field of psychology was often limited to white, middle-class people. Even now, there are racial disparities in diagnosis; for example, Black clients are more likely than white ones to be diagnosed with schizophrenia in the presence of the same symptoms. Therefore, in addition to lower access to services, certain marginalized groups may harbor some (understandable) mistrust or hesitancy about therapy. Dismantling these kinds of barriers can involve acknowledging that all of these factors might show up in the therapy room, and addressing them in a sensitive and affirming manner.
You’ve said you have a particular interest in working with LGBTQ+ youth. Tell us more.
Hot take maybe, but I think being a kid is actually really hard. There’s a ton of new information coming at you and a ton of strange stuff happening in your body. My worst years with OCD were all before the age of 18, and I think a lot about how we don’t give kids credit for the work that it takes to get to adulthood. Trying to figure out where you fit in when your sexuality/gender differs from the dominant culture is an additional layer that complicates things. So at the intersection of addressing mental health concerns, navigating childhood, and exploring LGBTQ+ identity, I think there’s a magical place to help support and enrich these young people. Being in Tennessee where there is an active push to silence LGBTQ+ voices, it also seemed important to have this focus so that kids and families would have a safe place to land for therapy.
One topic people with OCD can be hesitant to talk about is how their obsessions and compulsions can interfere with their sex life. I was once terrified I’d have certain intrusive thoughts interfere, and it was easier (but more detrimental) to avoid intimacy. How would a therapist help a client work through an issue like this?
It’s tough because you really might have unwanted thoughts during sex or intimacy. Unfortunately, that part is hard to get rid of. However, there are a few things that people can do to reduce the impact of these thoughts on their experience of sex. One is a shift in mindset about the thoughts themselves: instead of seeing them as meaningful and shameful, you can think of them as merely the mental junk that OCD sometimes spews out. Depending on the content, the thoughts can be very compelling, I know. And they can also make it difficult to stay aroused.
Which brings me to point #2—if you can communicate about your symptoms with your partner(s), it can reduce their impact significantly. This doesn’t necessarily mean telling them all about your thoughts in detail, but it can be the difference between a partner slowing things down to help you stay engaged through these symptoms and them misinterpreting your behavior as a sign of disinterest.
Finally, practice refocusing your attention from the mental to the physical. How does it feel in your body to be touched? What textures, temperatures, smells, and tastes can you find on your partner’s body? OCD likes us to spend a lot of time upstairs in our heads, which can make it hard to feel things, well . . . downstairs. By reframing thoughts, communicating, and practicing body-focused mindfulness, you can experience intimacy regardless of whether or not OCD butts in.
If you could offer just one piece of advice to someone with OCD, what would it be?
Channeling Kimberley Quinlan a bit here, but I would start with encouraging self-compassion. Shame is so common with OCD, and it can make engaging in the hard work of therapy more difficult. So I would encourage everyone to practice holding your thoughts and feelings gently and kindly. And give yourself validation even when it seems hard. You can learn over time to be your own biggest advocate and that often starts with treating yourself well internally.