OCD Treatment in the San Francisco Bay Area
OCD is a disorder of doubt - doubt that you can trust yourself, that you can trust your body, that you know what kind of person you are, or that you know what is real. This is the cruel trick of OCD.
I offer evidence-based treatment approaches augmented with years of clinical experience specializing in OCD and related anxiety disorders.
What is Obsessive-Compulsive Disorder (OCD)?
OCD is characterized by excessive and intrusive thoughts/urges/images - referred to as “obsessions” - that lead to feeling distress and anxiety. To alleviate distress, you begin engaging in ritualized physical and/or mental behaviors - called “compulsions”. While compulsions temporarily alleviate anxiety in the short term, they actually reinforce the OCD patterns, and unless stopped, will lead to worsening of OCD over time.
While some OCD fears may be more far-fetched or magical thinking, most OCD fears are based in real possibility. The problem arises in that, while possible, these feared outcomes are not very probable, and the extent that a person is willing to go to prevent these improbable outcomes starts to negatively impact their quality of life and relationships.
OCD can pop up in an unlimited number of variations and themes, but most of the time, at its core, it starts with a moment of doubt that is out of context, illogical or irrelevant to the “here and now”. This way of thinking is most often not in-line with how someone typically thinks or makes decisions in other areas of life and leads them to feel more and more confusion, uncertainty, and fear. People begin making behavioral choices based on the possibility of something bad happening, rather than the probability of something bad happening.
For some people with OCD, there can also be a struggle to tolerate sensations or ideas, such as prominent feelings of disgust when faced with various common things in the environment, even though there may not be a specific fear associated.
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Contamination fears or disgust reactions / washing or cleaning compulsions
Harm fears (violent obsessions, hit-and-run, fear of causing harm to one’s self or others)
Obsessive worries about the possibility of being a pedophile, sexual abuser, or sexual predator
Obsessive worries about your relationships (whether they are the right one?, Are they attractive enough?, Am I faithful enough?)
Religious or Moral Obsessions (scrupulosity); worries about morality, right and wrong
Obsessive doubts about your sexual orientation or gender identity
Health related doubts / fear of getting various illnesses
Sensorimotor OCD (obsessive consciousness and tracking of normal bodily processes like blinking, swallowing, breathing, etc.)
Perfectionism and/or “Just Right” symptoms (difficulty moving on until there is an abstract feeling of something being “ok now” or “just right” or “perfect”)
Hyper-Responsibility and the fear of making a mistake, causing a tragedy, or offending someone
Magical thinking (if I step on a crack, someone in my family might die.)
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Body Dysmorphic Disorder (appearance-related obsessions)
Social Anxiety
Phobias (fear of animals, flying, vomiting, heights, etc.)
Panic Disorder (fear of panic attacks)
Trichotillomania (hair pulling) and Excoriation Disorder (skin picking)
Hoarding
ADHD
Eating Disorders
Substance Use Disorders
Depression
OCD is not a quirk, joke, or advantage!
Many people with OCD appear completely fine from the outside, leading to the misconception that OCD is just a quirk or that it is somehow advantageous. People with OCD are often highly adaptive, developing elaborate ways of hiding their torment and symptoms from the view of others. They may do this out of embarrassment or fear of judgment or even punishment. Because of this, other people often don’t realize how severe and impairing it can be when not adequately treated. In fact, the World Health Organization (WHO) lists OCD in the Top 10 most disabling illnesses.
People with OCD can lose hours in their daily lives while tracking fears in the environment and engaging in various rituals in an attempt to feel safe or clean or “just right”. This distress can make it very hard to be present with loved ones or focus on work or school.
There are common misconceptions that perfectionism or being overly scrupulous is advantageous and may even lead to more success. If that were true, we wouldn’t call it a disorder. OCD starts when these obsessive-compulsive behaviors begin to cause distress and negatively impact someone’s life. While the behaviors in the short term might lead someone to be very detailed oriented on a work project or score a higher grade on a test, it comes at the cost of a lot of stress, anguish, and wasted time. Usually it is only a matter of time that you can continue compulsively spinning these plates before things start falling down and breaking around you.
OCD Therapy and Treatment
The good news is that for most people, OCD is highly treatable when you work with someone who understands the disorder and can offer evidence-based solutions.
Medication Strategies for OCD Treatment
I offer evidence-based treatment approaches augmented with years of clinical experience specializing in OCD and related anxiety disorders.
First line strategies include classes of medications known as Serotonin Reuptake Inhibitors (SRI’s).
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Evidence suggests that most of the common first line meds used to treat OCD work equally well, but there can be a lot of nuance and art in finding the one that best fits your body in terms of tolerability and quality of life.
While many people get more than enough relief with routine dosing of these medications, there is a proportion of people with OCD who respond best to high-dose SRI’s above the range typically used in other conditions. Not everyone with OCD will need this, but it can be a strategy if you are not getting the symptom relief you are looking for.
Second line strategies often include combining two of the above agents or augmenting with a different class of medications (targeting dopamine or glutamate pathways).
While some of these strategies can come with significant side effects to consider, there is a subset of clients with OCD in which they are highly effective.
Third and Fourth line options have a smaller evidence base but often can be clinically helpful, and we can discuss where any of these options may make sense for you. While the evidence should guide us, I do not approach your treatment in cookie-cutter, algorithmic way.
Various permutations of Cognitive-Behavioral therapies (CBT) have developed over the years to treat OCD, but it’s important to know that finding just any general “cognitive behavioral therapist” is often not enough.
It is imperative to work with a clinician who understands OCD and is experienced with the specific forms of therapy that are evidence-based, because we know that other approaches can often lead to OCD worsening over time.
While it is true that some approaches have more evidence than others, treatment is not one-size-fits-all; it's about matching techniques, frameworks, and language to what vibes best with each client.
For more about understanding different therapy perspectives and finding the right fit, I recommend this article: “An Update on the Poetry of Evidence-Based Psychotherapy for OCD” - Jon Hershfield
OCD Therapy Strategies
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“Exposure Therapy” is a heavily behavioral form of CBT and is the most evidence-based approach to date. Modern ERP works for most people when delivered effectively.
ERP for OCD generally strives to help you tolerate feeling anxiety, fear, or discomfort in order to increasingly face your fears and live life without having to engage in avoidance or compulsions.
The key is to stop reinforcing the OCD, and to do that, we have to stop doing compulsions.
ERP for OCD should generally not be forced. You should not feel totally shocked or that you were thrown into the deep end against your will. This is usually done with your consent, at a pace you feel you can tolerate, slowly working through a hierarchy of fears or discomforts as you make progress. For some this process can be slow and tedious, but others may be able to move quite rapidly as they better understand the game of beating their OCD.
Over time we aim to increase forms of cognitive learning, extinguish fears, and train your nervous system to respond more rationally.
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I-CBT for OCD is a more cognitive approach. While it does have evidence to support it, it is a somewhat newer approach and not yet proven to the same extent as ERP, though some clients find it to be a very helpful framework.
I-CBT strives to attack OCD further up-stream before all of the anxiety has a chance to grow out of control.
We start by outlining a client’s OCD sequence, which generally follows the following format: trigger -> obsessive doubt -> feared consequences -> anxiety/distress -> compulsions.
The goal is to get better at catching the pattern of using faulty logic, imagined possibilities, or out-of-context facts that feed obsessive doubts. If we can cut that process off and help clients to trust themselves again, they can step out of the “OCD bubble” and stop the development of the overwhelming anxiety in the first place.
If successful, you will likely start re-engaging with many of the things you consider triggers, although I-CBT for OCD does not specifically focus on doing exposures in the way that ERP does.
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I engage in all forms of my practice from assessment to treatment through an ACT perspective. I think of ACT for OCD as more of a language or scaffolding from which one can deliver more specific modalities such as ERP and I-CBT.
Classical cognitive behavioral models have focused on tracking specific symptoms such as anxiety or depression, with the goal of treatment being to reduce the degree of symptoms. In ACT for OCD, we focus more on your values and the kind of person you want to be and the kind of life you want to live. We help you tolerate, carry, and manage anxiety symptoms when they show up, in the interest of keeping you moving towards the things you care about.
When delivering ERP, ACT helps us focus on the “why” in “Why the hell would I do this scary thing?”. We want to hone in on why it's worth it to do hard things or take reasonable risks in life. What is it that you care about that OCD is taking from you? Maybe you are missing adventure in life or success at work. Maybe OCD is getting in the way of showing up in relationships as the kind of friend, partner, or parent that you want to be. These values serve as anchors and something to fight for that is greater and more important than just having less symptoms.
Ready to Get Started with OCD Treatment in the San Francisco Bay Area?
Services offered throughout the State of California via Telehealth.