Q&A with an ERP Therapist

Erin VenkerMeet Erin Venker. I know her through the leadership team for OCD Twin Cities. Erin is lovely, thoughtful, and smart– and she has a unique experience of having OCD and being an ERP therapist. I’m so pleased to be interviewing her on my blog today!

Tell us a little about your background in regard to OCD, Erin.

I first had symptoms in 5th grade but I wasn’t officially diagnosed until 7th grade. At that time, my OCD was mostly rituals of “breathing in” and “swallowing on” the letter A so I would get A’s in my classes. I also did a lot of magical thinking, for example, having lucky and unlucky colors. It soon evolved to include repetitive praying and confessing to mom thoughts, worries, and “bad” things I did, or else I believed something bad would happen. I frequently had horrible intrusive thoughts, both sexual and violent. That period of my life is fuzzy; I just remember it was extremely painful. Daily life was exhausting. I thought I was a horrible person and in constant fear that something bad was going to happen to my family.  I was too embarrassed to talk about my intrusive thoughts, so I didn’t realize that was a part of my OCD until years later.

In college and post-college, my OCD evolved into primarily mental symptoms with rumination, trying to“figuring things out” by replaying scenarios over and over in my head, a constant fear of offending people, and reassurance seeking.

What led you to become a therapist? What are your educational credentials?

I didn’t receive the proper treatment for OCD until 14 years after I was diagnosed. It was at the OCD conference in Boston where I learned that exposure and response prevention therapy was the evidence based approach to successfully treat OCD. I also learned there how common taboo intrusive thoughts were, and that was a huge relief. I decided to become a therapist to help raise OCD awareness and expand the availability of treatment.

I received my master’s in counseling psychology at the University of Saint Thomas and have attended several workshops on exposure therapy. I currently work under the supervision of Dr. Vernon Devine who has 46 years experience treating individuals with anxiety disorders while I work toward my license as a professional clinical counselor.

What services do you offer, and what is payment like?

I specialize in OCD, agoraphobia, hoarding, body dysmorphic disorder, social anxiety disorder, phobias, panic disorder, basically all forms anxiety. I use exposure and response prevention therapy and integrate mindfulness and some dialectical behavioral therapy techniques.

Due to the rising costs of health care, insurance benefits have increasingly become more complex. Self pay ensures that the client’s records and diagnoses are entirely confidential documents as I will not have to submit them to insurance or a third party payer. The content of the sessions stays between myself, the client, and Dr. Devine.

Treatment often involves appointments that need to be longer than an hour, multiple sessions a week, at-home sessions, and public exposures. Self pay allows for treatment freedom as well as the time to get to the root of the problems the client is facing. It makes treatment much more effective. Typically treatment lasts no longer than three months before going to an as-needed appointment basis.

What are the benefits of exposure therapy? How does it work?

Exposure therapy works by essentially helping you confront what you fear the most. For example with contamination OCD, I’ll have clients work on touching and interacting with whatever they believe to be contaminated. If a client has a mental obsession fearing that they are attracted to a family member, we will make a script that they are in fact attracted to that family member. Basically whatever they avoid to protect themselves from their fears, we work up to doing that by creating a hierarchy. We start with whatever trigger the client finds the least distressing and expose them to that trigger until their anxiety decreases. We then gradually move up the hierarchy until the client is ready to confront the most difficult exposures.

Can you briefly describe how you guide a patient through ERP, especially what the first couple sessions might look like?

In the first session, I get to know the client, gather some background information, and go over an assessment I have them fill out before the appointment. We go over details about their presenting symptoms and explore their triggers.  We then begin to build a hierarchy of ways to expose the client to the thoughts, images, objects, and situations that they find distressing and provoke obsessions/compulsions. ERP is no walk in the park, but it is an evidence-based approach that has shown to be incredibly effective.

Many of my blog readers are very concerned about being judged by a therapist who doesn’t truly understand OCD. What advice would you give to them?

Know that whatever intrusive thoughts or rituals you have, no matter how embarrassing, weird, or perverted you believe they are, I guarantee they are extremely common in OCD, and thousands of individuals have similar if not the same thoughts and compulsions. Everyone has intrusive thoughts– people with OCD just get them stuck in their head and distressed. Whatever you find most upsetting, OCD will latch onto it and continuously project it in your head like a song stuck on repeat.

Find a therapist who truly understands OCD. It breaks my heart when I hear about individuals who saw a therapist, tell them about sexual or violent intrusive thoughts they are experiencing, and the therapist does not recognize these symptoms as OCD. This can create further isolation, shame, and hinder the therapeutic process.

Erin Venker 2One last question: reassurance is often a compulsion for OCD sufferers. How can a therapist practice compassion without reassurance? What is your approach to this?

I use a lot of humor in treatment. I try to help clients notice when there OCD is sneaking up on them. Depending on the context and the individual, I will push the exact opposite of the reassurance they are seeking.

I have a rule of thumb that in the appropriate moment, I will only reassure once. I know you are not a pedophile, this is the one and only time I reassure you. After that, it’s all about accepting uncertainty. Well, maybe that thought does mean you want to kill someone, let’s make a script of it happening. At the same time, I validate the client that ERP is extremely difficult, and what they are doing is brave and hard work.

Thank you so much to Erin Venker for a great interview! If you are in the Twin Cities and think you could benefit from working with Erin, click here for her contact information. 

all about CBT

Some people have been asking for more details on cognitive-behavioral therapy, the incredible tool that God used to set me free from obsessive-compulsive disorder.  It is my pleasure to share with you about CBT!  Please note that I am not a mental health professional– but I did have a wildly successful experience with CBT and am a huge advocate.

This is the preferred method of treatment for OCD; specifically, it is called Exposure and Response Prevention (ERP).  Long name, but actually, it is exactly what it says!  The patient is exposed to something that triggers an obsession and then the response (the compulsion) is prevented.  This therapy actually re-wires the brain– the brain physically changes in this therapy– and it helps an OC to live with uncertainty.

CBT either works or doesn’t in 12 weeks.  My psychiatrist, national OCD expert Dr. Suck Won Kim, told me beforehand that it would be worthless to meet with a CBT therapist longer than 12 weeks and that Dr. Chris Donahue wouldn’t ask me to meet any longer than those 12 weeks.  Three months.  You can handle anything for three months, right?

The first couple weeks were most intake.  Dr. Donahue asked lots of questions to help assess what my obsessions and compulsions were, and what triggered the obsessions.  He was basically probing to find what buttons to push later: “How much would that stress you out if you couldn’t do XYZ after ABC happened?” and that sort of thing.  I knew it would all come back to “haunt” me, but I was all in.  This honestly felt like my last hope for a normal, happy life.

I took the YBOCS (Yale-Brown Obsessive-Compulsive Scale) test and found out that I was a moderate case, which surprised me.  But then again, there are some people who can’t leave their homes, can’t touch a loved one, people who wash their hands with Brillo pads and bleach.  

Dr. Donahue outlined the measurable goals of my treatment plan: a fifty-percent reduction in distress when focused on upsetting stimuli and six consecutive weeks of no avoidance or rituals.  Three months was starting to sound like a long, long time.

Then Dr. Donahue and I wrote a story together.  Well, he started it and it was my homework to finish it.  Since my obsessions were primarily focused around hell, we had to do imaginative therapy (since, obviously, there is no way to really, literally expose me to hell).  So I wrote this story about an imagined worst day ever (I mean, really bad– I go to hell in it).  If you’d like me to share with you the story, I will.

My therapist recorded this story (along with his own additions to it) digitally, and I was sent home with an 18-minute recording from the pit of hell.  My job was to listen to it four times a day– two times through, twice a day– every day and record my anxiety levels when prompted.  And I needed to do this consistently until my anxiety levels reduced by 50% from what they were the first time through.  Oh, and I couldn’t perform my compulsions either to make myself feel better.

It. Was. Awful.

I won’t lie to you, listening to that recording– that exposure– was like torture.  It was being triggered left and right and not being allowed to do anything to ease my anxiety.  Doesn’t this sound like some type of cruel and unusual punishment?  It’s what it felt like, and I honestly wanted to quit at about week 8 or 9 when my anxiety levels weren’t dropping.

I hated it.  It made me sick to my stomach, made my heart race, terrified me.  I tried to listen to the recording right away in the morning, in order to get half of my required listenings out of the way early in the day, but eventually, I couldn’t do it that way anymore– the weight of beginning my morning in such misery made it hard to get out of bed, and I had to push it all back later in the day just so that I wouldn’t dread waking up.

But something clicked around week 10 or 11.  Praise. The. Lord.  It clicked, and all of the sudden, I was in the driver’s seat again!  I controlled my OCD and not the other way around.  One day I was listening to the recording– this device of torture and grief– and I thought, This is so annoying.  And then I smiled and thought, Finally.

This, of course, is a brief description of my experience.  I could tell you so many more things– about how hard it was, about what other exposures look like for other kinds of OCs, about the tools Dr. Donahue gave me for success.  It’s all detailed in my fictionalized account of it, my novel Lights All Around, which you can read here.

It was one of the hardest things I have ever had to do– but not as hard as living for 20 OCD-riddled years without help.  I hated to go through CBT, but I loved to have gone through it.  It rescued me and those twelve weeks are a defining period of my life.  I remember being so angry and upset with my therapist, absolutely despising him and the exposures, and feeling certain that I was going to fail at this, my last shot at freedom.  I very nearly quit.

But that moment came right before everything changed.

If OCD is ruining your life, you need to undergo cognitive-behavioral therapy.  It will be hard.  It will be hell.  But it will be worthwhile.

Questions, anyone?

To read a stark account of my life before and after CBT, check out this blog post!