An Interview with Clinical Social Worker Elizabeth McIngvale
Elizabeth McIngvale, Ph.D., LCSW is the Director of McLean OCD Institute in Houston, and a Lecturer at Harvard Medical School. She specializes in obsessive compulsive disorder as well as anxiety disorders.
Tori Steffen: Hi everybody. Thank you for joining us for this installment of the Seattle Psychiatrist Interview series. I'm Tori Steffen, a research intern at Seattle Anxiety Specialists. We're a Seattle-based psychiatry, psychology, and psychotherapy practice specializing in anxiety disorders. I like to welcome with us today clinical social worker Elizabeth McIngvale. Dr. McIngvale is the director of McLean OCD Institute in Houston, and a lecturer at Harvard Medical School. Dr. McIngvale specializes in obsessive compulsive disorder as well as anxiety disorders. She founded the Peace of Mind Foundation and ocdchallenge.com, which is a free self-help website for OCD, which is live in six languages and serves nearly 4,000 individuals. So before we get started today, Dr. McIngvale, could you let us know a little bit more about yourself and what made you interested in studying OCD and anxiety disorders?
Elizabeth McIngvale: Yeah, absolutely. So I'm actually a clinical social worker. I do have my PhD, but not a clinical psychologist. And I think for me, I really entered the field because of lived experience. I've lived with OCD since I was a young adolescent and went through intensive treatment that saved and changed my life. I then really led into advocacy and started doing a lot of advocacy work around talking and giving back in different ways, which led me into this field. So I ended up doing my undergrad master's and PhD in social work and really was just, and continue to be just really excited to be able to do for others what people did for me.
Tori Steffen: Awesome. Yeah. Thank you for sharing that. Well, getting down to the basics around our topic, could you explain for us what exposure and response prevention, or ERP, is?
Elizabeth McIngvale: Yeah. It's actually exactly how it sounds. So it's an exposure with response prevention. So what we mean by that is that from an OCD perspective, individuals with OCD have intrusive thoughts, triggers, things that scare them, and they engage in a lot of compulsive behaviors. And these compulsions or rituals are done to try to alleviate the distress caused from the obsessions. So when we talk about ERP, what we're encouraging patients to do is an exposure. So they face their fear, maybe they touch a doorknob that feels contaminated to them or they do some other exposure, but we're going to ask them to engage in response prevention. So we want them to prevent the response they usually do. So we want them to prevent rituals. So if you typically would wash your hands after you touch something contaminated, we want you to touch that doorknob and not wash your hands. So response prevention is that not ritualizing part. That's really important.
Tori Steffen: Got you. Okay. That makes sense. Is exposure therapy similar to ERP in any way or how might they differ from one another?
Elizabeth McIngvale: Yeah. It's a great question. Obviously there's a ton of overlap, and it's very similar in the sense that you are facing your fears, you're doing exposures. We see exposure therapy be really useful in trauma work, in social anxiety work, for phobias, you name it. But what we know is that individuals with OCD, if they're doing exposures, but they're also ritualizing, they're reinforcing their OCD. So for OCD, the big difference is that it's still exposure work, which is very similar, but we have to no longer do the ritual. If we follow the exposure with a ritual, we reinforce OCD versus being able to reinforce treatment and treatment outcomes.
Tori Steffen: Okay. Awesome. Yeah, that definitely makes sense. And what are the main goals of ERP as a treatment? Are there any specific things that a clinician expects to see?
Elizabeth McIngvale: Yeah. I mean, obviously we want to see a decrease in the anxiety in the disability and in the hold that someone's OCD has on their life. But across the board, the bigger pictures, we really want to start to change individual's relationship with anxiety and their relationship with their OCD. So we want to be able to teach them that anxiety and OCD isn't dangerous. It feels really dangerous because of how we respond to it, and that actually if we change the way we respond, we get to change the power that it has. So I think the bigger goal of ERP is that individuals understand how to change their relationship with anxiety, how to change their relationship or the way they feed their OCD so that this treatment can not just apply to any future OCD or anxiety triggers, but also to life as well.
When we think about fear in general, we either feed our fear or we fight our fear, and sometimes we think that what we're doing makes sense because it gives us short-term relief, but it actually just makes the fear bigger. If my daughter is afraid of a dinosaur in a room and I get rid of the dinosaur so I don't have to deal with her anxiety, I'm actually reinforcing that dinosaur's scary and that you aren't capable of being around it and being calm. Where instead, if I do exposures, I teach her to lean in and to not be afraid of it and to be with it, she can change her relationship with fear. She starts to realize that, "When I'm scared I don't have to run from it. I don't have to ritualize to make it go away. In fact, I can approach it," and that fear will go away.
Tori Steffen: Okay. Awesome. Yeah. It sounds like almost a training of coping mechanisms in a way.
Elizabeth McIngvale: It is a little bit. I think the thing we want to be careful about when we think about coping mechanisms is a coping mechanism often makes us think that we're going to give you a tool to make you feel better. Actually, what we're really doing is trying to allow you to change your relationship with distress. So when you have distress, we don't want to just get rid of it or make you feel better, we want you to learn that you can sit through it and you don't have to respond to it, and it doesn't have to be dangerous.
Tori Steffen: Okay, great. Thank you for explaining that. So when might a clinician know that ERP is the right treatment option for a client?
Elizabeth McIngvale: So ERP should always be the first line treatment for OCD, it is the most evidence-based and has the most research to support it. So we always want to start with exposure and response prevention. When we're treating a patient with OCD, of course, the most common treatment is a combination of ERP and medication, and that's often the route that most individuals will go, but we definitely always want to start there. We never want to start with other modalities that are not as proven because I mean, we want to start with what we know has the best chance of success and the best chance of helping our patients. What I will say is that it's really important if you're an outpatient clinician or a clinician who specializes in ERP, if a patient is not making progress, it's really important to sit back and understand why instead of to just keep trying the same thing we're doing.
So some of the reasons why, it could be that a patient... It appears they're trying to do ERP, but maybe they're actually holding on, maybe they are still ritualizing, maybe they're doing mental rituals or avoidance behaviors, and they're still feeding OCD or anxiety somehow. Maybe they need a higher level of care, maybe their OCD is so severe, so debilitating that they're not able to do ERP on an outpatient basis in the sense that if they just come and do it for 45 minutes with you every week, but they go home and they're ritualizing, we're not going to see progress there either. So they may need some support, maybe they need a more intensive treatment program. So lots of things to think about when we're doing ERP with our patients as well.
Tori Steffen: Okay. Awesome. Could you provide an example for us of an ERP treatment for a client that has a specific phobia, maybe fear of dogs?
Elizabeth McIngvale: I mean, I think that typically for phobias, we're going to do more exposure therapy than ERP, so it's really going to be getting them to approach that dog. So we might start with looking at pictures, watching videos, and eventually we want to get them working up to being able to hug their family dog, be with their dog, live by their values. I want them to tell me why being able to be close to dogs is important to them, or the reasons that if they don't do it will impact their life in a negative way. We want to really push on those values. I guess if it was an OCD fear, so for example, if the dog is contaminated, we want to do the exposure of getting them close to touching the dog and the response prevention of not washing their hands or not changing their clothes or not engaging in cleaning rituals that they may normally do.
Tori Steffen: Got you. So it's important for them to understand that even if the dog is contaminated, it's not going to kill them or give them a disease. Would you say that that's true?
Elizabeth McIngvale: Yeah. So it feels like that's what you'd want to tell the patient. You'd want to give them that reassurance, but actually we want to lean more into the fact that like, hey, people touch dogs all the time and there's value behind it. It's more important for us to focus on doing an exposure and touching our dog, but we don't want to reinforce that, I'm safe. It's okay. Nothing's going to happen. People don't get sick because the reality is that people could get sick. I can't guarantee if you touch a dog, you're not going to get sick. I also can't guarantee that if you touch a dog, you will get sick. So we want to focus less on confirming or denying our certain fears and more on living by our values and not responding to our fears, letting that fear be there that, well, what if I get sick? Being able to acknowledge that and not respond to it. So not try to make sure you don't.
Tori Steffen: Okay. Awesome. Thank you for clarifying that. What does the process of habituation look like in therapy? How is it usually conducted?
Elizabeth McIngvale: Yeah. So habituation is a term we don't really use as much anymore in ERP. Habituation traditionally is the thought process that when you face your fear, when you do something challenging, while it will be triggering, eventually your anxiety will subside, you will habituate. It's like you go into a locker room that smells, if you choose not to leave, eventually you'll get used to the smell. The smell doesn't go away, but you habituate to the smell that you were experiencing. And that's really the thought process behind habituation, especially for OCD, is that if you face your fear and don't do anything about it, eventually your anxiety will drop and you'll see that you didn't need to do that ritual to feel better.
We have transitioned in recent years to what we call inhibitory learning, and the point of inhibitory learning is for us to recognize two things. The number one thing is that not everybody habituates the same, and so we don't want to give you the thought process of like, you're going to just sit in habituate, because some people, it takes a couple of hours or their anxiety lingers, and I want them to be able to go do what they want to do and be able to live their life, not sit there and feel like I have to wait to habituate first. But the second, which is more important, is what is the message of habituation versus what we call inhibitory learning? Habituation is an old school model where you might sit and touch something that's contaminated if this is contaminated, and the thought process was you just sit there and you sit with the distress until it goes away.
The problem with that is that what we're teaching you is that you can't move on until you feel better, and we're putting a lot of emphasis on the anxiety and distress. On like okay, the success measure is if you start to feel better, that means that you can face this habituate. What inhibitory learning says and what we're learn, what we learn and really want to practice is that actually you can face challenging things. You can lean in all the way and you can still move on while you're experiencing some distress.
So we want the emphasis to be much less on the distress because again, we don't want you to believe the distress is dangerous, and we don't want to send that message that the distress is really important. It's actually not that important, and it will subside if you don't feed it. But what we don't want to do is sit and wait. We want to make sure that we're emphasizing the distress less, and we're more living by our values. So you're touching this contaminated thing. You're still slowing down to lean in to feel the distress, to think about the fear and choosing to move on and go do other things even if the distress is still lingering.
Tori Steffen: Got you. Okay. That definitely makes sense. What can a client expect to experience when ERP is working correctly for them?
Elizabeth McIngvale: I mean, alleviation across the board, they should start to see their intrusive thoughts come with less frequency and with less intensity, and they should start to feel like they're able to get back to their life and functioning the way they want to. They should be able to envision living by their values and OCD not having a grip. My biggest piece is that I want all my patients to be at a place where OCD no longer makes any decisions for them or their life, and instead they're making those decisions for themselves.
Tori Steffen: Okay. Awesome. How can a clinician tailor ERP for a client? So for example, how might ERP differ for a client with OCD versus panic disorder?
Elizabeth McIngvale: Yeah. So again, remember with panic disorder, you're going to be doing more exposure therapy because there's not going to necessarily be as many rituals. There will be avoidance. So we're going to get patients to avoid less, start living their life, and we're going to encourage them to engage in exposure therapy. We may also be doing some CBT skills with panic disorder because there may also be a lot of distorted thinking, or maybe there is some ruminating after certain events that we want to help break that cycle. But there's not as many outward rituals with panic disorder, and so the emphasis is much more on exposure compared to OCD. It's going to be much more focused on exposures and preventing those rituals or responses.
Tori Steffen: Okay. Awesome. How can a clinician train a client to continue ERP or exposure therapy on their own, even outside of therapy?
Elizabeth McIngvale: Yeah. This is a great question, and really this is about that bigger piece we talked about early on is what do you want patients to get out of ERP? What we don't want them to get is just that they succeeded because their symptoms went down. While that feels like that's successful, what's really successful is that their symptoms go down and they understand the why, and that learning actually took place. So the goal with ERP treatment is that patients understand across the board that they've truly changed their relationship, their responses to anxiety and to OCD.
And if they've done that, then they get to do what I call ERP as a lifestyle where all the time you're having opportunities to face anxiety, to feel it, to lean in, versus to respond to it in a way that you run from it, or you try to get rid of it with a ritual. So ERP should be something that it shouldn't have to feel like sometimes when you're first stepping down from treatment, you need to do more dedicated ERP, but eventually it should just come innate. It should be natural that I'm responding to my life, to my values, not to my OCD, which means I'm doing active ERP all the time. But it shouldn't have to feel like it's active ERP, if that makes sense.
Tori Steffen: Okay. Yeah, that definitely makes sense. Is it ever possible for ERP not to be effective?
Elizabeth McIngvale: Absolutely. I think that we definitely see ERP not to be effective if there's a lot of comorbid conditions. I think for me, one of the big things I want to know is if ERP isn't effective, why? We want to understand the why, and oftentimes it's because the patient's not ready or able to do ERP yet. So just because ERP is not effective right now, it doesn't mean it won't be in the future. For example, if a patient is dealing with a lot of distress intolerance difficulties, they're struggling to emotionally regulate, they may need DBT skills first so that they can do ERP. ERP probably wouldn't work right then for them. If their emotion regulation skills were really poor, their insights really poor, but it may be able to in the future.
Tori Steffen: Okay. That's great to know. How might a clinician move forward? Let's say ERP isn't working for the client, and yeah, that definitely makes sense with DBT. Is there any other ways that you might move forward in that scenario?
Elizabeth McIngvale: Yeah. I mean, I think the biggest thing when ERP isn't working is to make sure that your patient's ready for ERP. So we need to slow down. We need to think about motivational interviewing, we need to think about rapport building. We need to make sure that they understand why we're asking them to do this, that they're bought into it. No patient should be doing ERP because we're telling them to, they should be doing ERP because they see the value in it and they want to be doing it.
Tori Steffen: Okay. Awesome. Well, do you have any final words of advice for us, Dr. McIngvale, or anything else you'd like to share with the listeners today?
Elizabeth McIngvale: I think the biggest thing is just to remember that help and hope are always available, and what I want to make sure people know is that there is evidence-based treatment for any diagnosis you're going through. Make sure you figure out what that is and that you find somebody who has specialty training and background in that area.
Tori Steffen: Awesome. Great advice.
Elizabeth McIngvale: Okay. And for OCD resources, please always check out iocdf.org, which is an incredible nonprofit for OCD and host an annual conference, and is a great way to continue to get connected with the community.
Tori Steffen: Awesome. Well, thanks so much for sharing your knowledge with us today, Dr. McIngvale. It was great speaking with you.
Elizabeth McIngvale: You as well. Thank you.
Tori Steffen: Thank you guys, and thanks everybody for tuning in.
Please note: The views expressed by the interviewee are for educational and informational purposes only, are not meant to diagnose or treat any condition, and do not necessarily reflect the views of Seattle Anxiety Specialists, PLLC.
Editor: Jennifer (Ghahari) Smith, Ph.D.