OCD TREATMENT OPTIONS: Do I need a higher level of care? | Ep. 326

OCD TREATMENT OPTIONS Today, we have Elizabeth McIngvale and we are talking all about different OCD treatment options. Elizabeth (Liz) McIngvale is the Director of the McLean OCDI Houston . She has an active clinical and research and leadership role there. McLean OCDI is a treatment center for people with OCD and she talks extensively about different OCD treatment options in this episode. She's the perfect one to talk to in this episode about knowing when you need a higher level of care, particularly related to OCD. In this episode, we walk through the different levels of care from self-help all the way through to inpatient facilities. Elizabeth spoke so beautifully about how to know when you're ready for the next step of care, what to look out for, what you should be interested in, and questions you should ask. This is such an important episode. I'm actually blown away that I haven't addressed it yet, but I'm so grateful we got to talk about it today. Elizabeth McIngvale is also a lecturer at Harvard Medical School. She treats obsessive-compulsive disorders, anxiety disorders. She's got a special interest in mental health stigma and access to mental health care. It was actually such an educational episode and I felt like it actually made me a better supervisor to my staff and a better educator as well. You're going to love this episode if you're really wanting to understand and take the stigma out of increasing your care if that's something that you need. That being said, I'm going to let you listen to Elizabeth's amazing words, and I hope you enjoy this episode just as much as I did. Have a great day, everybody. Kimberley Quinlan: Well, welcome, Liz McIngvale . I'm so excited to have you on for two reasons. Number one, I really want to talk about giving people information about OCD treatment options, but I also understand that you can also bring in a personal experience here. Anytime, someone can share their personal experience, just lights me up. So thank you for being here. Elizabeth McIngvale: Thank you for having me. I'm so excited to be here and yeah, I hope that both my personal but also professional kind of background in this arena might help guide. Some individuals who are kind of wondering what treatment do they need right now and and what does treatment for them look like Kimberley Quinlan: Wonderful. Do you want to share a little bit about your history with OCD and your story as much as you want to share? Elizabeth McIngvale: For sure. Yeah, I'll try to not take up too much time but you know, basically, I grew up here in Houston, Texas, where I'm from, and was diagnosed with OCD right around 12. I started showing lots of different symptoms prior on and off, but nothing that was disruptive nothing. That really would have warranted a diagnosis. I would do things like track the weather, or every time I read a book, I would start at page one because I didn't like the feeling if I picked up in between and things like that… Elizabeth McIngvale: but nothing was really out of the norm normal in the sense that I was still doing okay. And academically you know, Relationship-wise and I was functioning well until I wasn't, you know, until my intrusive thoughts, got louder and the disruption became more and more severe. Here in Houston, we have the largest medical center in the world and we are known for our healthcare and so you would think access to good care would be really accessible, but unfortunately, it just wasn't and granted, this was a long time ago, almost 20 years ago but we really started searching for treatment here in Houston and, you know, I was lucky enough that pretty early on I got a diagnosis and for most of us in the OCD world, we know that that's rare for it to happen that soon. So that was great. That was a huge blessing for me, however we couldn't find good treatment. Every provider would say things like we've never seen a case like this. We don't know how to treat this and there's not help available. You guys should assume that Liz live in a mental health hospital, the rest of her life. And so my parents were just really struggling with What do I do and How do I help my child. And so they kept researching and kept trying to figure it out and actually they got lucky enough that they stumbled across the newspaper article and in that newspaper article talked about an inpatient treatment center at the time which was called the Meninger Clinic and how they had an OCD program. There was a little bitty excerpt and immediately my dad, called my mom, they ended up calling Meninger and learning more and I ended up going to the Meninger clinic when I was 15. I went three days after my 15th birthday, I'll never forget and I talk about this a lot because my treatment stay at Meninger was the first step to my life being changed. It was the first step to me getting appropriate treatment. It didn't cure me, you know, I want to be honest about that. I think sometimes we think, okay, we go do that. We either like get cured or We don't. And, for those of us who live with OCD, we understand that management of our illnesses different than a cure, right? It was a lot of work, but it was also the beginning of a journey where I had to learn to do my own treatment and I had to learn to become my own therapist. And as much as the treatment was super successful for me, I was there for three months and my life changed. I went from being suicidal being hopeless, and not being able to function at all six to eight hour showers and completely, homebound completely riddled by rituals, to being a kid who could fully function. I was able to go back to school. Take five minute showers, do things I never thought I could do again. At the same time, I didn't realize that I had to still take ownership of my illness, I think I thought Oh like the ownership is, I did treatment and that's what it meant. Not that I needed to keep engaging in treatment. And I talk about that because I did relapse later, I ended up going… I ended up doing some outpatient in between and then back to impatient again. And for me, I had to kind of learn what level of care works for me? What does that look like? And how do I manage my illness? And to this day, I still go to outpatient therapy. It's still a big part of my life. Am I actively doing OCD work every week? No I'm doing other stuff right? Family system and boundary setting and things that are important in my life that are tough. But it's been a journey even for myself personally, to know what level of care do I need and at what point. And I think what's really interesting is that when I was 15 I would have told you I'm not going to treatment. My parents had to take me involuntarily and it was a pretty awful day the day they took me to treatment. And, you know, I say this because a lot of times when people hear my story they think Oh, well, y'all did everything right and like, it was just this, like, beautiful path to recovery. That's like, no. It was really messy and it is messy and that's okay. There is no perfect way for us to get treatment in a way that can change our life. And so I really want us to think more about the outcome and what treatment might mean to us versus being super close-minded about the process,… 00:05:00 Kimberley Quinlan: Right. Elizabeth McIngvale: because I think a lot of times we have so much anxiety around I want to go to intensive treatment. I don't want to leave my life. I don't want to put things on hold I don't want to go to this hospital like setting if that's where I'm going and really, it's not about that. It's about what might it give us in the long run, right? Kimberley Quinlan: Right. Elizabeth McIngvale: And just that chance at freedom that maybe outpatient care can no longer do. Kimberley Quinlan: Right? So for the folks who are new here and if just new to us let's sort of just because I feel like I really want to cover this as as much as we can. When you went to Meninger what was the correct OCD treatment in which you received like was it,… Elizabeth McIngvale: Yeah. Totally. Kimberley Quinlan: can you kind of give us a little bit of a view of what that looks like? Elizabeth McIngvale: Yeah. So before Meninger I had gone to outpatient providers and… Elizabeth McIngvale: I remember playing the board game life with a therapist once and I crossed the bridge and I remember her saying Liz, how does that feel? And I was like Well I don't know. Like How does it feel to you? Like what? I remember going to my mom and I was young, right? I was adolescent. I said Mom like this isn't working like we're playing the board game life, I'm not getting better, like this is not therapy and my mom was just like, well, I don't know, she didn't know, she didn't know what she should be doing or not. And so I got to Meninger and I remember there were three things that really put things in perspective for me upon arriving. The first was I met someone else like myself. I met a young girl named Amy who struggled with an eating disorder and OCD and I remember I was crying. I was vomiting. I was so sick. That was so anxious about being there and all she said to me is it's okay. I cried too. And it was the first time in my life. I met someone else like me. And for those of you who know, you know, the the value I believe advocacy has in the OCD world is because we need to feel part of a community, even when we're struggling, And so I got that but it was the first time in my life. I remember, I sat down with my therapists in this conference room and you know, I didn't believe in therapy, candidly. I had gotten really bad therapy for a long time and I just continued to get worse. So I didn't think therapy could help me. I didn't think I could get better and I really was starting to accept that I would just live a life with bad OCD forever and then I would just live in this basically, in the state of misery. And I remember I sat down and for the first time My provider starts asking me all these questions, and he doesn't seem scared. He's like, Oh yeah, no problem. Okay, tell me about this. Tell me about that. And there was this like, not egotistical like this, very humble confidence that. Oh, yeah. Like I know how to treat you, and I was just like, what? And I remember, He said, Yeah, we're gonna do Exposure & Response Prevention (ERP ) I've done this before. You're not the worst case. I've seen, you know, I know how to treat this. I've done all in, It was the first time I realized, Oh my gosh, someone actually knows how to help me. Elizabeth McIngvale: And so my entire treatment was based on exposure and response prevention and you know I think ERPs come a long way as somebody who now works in this field and runs a program doing, you know, runs at the same program. We don't do ERP the same way we did when I did it. Right. When I did ERP, it was an older school model. It was a very habituation model. I remember holding contaminated sweaters and just sitting there for an hour or two, right? We don't do that anymore, but there's something about the basis, right? The core of the treatment hasn't changed and it's it's what changed my life and it's it's really important that I will say, I can't imagine what it had been like if I would have gone to an impatient or a residential setting that wasn't OCD specific and that wasn't doing evidence-based care. I would have believed in treatment even last and I would have been even more helpless. Kimberley Quinlan: Yeah, there is so much beauty to being with someone who's like, Oh yeah, I've had a worst case than you like. I've had so many clients say like that is the best thing anyone has ever said to me. Elizabeth McIngvale: Yeah. Yeah. Like okay not like Oh like I mean literally providers would say to me in Houston like we've never seen a case of severe. We don't know how to help you and it's like, Well what? So like What do I do? Kimberley Quinlan: Right. Elizabeth McIngvale: You know, Can you try and they're like, we don't know, we don't know how to try. Kimberley Quinlan: Right, right? I'm so grateful that you had that experience. This amazing. So, Let's sort of fast forward to now. You of course are an OCD specialist, we know this an amazing one. I first want to look at the term outpatient For some people, they don't know what that means. So what does OCD outpatient treatment look like? Elizabeth McIngvale: Yeah. OCD TREATMENT ONLINE Kimberley Quinlan: And would you also speak to now since covid? We also have like an online version of that so you want to elaborate on OCD treatment online? Elizabeth McIngvale: Yeah, there's so many. So actually, let's have you start first by describing self-help because I think it's. So I think it's really important When we think about levels of care to think about the continuum, right? I look at it as like,… Kimberley Quinlan: Right. Yep. OCD SELF HELP Elizabeth McIngvale: there's self-help options, there's outpatient options and then there's intensive option. Elizabeth McIngvale: Yeah. 00:10:00 Kimberley Quinlan: Beautiful, yeah. Like thats the epitome of me, like even with this podcast, right? How can we provide free or not one one one treat metn for people or in the case of CBT School, how can we help you to do it on your own? RIght, so there are sort of self lead courses or we have the self-compassion workbook for OCD , which is ultimately me as a clinician saying, If I was with a client, this is the steps I would take. So, that's the first step and we offer that all the time. And and I think I don't really actually think we've got that much research on it yet. I think we're in the early stages of that, but that is being really helpful for people who sort of want to become educated, want to understand what's going on and they feel motivated and able to do that on their own. So that's that's the self-help model, then what would we use? Elizabeth McIngvale: Well in one of the things, I want to back up for a second to just and I know you've done so many podcasts on this but for those who've skipped over this one, right, what's really most important is that you're engaging in evidence-based treatment and what we mean by that is that we want to make sure you're getting access to treatment that's been researched and that we know works for OCD. And so there's self-help that is not evidence-based for OCD and they're self-help that is evidence-based for OCD. And one of the beauties of self-help is that you don't have to look at it as a soul intervention, right? Do it while you can, you can do these workbooks, you can do these self-help, you know, in different modalities while you're going to an outpatient therapist. And then one of the things that's really beautiful is that if you live in an area where there isn't OCD providers or OCD specialists your clinicians can actually also use it as a guiding tool in treatment, right? And so again it's allows there to be this rubric of good treatment, all right? This kind of like guide book to,… Kimberley Quinlan: Yeah. Elizabeth McIngvale: you know, or handbook to say. And so Always think of that as kind of our least, invasive level of care and… Kimberley Quinlan: Right. Elizabeth McIngvale: it's a level of care. That's my goal that everyone ends up at right that you're able to get to a place… Kimberley Quinlan: Yeah. Elizabeth McIngvale: where like, yes, you're still actively engaged in a treatment community whether that's through self-help workbooks or podcasts or different ways that you connect because that's really helpful, but that you may not need one-to-one anymore, right? I go to one-to-one therapy because it's important for my soul. I don't need it and… Kimberley Quinlan: Right. Elizabeth McIngvale: that's very different, right? I'm at a place where I can engage the tools inependently, using some resources with and when I need them. And so then the next level is outpatient therapy and traditional outpatient therapy would be oftentimes once a week 45 to 50 minutes session with an OCD specialist in person, one to one in the past three years, that's totally shifted right actually, I would say more commonly it's virtual than it is in person and you know, there's pros and cons. I think most of us Most of us still think in person is better, right? That just if it's feasible, But from a scheduling perspective and feasibilities perspective online is so much easier, right? So most of us, myself included, I do my therapy online because it's, I don't have to schedule the time to drive and get to my clinician and drive back. And so, that's really important. The second piece that's really important to think about is, I would rather you 100 times over be doing virtual sessions with someone who specializes in OCD and knows how to treat OCD then do in person with someone who doesn't. Elizabeth McIngvale: Right, so really, when we think about therapy and interventions, we want to make sure and this is important because a lot of times people will say, Oh well I've tried out patient therapy, It doesn't work for me but they haven't necessarily tried it with an OCD specialist and they haven't been appropriate evidence-based treatment and really we want you to do that first before you start thinking about next level of care or you know some people will want to do like a medication trial and it's like Well you don't get in the research study in a trial if we haven't tried evidence based stuff first, right? So that's really important. With that being said, outpatient can be a continuum, Some outpatient providers can offer two to three sessions a week for 45 minutes, you know? So they can do kind of what we would call like intensive outpatient and that they may make in their own program, but traditionally most clinicians who carry an outpatient case. Load would see someone once a week for 45 minutes session. Kimberley Quinlan: Yeah and I think that's for our center as well once maybe twice if there's more of a crisis but that's the level of care that we that's the kind of clients that we have and that's the level of care that we do provide. So I think and I will say going back to your online is quite a few of the people who take ERP school have therapists, right? It's like 55% of the people who take ERP School are therapist. So therapists are, you know, even though that might be their specialty, Let's say they're the only person in their neighborhood. That is what they're doing, right? They're just doing the best, they can learning whatever skills they can. So that's very positive in my mind. Elizabeth McIngvale: That's right. Yeah, and want people to have a good sound background in ERP but have to mean that they only treat OCD,… Kimberley Quinlan: Right. Elizabeth McIngvale: you know, and I think it's important that you can get really great progress right on an outpatient basis with someone who's knowledgeable and ERP. If you are at a place where outpatient level of care is warranted and important to think about, 00:15:00 Kimberley Quinlan: Right, and that brings me to my next question, how would someone know if they needed a higher level of care for OCD? What would be some symptoms or signs that would be showing up for them? Elizabeth McIngvale: And so the first thing I want you to think about is, Are you seeing somebody who does evidence-based care and are you not getting better, right? That's really the first like thing we need to look at is, Are you going to therapy and have you given in a good therapeutic dose, right? So we're talking, you know, at least a couple months. You don't expect that in two sessions, right? We're like better. Because often it may get worse than better. But at least, you know, maybe a couple weeks to a month or two. Are you on your own saying, I'm not seeing the results that I want, right? That this is, this is not getting me where I want to be. The second question is what level of functioning has your OCD impacted? Elizabeth McIngvale: Traditionally most of our patients in residential care are not working full-time. So their OCD is really impacting their functioning on a level that's disruptive so whether that's either their family life or their job or their school or their career, right? Something is pretty significantly disrupted from their OCD. That once a week may not be enough, right? It again the level of disruption is a little bit too high and then the third thing to really think about is what your provider telling you A good OCD clinician should not be trying to make some sort of a program for you that they don't typically do to keep you on their caseload. Kimberley Quinlan: Right. OCD INTENSIVE TREATMENT Elizabeth McIngvale: They should willing to say to you, You know I think I think you need more right now. And this is what more might look like. And the reality is that you're going to get to go back to them, right? As long as they're doing good ERP and evidence based care, right? You're gonna be encouragedto go back to that outpatient provider but it's about stepping up the level of intensity, right? If we have a medical diagnosis and we're going to our doctor but it starts to warrant the level of hospitalization or certain you know more intensive treatment, we don't want our outpatient doctor to keep seeing us in their private practice, right? We want them to send us to the hospital so that it can get managed and we can get more intensive treatment until we can return back to an outpatient level of management. We cannot treat the brain differently. Elizabeth McIngvale: You know, and I hear people all the time. Well Liz, you know, I don't really want to go to treatment for four six weeks and my answer is like, well, what's 4 6? 12 18. However, many weeks you're at a treatment center if it gives you the rest of your life. Kimberley Quinlan: Right. Elizabeth McIngvale: Right? When we are talking about meeting this level of care, the disruption is not minimal the disruption is significant, right? We know that for patients with OCD, OCD impacts all aspects of your quality of life, right? All facets of it. I'm looking at our data yesterday and all like our 2022 outcomes data. We see significant statistically, significant decrease in OCD scores in phq-9. Kimberley Quinlan: Right. Elizabeth McIngvale: But then also in disability scores, right? Because we want you to be able to get back to functioning and get back to the life, you love, or you deserve, or you're excited about that OCD is taking away from you and so, I always want, I always want you to think about that and often with that means is that you typically can't do the homework, you're being assigned,… Kimberley Quinlan: Yeah. Elizabeth McIngvale: you know, being assigned homework, and you're trying to do it, you're trying to engage in it, but you're struggling and you find that you're you're not able to do that homework independently. And so often times patients in our level of care, need extra support. They need support in the evenings. They need support outside of their behavioral therapy sessions to be able to do this ERP They need extra coaching, they need extra support. They need extra motivation. Kimberley Quinlan: Right. And and recently, we had Micah Howe on the podcast. I was sharing with you before and he was really saying… He said, I went to inpatient thinking that it would be like a new kind of therapy and he's like, it was actually good to see, it's the same therapy, but more, right? Like just so much more. Elizabeth McIngvale: That's right. Yeah, if you're with a good therapist, right? It's same, if you're with someone who's doing evidence-based care, it's the same therapy but more and maybe maybe it's implemented a little bit differently, right? I do believe that we use some different language. We try to get things to stick in different ways, right? That sort of thing, but the model of treatment shouldn't change. OCD INPATIENT TREATMENT Kimberley Quinlan: Okay, so this is all beautiful and I think it all of those points that you made are so important. The homework piece the therapist feeling like that's what they're recommendation is. What would be the next step up from outpatient? OCD treatment, in your opinion? Elizabeth McIngvale: Yeah. So you know I can't speak for all the programs but what I can tell you is that here at the OCD Institute in Houston , Right? Houston Ocdi. We really focus on a super detailed admission process. And so what I mean by that is Kim,… 00:20:00 Elizabeth McIngvale: if you call tomorrow and said Hey I have sever OCD, I need to come to your program. We don't say great, here's our next opening, that's not how it works at all. So for us we require a provider referral form a family referral form. You have to complete intake forms and then we do a one hour zoom session with you And during that zoom session we want to gather information. We want to understand your current symptoms. We want to make sure two things A: You're a good fit for our program and B: that we think this level of cares appropriate for you, you know, just because sometimes people have really bad OCD but they're actually not right yet for this level here. I run my program with this super strong whatever we want to call it…but deep rooted ethical means because it's happened to me in different ways and I'll never do it is I want to make sure that if someone is coming here and using certain resources that aren't you know, They run out. I want to make sure they're having the best chance of Elizabeth McIngvale: Managing their symptoms being able to return and live return to their life or live their life. And so, what I mean by that is that I don't take a patient if they want to come here, but we don't think they're good fit and ethically, I'm never gonna do that, right? I want you to get the right treatment and go to the right providers and the same thing happens when you come here. I think a lot of times people think, Oh, if I go to intensive treatment, I just, you know, they're gonna take my money and hopefully I get better. Absolutely not. You should run from a program that you feel like that programs should be reassessing every week. We have team meeting every day, we have rounds and we're talking about, Is this the right fit? Are we helping move the needle? Is the patient getting better? And so just because you start, somewhere, doesn't always mean you're gonna end somewhere. Sometimes we learn a lot about a patient. And example might be You come here with strong with with really high level OCD. But as you start doing intensive, work we realize. Wow you you're really struggling with emotion regulation and we actually think you need to go get some DBT work first before you're going to be able to effectively engage in ERP. And so we may encourage a patient to discharge,… Elizabeth McIngvale: go do DBT and come back to us so that there's a chance at us being successful. I never want to patient to stay in my level of care and not be successful because it wasn't the right time or they needed to do something else first because then guess what they think treatment doesn't work for them and they think they can't get better when that's not the case. I talked about this with John Abramowitz the other day on a webinar with Chris Johnson and then we were talking about ERP and I said Guys for all intents and purposes there's years if not decades a decade in my life where I could have said to you ERP doesn't work for me. But it's not that ERP didn't work for me. Kimberley Quinlan: Mmm. Elizabeth McIngvale: It's that I wasn't accepting ERP and I wasn't engaging in ERP. I was doing it with one foot in one foot out. And the good news with intensive treatment is, we're going to try to help you get both feet in, right? We're gonna try to increase your motivation, increase your willingness, and we can support you 24 hours a day in that process, which is what outpatient therapy cannot do. An outpatient therapist does not have the capacity to offer that level of support… Elizabeth McIngvale: where we can and we do. At the same time, If we're trying and you're not able to do that right now, we're not going to keep trying the same thing. We're not gonna keep saying Well let's just keep doing ERP because guess what ERP isn't gonna work for you right now, but it's not that ERP doesn't work. It's because we need to get you ready to do ERP even at an intensive level. And so we should be thinking about that as well. And so my point is that it's not a one size fits all model. And if you're looking for intensive or residential programs, be cautious of that, be cautious of programs that, you know, require you to stay a certain amount of time and take all your money up front and they're not going to, you know, customize a plan, you know, that sort of thing. Kimberley Quinlan: Mmm. I love that. I love that. So, just for the sake of people understanding and I actually will even admit, like, I really want to know this too because I've only ever been an outpatient provider. I've never been an inpatient or a residential provider. So could you share Maybe the differences between OCD intensive, outpatient therapy, right? With OCD inpatient treatment or residential treatment. What, what would the day look like? And how would that be different for the person with OCD? Elizabeth McIngvale: Yeah, it's a great question and let's actually walk through. There's a couple levels of care, so there's IOP, which is intensive outpatient, which is often three to five hours a day. Three to five days a week. There's PHP, which is partial hospitalization, which is often five days a week about eight hours a day. And then there's residential level of care, which is 24 hours, a day, 7 days a week. And then there's inpatient level of care, which is also 24 hours a day, seven days a week, but impatient is a little bit different than like what we have here at the Houston OCDI where we're residential. Inpatient can take patients with a higher level of acuity. So impatient is often a locked unit. That's a hospital setting. So they may be able to take patients that are active safety risk, you know, harm of hurting themselves that sort of thing, where residential program like ours, we don't, we don't accept those patients because we can't maintain that level of acuity for them. We are not a facility that can help keep patients safe. And what I mean by that is that while our program operates 24 hours a day. We are a non-locked unit. We have a full kitchen, we've got washer dryers, we get for all intents and purposes, like You're living in a beautiful residential home and you have access to knives, you can leave whenever you want. You can go off site, you can go to the Astros game if you're here in Houston. And we want you to do that. Actually, we want you to start to reintegrate into life, while you're in treatment with us. 00:25:00 Elizabeth McIngvale: And so, the reality is that, we need patients to be at a certain level of acuity right? So they have to be safe, and they have to not be a risk or harm to themselves for us to feel comfortable that they can engage in our level of care safely. And so, the difference between let's say IOP is that often times, we're talking about three to five hours a day, three days a week and so you're doing intensive sessions together, right? Imagine you're going to your therapist and for three hours a day, you're doing some, you know, individual or even group stuff, but you're working together, you're doing exposures and you're getting three hours of support versus 45 minutes. Elizabeth McIngvale: Residential however, is 24 hours a day. And so, for our residential patients, there's programming from 8:45 to 4 pm Monday through Friday, 8:45 to 3 pm on weekends. But there's residential counselors here 24 hours a day, which means that when we do outings with our patients, Wednesday and Saturday night our RCs are going with you. They're encouraging you. They're helping you. They're supporting you. Because for all all of our patients actually with OCD, there's exposures built into outings you know, to going off, site to going and doing enjoyable things. And so you have that support 24 hours. If you need support in the shower, you have that support. If you need support cooking a meal, you have that support doing your laundry, you have that support in a residential setting. So really, if you need extra support around activities of daily living, we want you to be thinking about a residential level of care, compared to more of an outpatient level of care. Even if it's intensive outpatient or PHP, you're gonna go home in the evenings and you're gonna be expected to be able to engage in those activities on your own. Kimberley Quinlan: Right. Right. So just because I'm thinking of the listeners and I'm wondering if they're wondering, Does that mean that when they come into your Houston residential program that, let's say, if they're someone who showers for, let's say, two or three hours, that you're immediately, your therapist on staff are going to be cutting them dance for like down right away. Or What does that look like? Is it gradual? Like How would that like, That's just an example… Elizabeth McIngvale: Oh yeah. Kimberley Quinlan: But what would that look like in the residential format? Elizabeth McIngvale: It's a great question, right? So I can tell you up front, if someone is coming with contamination OCD and they have, Let's just say a two to three hour shower. My goal is definitely gonna be that we're cutting that down, right? And the goal is that you're not going to be engaging in that long of a shower, by the time you leave and that's not your goal, right? Or you wouldn't be coming, but everything is done slowly and systematically and it's done effectively. So, what I mean by that is that we're not gonna push you to do exposures, if you can't engage in response prevention yet. We know, that's not useful. And so, what you would expect really weeks one and two are getting to know our model. You're starting to, you know, engage in readings and videos. And, you know, you have some small exposures. We're starting to do and you're building trust and repor, but you're starting where you want to start. Some of our patients might show up with the two-hour shower, but that's actually not their most distressing compulsion, something else is and that's what they want to work on first and that's where we're gonna meet them, right? We're not gonna start with a place you don't want to start and so we slowly work up to things and we get there together and we do like monitors in the shower and in our staff room so that we can have coached showers. So we might say things. Like If you set a goal of you know I want to be done with shampooing my hair within a five minute period or this, right? We're telling you the time we're communicating with you throughout we're asking you if you need a different level of support, we're talking to you about the amount of supplies you take into the shower prior. So we're doing a lot of planning, a lot of prepping. But I have a lot of rules. For exposures as an OCD clinician and certainly as the program director here. Number one is exposure should never be a surprise? We never throw exposures on someone, right? We talk about it with you. We're all on board. It's not an unplanned exposure by just, you know, say Hey today you're doing this or I just purposely contaminate you. The second is exposures should be agreed upon mutually right? You should be wanting to do it. You should be agreeing to do it. It shouldn't be something that I think makes sense. It should be what you think makes sense. And of course the last is that it should always be something I'm willing to do, right? I'm never ask someone to do an exposure that I'm not willing to do and so that doesn't shift in the residential process, right? Yes. In a residential program, I might be able to push patients a little bit more because I, I know they're gonna have support. I know that we can help them or you're with four hours of activity or people blocks a day compared to you know, 20 minutes within my 45 minute outpatient session. So sure we may be able to push a little bit more or a vote higher levels of distress when we're doing er, 00:30:00 Elizabeth McIngvale: Than what would be comfortable with on an outpatient level but across the board motivation. Willingness that's on the patient, not on us, and it shouldn't be Kimberley Quinlan: And I'm just curious because I don't, this is so wonderful and thank you for sharing all that. Because I think that's true for outpatient and… Elizabeth McIngvale: forced, or Kimberley Quinlan: for residential, but I think is so beautiful in that setting and I'm mainly just curious because I haven't been able to visit your center is,… Elizabeth McIngvale: Yes. Kimberley Quinlan: are they as everyone bunked in rooms together? Like, What does that look like? I know that in and of itself may be scary for people going in, right? Like, Do I have to sleep with somebody because I have compulsions around sleep and I'm afraid I won't sleep like, so, what does that look like? Elizabeth McIngvale: I know it's a great question and it's it's interesting because when I so I actually went to the Meninger clinic when I went impatient at 15 and it was a locked unit, it was a much, lover, level higher, level of acuity. And so it was this like, sterile hospital, like setting, you know, and I remember feeling super upset and anxious and away from my home and One of the things that I don't love about those sort of settings for OCD treatment perspective, is that like, we had a housekeeper there, for example, like there was an access to a washer dryer to a kitchen. So like meals were prepared for you and what laundry was done. And while that's fine or good, actually, for some of us with OCD. It's not good for OCD, right? Because we want patients to actually practice those skills. And so, However, before I jump into what our programs like I do want to say, I still got better. Elizabeth McIngvale: And I will tell you that, if the cost is being in an uncomfortable, sterile hospital setting, but it was me getting my life back. I do it all over again and so I really want us to think about that. Kimberley Quinlan: That's really interesting. Elizabeth McIngvale: You know that I think sometimes we we get so hung up on like, am I gonna be comfortable? What does it look like? What if I have a roommate and at the end of the day, you're getting your life back? So those sort of things are not what's more important, that should not override if it's an OCD specialty program, if you're going to be with other patients with anxiety or OCD, that's more important to me. I want When you're, if you're looking for a higher level of care, you need to be asking questions, like Are all the patients Patients with anxiety OCD are related disorders, is the treatment program specific to that, right? You don't want to be at a program with, you know, people with 20 diagnoses and there's just generalist modalities for groups or generalists, you know, groups and whatnot. You want there to be effective evidence-based care, being taught to you for anxiety and OCD. Elizabeth McIngvale: And so our program is actually so different. So our program is, in a beautiful Mediterranean, you know, 6,000 square foot, beautiful home and with the brand new kitchen, and it's got, you know, two washers too. Dryers and we have 11 beds total. So, six of our I'm sorry, we have six bedrooms, five of the bedrooms, have double beds. So, two queens and those rooms and then one has a single bed, that's our ada room, all of our bedrooms have their own bathroom and it's a really a home like home like experience. I think all of our patients would tell you, I hear this, I do it. Check out with every patient that comes through a program, I run groups and with them all the time, they always say that the entire experience was completely different than what they expected. You know, they were thinking this hospital setting this kind of rigid treatment where it was really instead it's like, hey, you come here and we help together create a supportive environment to get you back to the things you want to be doing in your life. Kimberley Quinlan: Yeah, I love it. I mean, when I used to work in the eating disorder community, it's like a big family. Like and and I think for me from my experience of clients, going through residential programs is, I think they had this idea of What the other people would be like only to find out. Like, these are my people, like, these are my people and and I want to encourage people listening. I know it's scary, the idea of increasing your, at the level of care. But usually, when you increase the level of care, you meet more of your people which is like the silver lining, I don't know, that was just being my experience of people and… Elizabeth McIngvale: I couldn't agree more,… Kimberley Quinlan: what they've said, Elizabeth McIngvale: you know, and we we see our patients and they leave. And we do this mentor support group where they can come back and run them into our group to the newer patients, or the patients currently in the program and it's so great to see. But I cannot tell you how many of our patients are great friends now and they go to the conference together and… Kimberley Quinlan: Yeah. Elizabeth McIngvale: they, you know, connect together and they run a support group for each other outside of when they leave here to keep and hold each other accountable. But you know one of the beauties is that in our home like setting you get to truly practice everything, right? And so you practice, the things you're gonna have to be doing at home, from cooking a meal doing your laundry, cleaning your room, right? All these sort of things that are important skills. We don't want to isolate and create this sterile environment. We want it to feel and to mimic your home. And so, there is so many memories and so much connection that's made when you're cooking together with your residence or when you're sitting in the living room together and watching them a movie, or going out to dinner in the community together and those are some of the most Important impactful and meaningful experiences and treatment, right? Not only because you make peers and connections, but you also get to encourage each other in the treatment process together. 00:35:00 Kimberley Quinlan: Mmm, I love that. Okay. So we've worked our way to the higher level of care. You've done the higher level of care. Let's make sure we finish this story. Well, right? It's like, it's like a movie plot to, the right is, How do we come down the level of care, right? So what does it look like for somebody who's done higher levels of care? What what is like you said at the beginning? It's not just like a one and done, you can sort of dust yourself off and maybe you can, I don't know. What is your experience? What's your suggestions in terms of reducing the level of care, Elizabeth McIngvale: Yeah. So our goal from treatment is that anytime someone discharges from our program, their discharging to an outpatient level of care and at some times for some of our patients, they're going to discharge back to their outpatient provider and they may see them two or three days a week, a first couple weeks and then two days a week and then, you know, to kind of taper back down to traditional outpatient or whatever, their therapist has available. And so that's the goal. But getting there looks different for everyone. So some of our patients will do residential the whole time, they're with us 12 to 16 weeks. However, long, they're in treatment and go straight back to their outpatient level of care, especially if they live out of state, different things that may make the most sense for them, but some of our patients may actually discharge to our day program. So they may, you know, spend eight weeks with us in the residential. And then discharge to our day program, for the last four weeks, especially if they're local, but even if they're not, they may get an airbnb and discharge to that level of care because it might actually be recommended and warranted for them to really practice independent things outside of the treatment day without 24 hours support Elizabeth McIngvale: And then again be able to tailor or taper back down to an outpatient level of care. So for us that is always our goal. One of the questions I get a lot is like Well when will I know if I'm ready to leave Liz and What will that look like? And my response is always the same is that I don't expect or actually want patients to leave here without any OCD. If you're leaving here without any triggers or any anxiety or OCD, then we probably kept you too long, right? Because it's important to remember that. You only should be in this level of care for as long as it's warranted. We should not be keeping you and charging you and having you stay. If you're ready to go to an outpatient level of care at that point. And so, my response is always, I'm, I, I want people to discharge when they're at a place where the treatment team and the patient feels confident that they're going to be able to maintain their progress on an outpatient level. And so the goal is that you've gotten all the tools, you've got the skills, you understand the concepts, you know, the difference between feeding your OCD and fighting your OCD and what that looks Elizabeth McIngvale: Like, you've changed your relationship with anxiety and OCD and now you're ready to keep doing that on your own. And so for a lot of our patients, we recommend and have them do what's called a therapeutic absence. This is typically about three fourths through treatment. We'll ask you to go home for about three to five days. Practice your skills. See how you do, see where you got stuck? Come back. We'll tweak things will help kind of read those final things before you leave, but the goal is that you're gonna discharge to outpatient care and you're gonna discharge to a functioning structured schedule. So this is really important, right? I want you at discharge to have a clear plan for what you're going to be doing, we don't want you to go home without a plan and to, you know, potentially revert back to sleeping in staying in your room, right? Those sort of things we want you to go back to a schedule because one of the benefits of being in our program is how scheduled and structured. It is Kimberley Quinlan: And I love this because as a treatment provider, anytime a client of mine has come back from residential or some kind of intensive treatment, the therapist that they were working with gives me this plan right? Or the The client brings me the plan and so I'm I hit the, what's The saying? Hit the ground running. Like I know what the plan is that we already have it. Elizabeth McIngvale: Yep. Kimberley Quinlan: It's not like we have to go and create a whole nother treatment plan. It's usually coming handed off really beautifully, which makes that process like so easy. Elizabeth McIngvale: that's, Kimberley Quinlan: For an outpatient provider to to take that client back. Elizabeth McIngvale: Our goal, right? Our goal is that if you referred someone to meet him, I'm gonna be talking to you before I start working with them and I'm certainly going to be talking to you as we're getting close to discharge and around the time of discharge to transition that care. Right? Seamless,… Kimberley Quinlan: Right. Elizabeth McIngvale: we want it to be smooth and we want the patient to feel like there's not an interruption in their treatment. Kimberley Quinlan: Right. Oh my gosh. So, good. Is there anything we've missed? Do you feel? Elizabeth McIngvale: Not really, you know, I think I get this question a lot, you know, across the board everything we've talked about just because I've personally experienced this, I do this myself professionally and Here's what I'll tell you guys. Treatment is fair is scary No matter what. It doesn't matter if we're doing on outpatient level or an intensive level, right? We're being asked to face our fears or being asked to do things that terrify us I know and many of our listeners know that treatment can and will save your life. And so if you're questioning if you're ready, if it makes sense, you may not ever feel ready and it may not ever make sense. But what I can promise you is that if you put forth the work,… 00:40:00 Kimberley Quinlan: If? Elizabeth McIngvale: the outcome is incredible. And I am someone who sits right here as Elizabeth McIngvale: Someone who really believes in full circle moments. Because the program that I attended when I was 15 is the program. I now get to run every day. Kimberley Quinlan: It makes me want to cry. Elizabeth McIngvale: And it is, it is I can tell you. I I love my job and every person at our team here at the Houston OCD Institute. We are driven by the opportunity to help individuals change their own life through treatment and it works. I wouldn't you know Kim those of us with lived experiences even if it's different we wouldn't be doing the work that we do. If we didn't know it worked What a friend,… Kimberley Quinlan: All right. Elizabeth McIngvale: what a horrible life if I had to be a fraud every day pretending for didn't, you know, I couldn't but we do this, we make a career out of it and and we get to keep changing lives and keep hopefully doing for others. What some people did for us when we really needed it. And I'm very grateful that I have the opportunity to be at a… Kimberley Quinlan: So beautiful. Elizabeth McIngvale: where I can now help other people. And what I can promise you is that with the right treatment, you can be at a place where you can be doing, whatever it is. You're meant to be doing not what OCD wants you to be doing. Kimberley Quinlan: So beautiful. My curiosity is killing me here. So I'm just gonna have to ask you one more question, is it the same location? Elizabeth McIngvale: It is not. So when I was a patient it was impatient actually at the Meninger clinic. So it was in that hospital setting and they closed their program in 2008 and then it became an offset. And so it's now we're our own facility and a beautiful house. And we're in a beautiful neighborhood in the Heights that you can walk around in Houston. Kimberley Quinlan: Yeah. Elizabeth McIngvale: So it is not a hospital setting but it is the same program for all intensive purposes. Kimberley Quinlan: Right? That is so cool. I am so grateful for you. Thank you so much now um I know you've shared a little bit but do you want to tell us where people can get a hold of you, any social media websites, and so forth. Elizabeth McIngvale: Yes. Yes, please feel free to reach out anytime y'all want my instagram and handle is Dr. Liz OCD. So you can always reach out there or find resources and support but for our website you can go to Houston OCDI.ORG or you can give us a call at 713-526-5055. And what I'll tell you is that I'm always available to help answer questions offer support and that doesn't mean you have to choose our program, but I would love to give good insight into what you should look for. And what I will say is, I know, can you talk about us all the time? You want to make sure the program that you're attending engages in evidence-based care so for OCD that's going to be ERP and often a combination of medication and that they really specialize in treating solely anxiety and OCD and OCD related disorders at the intens Or you want to be cautious? Not to go to a program. That's a really mixed program that says, they can also treat OCD. I don't think that'll be the same experience. Kimberley Quinlan: Agreed agreed, So grateful for you. This I feel like this has been so beautifully. Put like in terms of like explaining the whole step, their questions. I will be I'll be referring patients to this episode all the time because these are common questions we get asked. So thank you so much for coming on.Elizabeth McIngvale: Well, thank you for having me. Anything I can never offer. Please never hesitate to reach out, and thank you for all that you do in the awareness and education you spread in our field.