Episode 78: OCD (Part 4): I-CBT and Neurodivergent Approaches to OCD [featuring Brittany Goff]
Oct 31, 2024
Show Notes
Neurodivergent individuals often find mental health topics like OCD, autism, and ADHD intertwined in ways that can complicate their personal narratives and self-identity.
In this episode, Patrick Casale and Dr. Megan Anna Neff, two AuDHD mental health professionals, discuss with Brittany Goff, an LCSW, the Clinical Director at Zen Psychological Center, and an instructor at the Cognitive Behavioral Institute, about the critical intersections of OCD, autism, and ADHD, their impact on well-being, and the use of I-CBT in the treatment of OCD for neurodivergent individuals.
Top 3 reasons to listen to the entire episode:
- Understand how sensory discrepancies can lead to the development of obsessive stories, particularly for autistic individuals, and how inference-based cognitive-behavioral therapy (I-CBT) offers a tailored approach to counteract these doubts.
- Discover the unique challenges and strategies for neurodivergent individuals, including those with undiagnosed autism or ADHD, in managing OCD symptoms and building self-trust through a neuro-affirmative lens.
- Learn about the intersection of personal experiences, vulnerable self-themes, and logical reasoning with OCD, and how neurodivergent traits such as hyperempathy and rejection sensitivity influence the creation of obsessive narratives.
As you reflect on this episode, consider how your sensory experiences and neurodivergent traits affect your perception of reality and self-trust, as well as how I-CBT can offer tools and strategies to foster a stronger sense of certainty and understanding in your daily life.
DISCLAIMER: I-CBT is currently only evidence-based for OCD.
More about Brittany:
Brittany Goff is a Licensed Clinical Social Worker and the Clinical Director at Zen Psychological Center, a neuroaffirming OCD practice in Maryland. Additionally, she serves as an Instructor at the Cognitive Behavioral Institute, where she provides continuing education in Inference-based Cognitive Behavioral Therapy (I-CBT) for OCD. She authored the first-ever I-CBT workbook and was one of the first adopters of I-CBT in the United States. She is the first clinician to offer I-CBT training specifically tailored for individuals with Autism and ADHD, a neuroaffirming approach to treating OCD.
For those wanting to learn more about Inference-based, Cognitive Behavioral Therapy, visit the following two Facebook groups:
- I-CBT & Neurodivergence: For licensed therapists, graduate students, researchers, and occupational therapists to discuss the application of I-CBT. Free Resources will be shared for use with clients.
- I-CBT & Neurodivergence Community: A supportive space for all individuals to connect and share experiences. Free resources, games, and worksheets are accessible to those wanting to apply I-CBT with the help of an I-CBT provider.
If you’re interested in deepening your understanding, you can find Brittany Goff’s I-CBT training below, which focuses on resolving the OCD doubt. This fidelity of the model helps you teach your clients how to break free from the obsessive thinking patterns that create convincing narratives of doubt.
Trainings in I-CBT: icbtonlinelearning.com
If you are interested in learning how to adapt I-CBT for neurodivergence join the waitlist here and you will be notified when the training is released: y06gsdn8vfh.typeform.com/to/NidrJHd9
The neurodivergence training integrates the framework of neurodivergent identity traits and experiences—such as hyper empathy, a strong sense of justice, interoception and proprioception differences, Alexithymia, Rejection Sensitivity Dysphoria, PDA (Pathological Demand Avoidance/Persistent drive for autonomy), Synesthesia, monotropism, co-occurring health conditions, masking, and burnout—and explores how these traits and experiences can lead to self-doubt and obsessional stories.
Brittany Goff’s I-CBT Workbook: a.co/d/7WdHOnq
Zen Psychological Center offers neuroaffirming autism evaluations, neuroaffirming therapy, medication management, gene site testing, and support groups. Visit us at zenpsychologicalcenter.com to learn more.
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Transcript
PATRICK CASALE: Hey, everyone. You are listening to the Divergent Conversations podcast. We are two neurodivergent mental health professionals in a neurotypical world. I'm Patrick Casale.
MEGAN NEFF: And I'm Dr. Neff.
PATRICK CASALE: And during these episodes, we do talk about sensitive subjects, mental health, and there are some conversations that can certainly feel a bit overwhelming. So, we do just want to use that disclosure and disclaimer before jumping in. And thanks for listening.
Hey, everyone. Welcome back to Divergent Conversations. Today is the last episode of our OCD collection that we are releasing for OCD Awareness Month.
Today, we have a really cool guest on, Brittany Goff, a licensed clinical social worker and the clinical director at Zen Psychological Center, a neuro-affirming OCD practice in Maryland. Additionally, serves as an instructor at the Cognitive Behavioral Institute, where they provide continuing education on inference-based cognitive behavioral therapy, or I-CBT for OCD, authored the first ever I-CBT workbook, and then, one of the first adopters of I-CBT in the United States, one of the first clinicians to offer I-CBT training, specifically, tailored for individuals who are autistic and ADHD in a neuro-affirming approach to treating OCD.
Thank you so much for coming on and making the time.
BRITTANY GOFF: Yeah, thanks so much for having me, guys.
MEGAN NEFF: So, as soon as Patrick was done reading the bio I was like, "Oh, no, hot potato. We've got to start the conversation somewhere."
I kind of want to start the conversation, if you're comfortable with this, where, like, our email thread picked off because you and I emailed a bit when I asked if you wanted to come on. And it was really interesting to me how much our OCD stories overlapped, and like, how we've had some similar OCD experiences.
So, if you're comfortable, do you mind with us starting with kind of your experience with OCD, and then, we'll get into your professional experience and expertise?
BRITTANY GOFF: Yeah, no, absolutely. So, I was diagnosed with OCD maybe about when I was like 26 or so. So, I guess, is there like leading point that you want me to go off? I'm trying to remember, like, what exactly we talked about in our email. I know we talked about, like, special interest and OCD.
MEGAN NEFF: Yeah, let's start there. Like, I think one of the things that we connected on was how special interest in OCD tended to overlap, but also, just a sensitivity in OCD. Like, I know you've spent some time living in Thailand.
And one of my special interests, it sounds weird, but it's a justice special interest, for about a decade of my life, from when I was 14 to about 24 was looking at the child sex trafficking trade in Thailand, specifically. And I know that's something that has also been a special interest for you.
And then, one of the things that we talked about was how OCD can kind of take hold of some of these special interests and turn them against us. And that's actually come up in some of the other conversations we've had with guests on here, how OCD will, kind of, target those parts of our lives that we care about.
So, I was curious for you and your experience, kind of, I guess, this whole overlap of how OCD and special interests sometimes intersect, or just how OCD has targeted some of the high-value parts of your life.
BRITTANY GOFF: Yeah, which is exactly what happened with me. You know, I knew I had OCD, but I wasn't aware of the autism piece until maybe about just a couple years ago or so. So, when I was living in Thailand, and I witnessed this for the first time my justice sensitivity just was off the charts. And I couldn't really understand why it wasn't as bothersome to other people, or why it affected me more than it affected other people.
So, a lot of this started to create a lot of obsessional stories around just, like, being too much or being too sensitive. And you know, when your special interest is in something like human trafficking or something, you know, pretty like sad or just awful, I started to create stories about myself, like OCD stories or, like, doubting my own, like, morals or intentions, which is funny because, like, a lot of it was, you know, because of a heightened social justice. But I started to create stories, OCD stories about, like, you know, could I potentially be a sociopath because I'm so obsessed with these things? Which is just, like, so opposite from what was actually happening. I had way too much empathy rather than no empathy. And, you know, other little details throughout my life, kind of, like added to that story.
Like, you know, when I was younger, you know, I was criticized by my family members about the way that I express empathy. I was criticized for, you know, sharing relatable experiences with people as a way to try to relate. You know, accused of, like, trying to dominate the conversation or being selfish. So, you know, when you have all these very, like, little experiences, they start to add up, and like, that's why I really got into I-CBT, is because it looks at like the logic behind the OCD and like, those personal experiences that you have and how they start to influence how you see the world now, and creating a lot of those obsessional stories that I had.
MEGAN NEFF: Yes, so this is new language that I haven't heard a lot, but I'm really liking it as I'm hearing you use it, obsessional stories. Is that part of inference-based OCD to talk about obsessional stories? Or is that that Brittany language? I just totally like [CROSSTALK 00:07:49]-
BRITTANY GOFF: It's I-CBT language. So, I-CBT refers to the obsession. So, there's the obsession, then compulsion. It refers to the obsession as the obsessional story, or the OCD story, or obsessional narrative. And the obsessional narrative is full of different logical reasons as to what makes up somebody's OCD, which was very different from what I was originally trained and taught with OCD is that OCD is random. It doesn't make any sense to not really go into the content because it's seen as like rumination.
MEGAN NEFF: Yeah, it's the mind getting stuck. Like, that's often the narrative around OCD, the mind has gotten stuck and it's now malfunctioning. But you're saying, actually, let's look at why the OCD and the OCD stories make sense based on this person's life. Okay, that's fascinating.
BRITTANY GOFF: Yeah, and it's just very different from, like, the exposure-response prevention modality. And it's looking at, like, the process of how OCD unfolds for the person because it's so different from person to person. Like, why does one person get contamination OCD and then, like, another person is not bothered by that at all, and they get, like, relationship OCD. Well, it's because OCD is not random. It's based on these different reasoning categories is what I-CBT refers to them as. And looking at the process of how it unfolds, which is a much more validating process, I feel like then not really going into the content and focusing more on, like, response prevention and the compulsions.
MEGAN NEFF: And I can't remember if we maybe already did this in the bio, but for those listening, I-CBT, inference-based CBT. And can you explain what the inference-based is? Because I feel like that's connected to this idea of obsessive stories.
BRITTANY GOFF: Yeah, so I-CBT doesn't refer to thoughts as intrusions, or it refers to these thoughts as inferences because they're being created based on our prior knowledge, experience, and the different reasoning categories that it goes through. So, it's called inference-based cognitive behavioral therapy because, you know, it believes that these aren't intrusions. Like, these are inferences that we're creating based on our own prior experiences.
MEGAN NEFF: Okay, that's really interesting. So, one thing that I talk a lot about sensory stuff. And something that I talk a lot about is, like, our senses are so integrated into our personhood, like who we sense ourselves to be as people. And I think a lot of us grow up in ways where we learn to distrust our sensory perceptions and our sensory experiences, which I think leads to a really profound loss of self-trust.
I'm curious, do you see a connection between, like, having a kind of, I don't want to say faulty sensory perception, but it's like we have a sensory perception of the world that doesn't match the feedback we're getting, right? Like, I might think it's too hot or it's too cold in here, and I get feedback, no, it's not. Or like, it's too spicy, no, it's not. Or like, why is it loud for me, but it's not loud for others? So, there's all this invalidation of our sensory experience, which I think leads to a loss of self-trust. Would you say that predisposes a person to make faulty inferences? Or, I don't even know if you would use the word faulty you might…
BRITTANY GOFF: Yeah, I use the term faulty inference [CROSSTALK 00:11:29]-
MEGAN NEFF: Okay.
BRITTANY GOFF: Sorry. Can you repeat the question?
MEGAN NEFF: Yeah, the connection to, like, sensory, like our experience of sensory and difficulty trusting our perception of our self, and the world, and then the development of faulty inferences and obsessive stories. Do you see a potential connection there for autistic people?
BRITTANY GOFF: Yeah. And you know, one of the reasons that I gravitate more towards I-CBT is because the idea behind it is to actually gain certainty in yourself through your senses, which is a very different approach from other [CROSSTALK 00:12:06]-
MEGAN NEFF: I love that. I love that so much. I just want to pause to be like, I can't probably capture what you just said, but to regain a sense of trust in yourself.
BRITTANY GOFF: Yeah, I mean, because you know, when you have OCD, it's the doubting disorder. It makes you doubt yourself. It makes you doubt everything. And I-CBT, it's not using an approach of having to sit on the uncertainty because you don't need to sit in the uncertainty. Like, I-CBT is doing the opposite. It's actually teaching you how to be more certain in yourself through your senses. And like, using your sensory perception to make the decision if this is OCD, or if this is not OCD, if this is something worth paying attention to, or if this is just one of those OCD stories that are coming in.
So yeah, and you know, when you're autistic and your sensory experience doesn't match the world, it's not uncommon for autistic people to start to create stories about, like, why that's happening, especially, if you're late diagnosed or not diagnosed at all. Like, for example, just right, OCD, right. Like, so somebody puts on a shirt and it doesn't feel just right.
Well, let's look at, like, the sensory component here instead of, like, having that person sit and habituate to that uncomfortable feeling, have them change clothing. Like, and when they don't have that awareness that you're autistic, right? You don't understand why your clothes, like, hurt your skin. So, then, it's not uncommon for people to go on to create stories about that. Like, if they don't have the awareness that they're autistic and experiencing like, sensory differences, oftentimes, their brains will try and fill in the gaps, and try and make sense of what's happening. Because oftentimes, like, we have that very bottom up processing where we use a lot of, like, prior knowledge and experiences to kind of, like, determine concepts of, like, what we see in the world.
And oftentimes, like, that bottom-up processing, that reasoning can get faulty, and it becomes hijacked, and then, the person goes on to doubt themselves. And then, that doubt then turns into an obsessional story.
So, for example, like, with just read the trigger might be like an uncomfortable shirt. Well, then they're going to go into the doubt of, like, what if I can't handle this feeling, or what if this feeling never stops? And then, they'll go into the OCD story, and then, they'll do the compulsion to relieve the anxiety from it.
So, yeah, I really love I-CBT, specifically, because it focuses on, like, the sensory experiences.
MEGAN NEFF: Yeah, yeah, that sounds so powerful. Okay, so we've talked a little bit about sensory. I'm curious, because I know this is something that you talk about in your work. So many ideas like the neurodivergent traits that perhaps because, I mean, the statistics are pretty astounding, right? Like, both for autistic people and ADHD, OCD is a decently common co-occurrence. Beyond, like, I know that there are some genetic underpinnings to that, but beyond that, do you see other neurodivergent traits beyond how we process and sensor information, kind of predisposing us to obsessive stories and predisposing us to OCD. Like, I think you mentioned RSD.
BRITTANY GOFF: Yes, I do. I think Patrick's camera went out. Oh, there he is, okay.
So, yeah, I actually do see a lot of different neurodivergent traits kind of like kick-off obsessional stories. So, for example, you know, say somebody has rejection sensitivity, and they don't necessarily understand why they have that because they're either not diagnosed or late diagnosed. And then, they go on to create stories about their relationships, which can enter into relationship OCD.
So, also masking is a big part as well. So, if somebody is masking their whole life, and they don't know that they're masking, for me, what happened was, like, I always knew that I was doing something. I just didn't know what it was. I knew that I could never be myself and that I had to, kind of, like put on a mask towards different people. But I never knew why I was doing that. And because I didn't know why I started to create stories about, like, my intentions, being an impostor or fraud, having a hidden agenda, obsessional stories about my morals, and even, like, obsessional stories about harming other people because I didn't know why I was doing this. And like I said, I knew I was doing something, I just couldn't figure out what it was.
Also, so autistic meltdowns as well. So, I had frequent thoughts and stories about, like, losing control, or like snapping, or snapping and harming someone, or driving my car off a bridge, or like jumping off a building, and anything losing control. Or, like, for example, like shouting something out in public.
Well, I realized that a lot of those stories were actually coming from, like, having autistic meltdowns. And I didn't realize I was having autistic meltdowns. I just knew that I was losing control. And so, then, I started to, kind of like, apply that into other areas, and that's where, you know, OCD kind of snowballed and grew from there.
So, some other neurodivergent traits is, for me, at least, a lot of my autoimmune disorders related to being autistic triggered a lot of stories about like my health, which then turned into health OCD because a lot of doctors couldn't figure out what was wrong with me, which, you know, not an uncommon thing when you are autistic. And because doctors couldn't figure out what was wrong with me, I started creating stories, trying to figure out, just trying to fill in the blanks of, like, what was going on with me?
MEGAN NEFF: Absolutely. Like, one is having a high influence of social justice. I often can create, like, OCD stories around, like, scrupulosity, morals, the person's integrity, or having hyper empathy as an autistic person. Hyper empathy, for me, at least, like, gave me this very over [INDISCERNIBLE 00:18:31] sense of, like, responsibility for other people because I would, often, like, mistake other people's emotions as my own, and that will lead to a lot of, like, people pleasing behaviors that I would end up, you know, getting in situations that I didn't necessarily want to be in, helping other people, or just exhausting myself doing way too much. Because, you know, if somebody tells me that they need help with something, because they just got their house foreclosed on, they lost their car, they don't have any money, I start to feel all those emotions as if it's like, actually, happening to me.
And like, when you don't know you're autistic, like, that's really confusing. And so, I kind of interpret those emotions as mine.
So, I'd be like, "You know, you can have all my stuff. Come stay at my house. Like, have my car." And then, like, 20 minutes later I'll turn around and be like, "Why did I just give a stranger all my belongings?" So, there's a lot different ways of just being autistic that kind of like kick off obsessional narratives.
BRITTANY GOFF: Well, and this is interesting. This is overlapping. So, I work with a lot of kind of newly discovered people in their journey, and it's such a powerful thing to witness. And I remember it for myself, of like, there was… And what I was actually working on in therapy at the point that I got to discovery was that there were thousands of things about my experience, about myself I didn't understand. And what I was working to get to was a place of acceptance of, I'm never going to understand why I am this way. Like, I'll probably never recover a trauma narrative that's been repressed that explains why I am this way. That's kind of what my obsessive story was around that because it was the thing that, like, well, maybe that would explain why I am the way I am.
So, as coming to work toward acceptance of that, and then autism discovery, it just felt like it answered a thousand questions. And I think that this is probably so common for those of us who are late in life identified, or for autistic people who just maybe they were identified early in life, but they were never given the education about, like, this is what a sensory meltdown is, this is what a shutdown feels like, this is what disassociation is, this is how your brain works, this is how your body works, that there is so much confusion about our experience of being human that it makes so much sense we would develop obsessive stories to fill in the gaps.
I mean, that's what our brain just like naturally does as, you know, most autistic people have that, like, bottom-up thinking process. And when we don't have answers to things, we try and fill in the blanks, and try and figure out why.
And I had a very similar experience as you when it comes to, like, wondering if you had, like, some suppressed trauma. I had, you know, similar obsessive stories around it, and also, like, obsessive stories about being a sociopath again. So, you question, like, it's no wonder why we have issues with our identity, like having OCD because we're not always given, like, the tools and the resources when you are autistic, or have ADHD, or neurodivergent into understanding some of those things. And I think a lot of those stories kind of kick in is us trying to understand them.
MEGAN NEFF: Yeah, yeah. It's a very, like, gentle kind of take on OCD is like the brain is trying to help you. It's not, it's hurting you, but it's trying to help you, but it's trying to fill in the story. Yeah, it's interesting. I will take that concept for a lot of things. I haven't thought about taking that concept for OCD before because mostly I treat OCD like this. I just want to swat it away. So, it's really interesting to hear you talk from such a different framework.
PATRICK CASALE: It almost sounds like, and this is how I'm experiencing it, like my own OCD, about identity, about confusion, about why am I struggling with the things that look so natural to everyone else going through my discovery phase? Filling in the gaps almost feels like it's comforting, in a way. Like, it's creating some sense of comfort and relief to say, like, this is why, this is the reason you're experiencing A, B, and C when you maybe don't have the education, or the language, or the resources to put to that actual experience in a lot of ways.
BRITTANY GOFF: [INDISCERNIBLE 00:22:59] do everything to avoid uncertainty, right? And, you know, creating these stories gives us certainty. So, I can absolutely see what you're saying, Patrick. I experienced the same thing as well. I just never put it into words the way that you did.
MEGAN NEFF: I think about how, like, the kind of the trope of how, like, autistic children will ask why or adults. Like, I remember my dad has this story of like, I just ask why all the time. And he has this one story that I think is really funny. I had asked why he was in the middle of explaining whatever question I'd asked, and then, I interrupted him, and I said, "Dad, why are you talking?"
And we need to know why. We need to know the context. And part of what I'm [INDISCERNIBLE 00:23:49] you're saying, Brittany, is when we answer that why we're helping build self-trust, we're helping kind of bridge the gaps of understanding so those obsessive stories don't come in.
And so, you know, for the parents out there, for partners out there, for anyone who, you know, is caring for another autistic person, when you answer that why you are, actually, doing something pretty powerful in their life, in their brain.
BRITTANY GOFF: Oh, absolutely, yeah. And it's funny that you give that example because, like, in my training that I'm putting together for autism and OCD is I talk a lot about like, you know, giftedness and, you know, our ability to always ask why. Like, we ask why for things, for, you know, clarification, for understanding. And oftentimes, like, the responses that we get to that are not productive. At least they weren't for me, like, you know, being in school, being told like you're disrupting the class, like, stop asking those questions. Like, why can't you just follow along with the directions? And, you know, of course, those are small little things, but when you experience that, like, on a daily basis, like, it's no wonder so many of us develop things like rejection sensitivity.
MEGAN NEFF: Yeah, absolutely, absolutely, yeah, yeah. I was just having a conversation with someone, and I really liked this framework where they were talking about how, like, a lot of times our efforts to self-advocate get shut down, and because people don't like the way we self-advocate. And I think the question of asking why, asking clarified questions, that is a way a lot of autistic people self-advocate, but it's often a form of self-advocacy that has gotten trained out of us or gotten shut down.
BRITTANY GOFF: Yeah, yeah.
PATRICK CASALE: So, we had someone on here two weeks ago, two episodes ago, I don't know, time, who knows, who was talking about creating a neurodivergent-affirming framework for ERP. And I've heard you say now, you know, I-CBT very different than ERP. Can you talk about the differences, too? I mean, in terms of, for those who are listening who are like, I've only heard of certain ways to manage or support OCD symptoms.
BRITTANY GOFF: Yeah, so ERP and I-CBT differ in a couple of different ways. So, earlier I mentioned ERP, the foundation of that is, you know, thoughts are intrusion. They're random. They don't make any sense. We don't go into the content. And it's about purposely provoking anxiety for things that we fear while implementing response-prevention techniques to prevent the person from engaging in a compulsion. So, regardless of what therapy that you're using, there's a sequence to OCD. It comes in five different steps. Actually, can I share my screen to… I'm a very visual person, so-
MEGAN NEFF: [CROSSTALK 00:26:57]-
BRITTANY GOFF: …to show you guys, okay.
MEGAN NEFF: We really need to, Patrick, start promoting our podcast as a like podcast video because we have so many guests that come on who are also visual thinkers.
PATRICK CASALE: Right, yeah.
MEGAN NEFF: I love this.
PATRICK CASALE: Brittany, can you figure out a way to zoom in on that just because I know people who are watching, yeah, perfect. That's great, yeah.
BRITTANY GOFF: So, no matter what treatment modality that you're using is there's a certain sequence in OCD. It's the same, predictable sequence, literally, every single time, like no matter what the subtype is. So, we have the trigger, then we have the obsessional doubt, then we have the consequence of the doubt, and then, we have the anxiety, and then the compulsion.
So, ERP, like I said earlier, it focuses on purpose and provoking anxiety to prevent the person from responding. So, it treats OCD at the level of the compulsion. So, the very last step of the sequence.
So, I-CBT, it actually treats OCD at the second step instead of the fifth one. So, it focuses on the obsessional doubt and resolving the obsessional doubt. So, if somebody's able to resolve the obsessional doubt the other steps go away. So, there's not a need to purposely provoke anxiety to get better from OCD anymore. Like, you know, ERP has been the gold standard for many years, been extremely helpful for a lot of people. So, there's no treatment that's better or worse. It's just a different way of looking at OCD.
So, ERP focuses on more of like the behavioral aspect, but when you treat the cognitive portion like the behavior isn't there. Like, the person just doesn't do their compulsions anymore. They just stop doing it and resume back to what their life is. So, they don't have to purposely put themselves in those situations anymore to get past the fear.
MEGAN NEFF: This is so fascinating. So, yeah, for folks who are listening who aren't seeing the visual, there's this typical OCD cycle that's talked about, where there's the trigger, the obsession or, and I like how you're calling it the obsessional doubt, the anxiety grows, and then the compulsion. And so, yeah, all the treatments I've classically heard about for OCD intervene at okay, if we stop doing the compulsion, stop doing the behavior, we'll learn to handle the distress of the anxiety as it's building.
And what you're saying is, here we want to actually intervene at that moment of obsessional doubt, that moment where an obsessive story has come online and we want to build self-trust, I'm guessing, is part of that.
BRITTANY GOFF: Yeah.
MEGAN NEFF: Of like, so like the contamination, okay? Maybe my hands are contaminated. So, like, yeah. How would you help a client build self-trust in that process? Are there, like, questions they would ask themselves in that moment, or, like, what's that process look like?
BRITTANY GOFF: Yeah. So, there are questions that you can ask them. So, when it comes to utilizing your senses, I-CBT talks a lot about imagination versus perception. And so, an imagined thought is when we don't have any direct evidence in the here and the now to support that it's actually happening. So, like, we can't see it, we can't hear it, we can't feel it, we can't smell it. So, none of our senses are getting hit.
So, then it talks about like the opposite of imagination is our perception. So, what we can see, hear, smell, feel, and taste. So, when we want to use reality sensing, so say somebody has an obsessive doubt of, what if I just, like, snap and punch my boss in the face? They can use their senses by asking themselves, okay, do you see yourself punching your boss right now? Like, do you physically see yourself doing it? Do you hear your boss, like, shouting because they just got punched in the face?
So, if nothing is like hitting on that person's sensory experience, like, that's how they can determine, okay, this is an OCD story versus, like, hey, this is something that I should actually pay attention to. So, that's kind of how they use their senses in a way of, like, determining if it's OCD versus if it's not OCD.
MEGAN NEFF: I like that. And then, I can hear in that how a person would over time, start developing more self -trust because they trust the ability to, like, okay, am I relying on my perceptions here?
Though, one area I could imagine could be tough would be like… So, one thing I talk a bit about is how a lot of us have kind of extra sensitivity to the emotional tone of the room, but it doesn't always match. Especially, when we're around allistic people, the emotional tone doesn't always match their non-verbal communication.
So, like, I've been in conversations where, like, I can tell they're sad or maybe that they're mad, and I'll ask, like, "Oh, are you sad or are you mad?" And, "No, no, I'm not." And then, there is a perception disconnect because of what I'm perceiving, and what they are telling me is that a disconnect. So, I could imagine there would be some senses where it's a little bit trickier to work through, like when an autistic person or a hypersensitive ADHDer is like picking up the emotional tone or picking up a perception that's maybe not as concrete as like sight, smell, some of the other senses.
BRITTANY GOFF: Well, you bring up a really good point, and I think that is one of the falls of I-CBT because I think that, you know, I-CBT focus on the five senses, but there's actually more than five senses. Like, it really doesn't take into consideration interoception, proprioception, which are not very common things that a lot of autistic people struggle with, which is why I've kind of been working on, like, making the treatment a little bit more like affirming for neurodivergent people because, you know, like interoception can very easily cause, you know, a person to develop, like, health anxiety. They're not aware of [CROSSTALK 00:33:19]-
MEGAN NEFF: Absolutely, yeah.
BRITTANY GOFF: …and sensations that they're having. Or I've even seen it like with harm OCD, that somebody might be confusing anxiety with like an urge, and then, they'll use that urge to justify their story as to why they should [CROSSTALK 00:33:35].
MEGAN NEFF: Yes. So, you almost to do, like, neurodivergent-affirming I-CBT. You almost need to start with, like, maybe a sensory-based OT approach, or like a sensory-based approach of first working on refining our senses and like, learning how to differentiate. So, like, with interoceptive challenges, a lot of us struggle with differentiating. Like, is this anxiety or is this hunger, or is this thirst? So, you'd almost need to start with building that trust of senses and then be able to build on I-CBT on top of that.
Because I would imagine this would be a hard therapy approach if, like, a person's perceptions, their sensor perceptions are difficult to trust because it sounds like it relies a little bit on the ability to put some trust in your senses. I'm not sure if I'm capturing that right or not.
BRITTANY GOFF: Yeah, no. I mean, you hit it spot on, is, you know, sometimes people need, like, interoceptive exercises before they even get into I-CBT. I really, really like Kelly Mallor. She's an-
MEGAN NEFF: Her work is amazing, yes. Oh, you know her.
BRITTANY GOFF: Yeah.
MEGAN NEFF: Yeah. I have learned so much from her. I had no idea what interception was, and then, like, her work has been so helpful for the community. Sorry, I cut you off. Go ahead and talk [CROSSTALK 00:35:04]-
BRITTANY GOFF: No, I mean, I'm obsessed with Kelly's work too. So, she's an occupational therapist for anyone listening. She has, like, an interoceptive curriculum. She has, like, different flashcards that you can use. I mean, her stuff is just brilliant. And I use a lot of her interoceptive stuff to help people get more back in tune with their senses. Because you know, when you're late diagnosed autistic or autistic, you know, you start to, you know, only doubt yourself, but like, you lose your ability to interpret different sensations. And I think some of that probably comes from masking, right? When you're disassociating from your body for multiple hours a day. It's like no wonder we develop difficulties around, like, understanding different sensations in our body and different emotions.
MEGAN NEFF: Yeah, yeah, absolutely, yeah. I kind of related to that. Definitely related to masking. I would also think, like, one obsessive story I see a lot, I see in myself, I see in most autistic people I know is if anyone's at all upset in the room around us we assume it's us. And again, I would think that there'd be a lot of, like, healing our relationship to our perception, to be able to address that story of like, no, it's not always my fault. I'm not always the one making people angry because I know that's a really common narrative for us, yeah.
BRITTANY GOFF: And where the inferential confusion comes in there is, like, the well, you know, what if this is my fault? Like, what if I did something? And then, we start to ask for reassurance, or whatever the compulsion might be to follow it?
MEGAN NEFF: Yeah, yeah.
BRITTANY GOFF: Because so often we have experienced ruptures without understanding why. And so, again, that obsessive story is protective because it's like, well, I will tell you why versus you living in that confusion.
Another, you know, aspect that kind of flows into what we're talking about with I-CBT is, you know, one of the last modules is called the real self. And I love it because it helped me figure out who I was as opposed to, like, who I was trying to be. Like, I was trying to be a neurotypical person for a long time because I didn't know I was autistic. So, kind of like redefining yourself at the very end, and like, looking at yourself from like a different position, from a more like neurodivergent lens, rather than, like, the lens of like, trying to be neurotypical. Yeah, just another cool aspect of I-CBT. At the end, you kind of get to, like, redefine yourself and look at yourself in a really different way, which I feel like is, you know, really helpful for people that have masked for so long and lose sense of who they are.
MEGAN NEFF: Absolutely, yeah. I would think that would be so powerful. Patrick, you looked like you had a thought a second ago, but…
PATRICK CASALE: I've had so many thoughts during this conversation, and then they just are fleeting, and then I'm just sitting here like I'm thinking about how powerful that would be, especially, with how much confusion there is, how much disconnect from the sense of self that there is, how many people try to, like, learn who they are post unmasking experience process. And like, Megan and I have joked about this before, but even the concept of like, what do for fun? Becomes really complicated. So, there's so much confusion in this process.
So, when you can't trust your brain, or your thoughts, or you can't trust your senses or your body. It makes a lot of sense why a lot of these inferences are becoming more and more present in your life, and how to manage them. This is a really fascinating conversation. I've honestly never heard anything about I-CBT before in my life. And this is really just educational for me, so I love that.
BRITTANY GOFF: It's fairly new to the United States. So, I remember I knew nothing about I-CBT. And I knew that there was some areas that like ERP really didn't like hit on for me very well, and so I was always kind of, like, looking for another therapy. And I saw on Facebook, like somebody was talking about OCD and described it in the form of like dissociation. And that resonated with me so much. Because, I mean, for me, like when I'm stuck in an OCD story, like I'm disassociated, like I'm in another world.
And so, when I started looking at I-CBT, there was nothing. There was no resources. The only thing that I could find was a clinician's manual that was translated from French. And so, it was really hard to, like, understand and digest. But once I did, I was like, "Oh my God. Like, how do people not know about this treatment? It's evidence-based, and it's a modality that they use in other countries, in Europe." But for some reason in the United States, it just wasn't really heard of yet.
So, when I read the book, I mean, my OCD, like, drastically changed. It changed the way that I looked at OCD. It changed the way that I treated OCD. And I started to kind of, like, introduce it to some of my clients, told them a little bit about it, and then they all started getting better from it, and they were asking me, like, the same question, like, "Where was this therapy before? Like, why don't we do this first?"
So, then I started introducing it to my clinician. So, I have like 15 therapists that I work with. And a lot of us all have lived experience. So, I started introducing it to them, and they were like, "Oh my gosh. Like, why didn't we learn this therapy sooner? Like, where was this?"
So, then I started to put together like some trainings to train other clinicians. And then, I published the workbook, like I was telling you, kind of like, accidentally. I never meant to publish it. It was just me, like, learning I-CBT and doing some pan-outs for my own clients to help them kind of learn it, and was convinced by some colleagues that I should publish it, which is why there's, you know, so many typos in it.
But I actually didn't know that I was autistic when I published that. So, it doesn't have any like the neuro-affirming aspect to it. I'm working on another one that does. And then, eventually, Cognitive Behavioral Institute hired me on as an instructor to teach I-CBT because, yeah, I mean, it just kind of blew up. I never really expected it to. But, yeah, the resources are very limited. It's still upcoming and emerging. So, yeah, it was really hard for me to find resources, too, because there was, like, no therapist trained in it, no books, no nothing. But I think the narrative is starting to shift a little bit around OCD, and it's starting to get a lot of traction, and there's a lot more people that are getting trained in it. I've trained like hundreds of therapists at this point. The Facebook group started out with like five people. Now, it's like 2000 just within like a year or so. So, it's definitely up and coming.
MEGAN NEFF: My gosh, that's so incredible. And like, first of all, just thank you. Thank you for your work. Because, actually, I feel personally grateful for it in the sense that I've been looking to try and find I-CBT therapists and I can't. And so, I'm so thankful that you are out there training therapists to learn how to do this, so that there will be more therapists who do this work.
And I am hearing it talked about most in neurodivergent-affirming therapy circles, which I think is probably no accident that a lot of neurodivergent-affirming therapists are looking for more affirming ways of working with OCD, and this just makes so much sense for autistic and ADHD folks.
BRITTANY GOFF: Oh, when I figured out that I was autistic that, like, really changed the way that I saw, like, OCD, and putting a lot of, like, OCD terms to… or putting a lot of autistic terms to what I was experiencing. So, yeah, there's nothing available about autism, ADHD, and I-CBT, unfortunately. But I've been working to kind of, like, adapt some of those terms. And, you know, incorporating things like interoception, proprioception.
And so, a part of I-CBT is the person has, like, a vulnerable self-theme, or they have different vulnerable self-themes, which is why their OCD stories are created the way that they're created. So, kind of going back to the logic of OCD, I mentioned that there's different reasoning categories. So, those reasoning categories are different facts that the person has acquired throughout life.
The second one is different rules that they follow, and this is, especially, like prevalent for social norms. The third one is hearsay stories that they've heard. So, it could be something that they saw on the news, something that they read about 20 years ago, or like a story from a friend of a friend, personal experiences that they've been through, and just the mere possibility of it happening. So, since everybody has, you know, different facts that they've acquired, different experiences that they've acquired, that's going to dictate, like, what kind of obsessional story they have, plus their vulnerable self-theme.
And when I learned that I was autistic, all of the vulnerable self-themes that I had, like I witnessed a lot of other clients have were autistic features like heightened social justice, rejection sensitivity, dysphoria, masking.
MEGAN NEFF: That's so interesting, and that makes so much sense. I kind of want to see like a diagram, like a map, where you kind of lay one on top of the other, like vulnerable themes and then, neurodivergent traits. I feel like, yeah, it just makes so much sense that there'd be so much common touch points there, yeah.
BRITTANY GOFF: Yeah, absolutely. How long does it take you guys to edit these until they're aired?
MEGAN NEFF: This will come out end of October or early November. This is the last episode in our OCD series.
BRITTANY GOFF: Oh, perfect. Okay, so my training will actually be out by then. So, in my training, I actually list out, like, all the neurodivergent traits, vulnerable self-themes, from, like, an autistic perspective. So, I'm happy to share any of that with you guys.
MEGAN NEFF: That sounds incredible.
PATRICK CASALE: Great, yeah, whatever you want us to include in the show notes and as downloads, or as links, or whatever you need us to put into that we will.
MEGAN NEFF: Yeah, Brittany, do you have any itchy thoughts? I refer to itchy thoughts when it's like, I know sometimes I come into an invited podcast or conversation and there's like, oh, I know I want to say this thing. As we're kind of maybe coming to the end of our conversation, do you have any itchy thoughts of things that you wanted to make sure and mention about I-CBT, or autism and OCD, or ADHD and [INDISCERNIBLE 00:46:30]?
BRITTANY GOFF: With I-CBT, when you have an obsessive doubt where you can't use the senses, the theory behind it is to rely on common sense, which is neurotypical.
MEGAN NEFF: Right, right [CROSSTALK 00:46:47]-
BRITTANY GOFF: [CROSSTALK 00:46:47]
MEGAN NEFF: …common sense.
BRITTANY GOFF: But instead of looking at common sense, like looking at things like interoception and proprioception, and how those can go on to create obsessional stories rather than kind of just saying, "Oh, compare yourself to a neurotypical person." And go off of that.
But, you know, I have a lot of faith in I-CBT. And I think that this is just the beginning of where it's going to go in the United States. And it has a lot of room for change and a lot of room for implementation. So, just something for people to be aware of, like when they do explore I-CBT is it's not created for autistic or ADHD individuals.
MEGAN NEFF: I just had a runaway thought when you were talking, is it okay if I chase the association?
BRITTANY GOFF: Yeah.
MEGAN NEFF: So, there's some really interesting research around kind of abnormal perceptions in autistic people, and that can be hallucination-like experiences. There's an article I read that was really interesting that looked at paranoia thought and it was comparing autism to, I think, it was schizophrenia form, or maybe it was, I don't think it was schizophrenia, but it was on the schizophrenia spectrum.
You mentioned proprioception and interoception. People with very sensitive proprioception, for example, might have this sense of someone just pushed me, or someone just touched me when someone walked by them, right? Like, we're talking about very extreme proprioceptive sensitivity. I could imagine that the experience of having either abnormal perceptions or just, again, proprioceptive input that's not matching environment, I could imagine that could create some obsessive stories around like psychosis. Is that something you see?
BRITTANY GOFF: Oh, yeah, oh, yeah. Fear of, like, developing psychosis is a pretty common obsessive doubt. But it's interesting, I never really linked it to proprioception, like you just mentioned, but that makes a lot of sense.
I always kind of assumed, this is just my theory behind it is a lot of people with OCD get like, kind of visual superimposed over their vision. It's not like a hallucination. It's more of like, you know, they can see things that aren't actually there, but they know that it's not there. And that's why, like, these OCD stories can be like, just wrap you in because the person can, like, actually visualize that scary story happening.
So, I always kind of just figured that some of that, like, psychosis, or like fear of psychosis was wrapped around that. But that's a really interesting point that you bring up about, like, proprioception.
MEGAN NEFF: Yeah, yeah. Okay, well, thank you for indulging my association. But I've had more and more questions come up around both, like, the experience of psychosis, but also, like the fear of psychosis, or obsessive stories around psychosis. And so, I thought I'd ask, because I was suspecting that that might be the case, yeah.
BRITTANY GOFF: And [CROSSTALK 00:49:58]-
MEGAN NEFF: Oh, sorry. Go ahead. No, go ahead.
BRITTANY GOFF: I was also going to just mention that sometimes I've seen that, like, being related to autistic meltdowns. Like, if a person is like losing control, it's not uncommon for them to start to like, "Okay, well, I'm I losing my mind? I'm I losing control of my mind?" And then, go into this, you know, obsessive story about, you know, could I develop psychosis? Could I have schizophrenia? So, it's interesting.
BRITTANY GOFF: Yeah, we should someday do an episode on the, like, messy, messy history of like schizophrenia and autism. And how, like, autism, you know, used to be classified as, like childhood-onset schizophrenia, but, yeah, the overlap of these are fascinating. And I just think the whole experience around having abnormal perceptions.
Years ago, I put an infographic out on kind of abnormal perceptions, hallucinations. And I had so many people reach out, and be like, "Oh, my goodness, thank you. Like, I thought it meant X, Y, Z, that I was having this experience." And having a name for it, like, abnormal perception that would just understand, again, why? Like, why do our brains work the way they do? Like, neurons sometimes randomly fire, and you might have an abnormal, like, perception that feels really scary and understanding that why it can just be so powerful.
MEGAN NEFF: Yeah, I interrupted you in middle of you were sharing resources and any key thoughts you had. So, you've mentioned the Facebook group, and you provided that nice disclaimer that for people getting trained, this isn't not in and of itself a neurodivergent-affirming modality, so there'll be some ableism language. Were there other things that you wanted to share in regards to either itchy thoughts or resources you wanted to mention?
BRITTANY GOFF: I don't think so. I think that we covered pretty much everything. I mean, the main thing that I wanted to talk about was like, you know, how different neurodivergent traits kind of, like, take off obsessional narratives, but I think we've covered pretty much everything.
MEGAN NEFF: Yeah, well, I'm sure there'll be lots of people who, A, like, want you to be their therapist. And I'm sure you're sadly limited. But B, would love to like, like for therapists listening, get trained from you. Like, where can people find you? Where can they find your work, your trainings?
BRITTANY GOFF: Yeah, so my trainings you can find at icbtonlinelearning.com. To contact me directly you can visit zenpsychologicalcenter.com which is the group practice that I run. So, I am not taking any new patients. I primarily do autism evaluations and teach now, but there is a directory on the official I-CBT website with a list of therapists that are trained in I-CBT. So, the name of the official like I-CBT website is icbt.online. So, they have a ton of resources on there.
We used to do something called I-CBT Fridays, which we're actually going to start doing again, where we had, like, different presenters come and, like, teach each module for free, and they're recorded. They're on the website. So, if you want to watch the videos, you're more than welcome to. There's also some, like, handouts on there. So, there's a lot of really good resources there as well.
Definitely recommend joining I-CBT and Neurodivergence, which is my Facebook group where we talk more about more neurodivergent or looking at OCD from the lens of, like, autism and neurodivergency rather than looking at it from like a neurotypical lens.
PATRICK CASALE: Cool.
BRITTANY GOFF: So, if you're a therapist that's interested in taking one of my trainings, you can visit icbtonlinelearning.com one more.
PATRICK CASALE: [CROSSTALK 00:54:17]-
BRITTANY GOFF: One more. Okay, so the last one that I wanted to mention, so the book that I published, not on purpose, so that's on Amazon. You can just type in, like, Inference-Based Cognitive Behavioral Therapy, and it's the only, like, workbook, besides, like the actual clinician's manual that comes up so you can find it on there.
PATRICK CASALE: Great. And we will have all of that information in the show notes with links to everything so you have easy access to find all of Brittany's information and everything she just talked about.
Brittany, thank you so much for coming on and wrapping up our OCD series.
BRITTANY GOFF: Thank you guys so much for having me. It's been great getting to just teach more people about I-CBT.
MEGAN NEFF: Yeah, I think there'll be lots of people that have kind of light bulb moments listening to this conversation. So, thank you so much for coming on.
BRITTANY GOFF: Absolutely. It's been fun.
PATRICK CASALE: And to everyone listening to Divergent Conversations, we have new episodes out on Fridays on all major podcast platforms and YouTube. Make sure to look at the YouTube channel, Divergent Conversations, if you want to follow along, especially, for video content, screen shares, and all the resources that Brittany shared today. Thanks, and have a good day. Goodbye.
