First day of IOP

I started IOP!!!

Yesterday was my first day. It was a 2.5 hour session at the clinic. The first 30 minutes was just filling out paperwork. Then I spent about 45 minutes with both Dr. Osborne and the director of the IOP program, Dr. Tininenko, talking about goals for the week. It looks like every Monday will be an in-office session like this to review progress and establish goals for the following week.

My goals for this week?

• Get my kitchen functional again.
• Use my regular dishes and silverware again.
• Cook a meal in my kitchen and clean up afterward.
• Develop and work on exposure scripts for contamination obsessions.
• Various other exposure exercises.

Then I had just over an hour to do some exposure work with Dr. Osborne. This was interrupted by a brief visit by one of the other clinicians I’ll be working with, Dr. Ravid, who came by to introduce himself and observe one of our exposure exercises. Dr. Osborne and I were then able to bang out exposure to a bunch of new words.

The rest of the week will be sessions in my apartment. Today Dr. Osborne will be spending 2.5 hours with me. Tomorrow I will have 2 hours with Dr. Ravid. Thursday will be 2 hours with Dr. Tininenko. Then Friday will be 2.5 hours with the final clinician on my team, Dr. Coco, and Ashley who is an intern from the University of Washington. Ashley will be sticking around another 1.5 hours to do additional exposure work.

One last note on the IOP… my insurance company has only agreed to pay for two weeks of treatment. At the end of the two weeks they want to re-evaluate to determine progress. This will likely be the pattern until I am either done with the treatment or the insurance company decides to stop paying for treatment. So, we’re really trying to figure out how to get the most out of these next two weeks in case they decide they won’t pay for any more. Worst case, I get two free weeks of covered treatment. Best case, they cover the whole program.

Milestone – somebody else in my apartment

Today I had somebody besides myself in my apartment for the first time in six months. Dr. Osborne came and did an in-home assessment and session.

This is a big deal for me.

I stopped having people in my apartment mostly because other people don’t know the rules of my OCD. I’ve been fearful that inviting other people into my home would stir the OCD waters and make what is already a difficult environment to navigate even worse. I know how to keep the “contamination” contained for the most part (or at least I know what is contaminated and what is not), but other people don’t.

Luckily, with Dr. Osborne, he understands how OCD works and I was able to get assurance from him before his visit that he would be careful and follow my instructions on where he could stand, where he could sit, and what he could touch. Before he arrived I placed sticky notes all around marking areas that have been contaminated so he would know how to maneuver through my apartment.

Another reason I stopped having people in my apartment is because I’ve been embarrassed about how messy it is. I like a clean and clutter free home, and OCD isn’t allowing that at the moment.

The mess was not an issue for Dr. Osborne. He also works with hoarders and he assured me ahead of time that whatever the state of my apartment, he had seen worse.

The visit went well. Having him in my home did exactly what I hoped it would do: it gave me a chance to show him all the OCD stuff that we’re not getting to in our in-office sessions, it gave him an opportunity to model how to do exposure work in my apartment, and it gave me permission to push the boundaries on some things in my apartment that have been “off limits.” On the third point, I’ve noticed that in my sessions with Dr. Osborne that when we discuss and do exposure to things that have been “off limits,” it’s almost as if discussing them with Dr. Osborne gives me permission to stop avoiding them. It’s like the OCD switch gets significantly dimmed, and while I still have an OCD reaction to the thing, it’s much less severe than it was before. This was the case with some of the exposure work we did today. Before, if I had tried to do this exposure work on my own, my SUDs would probably have been around a 6, but with Dr. Osborne there it dropped into the 2 to 3 range.

I’m looking forward to more in-home sessions. Luckily I’ll be getting much more of them once I start IOP.

IOP saga

Because of how disruptive my OCD has been, I’ve been trying to get into the intensive outpatient (IOP) program at my clinic. IOP treatment is administered by a team of three to five clinicians. It would be doing the same types of exposure therapies I’m doing now, but for longer periods of time every day. It would include frequent visits to administer treatment in my home. It also includes psychiatric consultation to administer and monitor medication. There are two tiers of IOP treatment: 20-hours-per-week and 10-hours-per-week. The clinic likes to start patients off at 20 hours per week because that is proven to be the most effective. It’s designed to be a totally immersive treatment and I’m told it works best when the patient approaches treatment with the attitude that he or she is going to tackle everything all at once and come out the other end in remission.

These treatments are expensive. They are respectively $6000 per week and $3000 per week. There is no way I could pay for this out of pocket. That’s why I was excited when I found out my insurance company would cover the entire treatment (or so I thought).

When I first discussed the IOP treatment option with Dr. Osborne about two months ago he asked me if my insurance was Premera (Premera has a history of covering in full for pretty much all of the their patients who request the IOP treatment). I said yes because I thought it was. My insurance is actually with Blue Cross Blue Shield (BSBC) of Nebraska which shares the same blue cross logo as Premera and I’d seen the Premera name on other insurance forms of mine. Because of this I just thought BSBC was subsidiary to Premera. Turns out that’s not the case. BSBC does contract with Premera to pay claims in the state of Washington (don’t ask me how or why… this insurance stuff is confusing, but this is why I had seen the Premera name connected with my insurance), but Premera has nothing to do with approving treatment in my case. BSBC will be the ones to approve (or not approve). The clinic’s history in dealing with insurance companies other than Premera is that they’re more likely to decline IOP treatment.

Great. This was going to be more complicated than we thought. If my insurance had been held directly with Premera it would have been a simple approval process that would have taken a couple days and I could have started treatment six weeks ago. Instead my clinic had to go through a complicated pre-approval and negotiation.

The first attempt at getting approval for the treatment was not successful. It was clear BSBC didn’t understand the treatment and the coverage the clinic was asking for. The first response was basically “your insurance policy covers x number of mental health visits per year.” They didn’t understand that the clinic wanted to set up an agreement for payment above and beyond what was stated in my policy. It took them a few weeks for them to first understand the treatment and another couple weeks to get on board, but eventually after a phone call with Dr. Osborne they agreed that the treatment is necessary.

But that was only the beginning.

I learned that the people at BSBC who approve the treatment are different from the payments people who determine coverage limits. The payments people initially said they would cover $500 per day. This is well short of the $1200 per day cost of the full IOP option. There was another week or two of negotiations and BSBC eventually agreed to $800 per day (only two-thirds of the $1200). Additionally, BSBC won’t allow the clinic to bill $800 to insurance and then balance bill me the remaining $400 (I’m uncertain why this is). Even if they did, I still wouldn’t be able to afford $400 per day.

It seemed like we were at an impasse… until I asked a question.

I talked to my clinic to get clarification on one point: did BSBC agree to pay for two-thirds of the treatment cost, or did they actually agree to $800 (two different things)? The answer was $800. The reduced 10-hour IOP option of treatment is only $600 per day, so I asked why not just do that. The initial response was that the IOP team usually likes to start people at 20 hours per week because it is the most effective. After a while they typically taper patients off to the 10-hour tier. I had to do some internal negotiations with the clinic to convince them that the 10 hour per week option was still better than nothing, and eventually we all agreed.

So… the pieces are all now finally in place. Dr. Osborne and the clinic are rallying behind me. Work has made accommodations. Insurance is on board and has approved the treatment.

So, after six weeks, it looks like I will finally be able to begin IOP starting next Monday!

Caught by my therapist

The other day I got caught washing my hands obsessively (because I was out in public without cleaning wipes) by my OCD therapist before my appointment. It felt a little like I was caught drinking by my AA sponsor. 😏

Here today, gone tomorrow

I really hate my OCD sometimes. …well most of the time. It tends to bounce around from obsession to obsession and it gets f^*king exhausting. What bothered me yesterday is replaced by something new today; and what is new today will be replaced by something new tomorrow. It feels like my OCD is always one step ahead of me. I can’t keep up. Grrrrr! 🤬

To move or not to move

I live in a two bedroom apartment… a very very small two bedroom apartment. It feels cramped, especially with all the OCD baggage I’ve brought into it. I’m constantly bumping into things that set off my OCD.

A few months ago I thought it would be nice (if I ever had the opportunity) to move into a more spacious apartment in my same building, so I told the manager to let me know if any apartments opened up. She put my name at the bottom of the list. Turns out the building is in high demand and six or seven other people are already in line for an apartment should one become available. Knowing this, I figured it might be a year or two before I would make it to the top of the list.

Well, a neighbor just bought a house and moved out of her one bedroom apartment a week or two ago, and it turns out nobody above me on the list is in a position to take the available unit. The manager contacted me and said it’s mine if I want it.

It’s a large one bedroom unit. It was designed to be an ADA accessible unit so the entry and the rooms are on the larger side. I would guess that the unit is roughly the same square footage as my cramped two bedroom unit.

It’s very tempting.

Pros:

• I would get to start over in a new apartment with a clean slate.
• More spacious rooms would probably mean less bumping into OCD things.
• It would be an opportunity to clean house and get rid of a bunch of stuff.
• Since I’m currently on leave it could be a good time to move while I don’t have work to worry about.
• It’s only one floor below mine, so an easy move.

Cons:

• Moving all my stuff right now would mean once again kicking up a bunch of OCD dust and it’s likely to settle on new stuff.
• I haven’t given an update on IOP recently, but it’s still a possibility. If I jump into that it would mean a lot more time in therapy and potentially higher levels of stress. It might not be a good idea to move while in this treatment.
• I’m also still on leave, but planning to slowly go back to work over the next two months. It’s probably not a good idea to try to move while reintroducing work.
• Since there is so much OCD baggage in my current place, staying here might be a good thing and provide some great opportunities to do exposure work.
• The unit is north facing, so no natural direct sunlight.

What would you do?

One of those days

It’s funny how the smallest trigger can set off a chain of obsessive-compulsive activity.

I was heading out the door to the dentist this morning and while putting on my jacket my hand passed in front of my blinds which are “contaminated” with a particular memory (and here’s the kicker, I’m not even one hundred percent sure my hand did pass in front because I caught it out of the corner of my eye… but the uncertainty of whether or not it did was enough to set my obsessive mind reeling). That contamination transferred from the blinds to my hands and then from my hands to the jacket. Then I stepped on lump in may carpet and it transferred to my foot. There’s no logical reason for the transfer of “contamination” other than the fact that my OCD brain said it was so.

I considered taking off the jacket and quarantining it somewhere until I could wash it. I considered removing my socks and decontaminating my hands. My appointment was fast approaching, though, and I knew doing all those things could take me another twenty minutes. Plus, I could hear the voice of Dr. Osborne in my head reminding me that wearing the contaminated jacket anyway was the best way to push back against OCD. So, I wore the jacket even though my SUDS was around 5 (and that had mostly to do with the fear of the contamination spreading). I did, however, put on another pair of socks over the socks I was wearing to contain the contamination on my feet (again, no logical reason… it’s just what OCD tells me will work). I think I also used a cleaning wipe on my hands, but honestly I don’t remember at this point.

I was late enough that I called an Uber instead of taking the bus. I was already on edge and sitting in that SUDS 5 for most of the ride in… until the driver took a different route than I expected and passed through a part of town that is also triggering for me. Then he turned up the talk radio he was listening to which happened mention a word several times that has also been triggering for me. Now, this is one of the words I’ve been doing exposure to and in a different circumstance I might not have reacted to it, but since I was already on edge from the prior events I had an obsessive reaction to it. My SUDS was now sitting solidly at 6 and I literally was developing a headache from it.

I was able to get out of the Uber and into the dentist without further incident, but I did stop to wash my hands in the bathroom. Interesting that it was enough to lower my SUDS to a 3. (This is why I engage in compulsive behaviors… they provide immediate relief.)

Then the dentist… sitting upside down in a chair for forty-five minutes unable to talk… my OCD brain can go wherever it wants. And of course it picks an obsessive thought to hone in on. This thought was only peripherally connected to the earlier stuff, but it was enough for me to feel contaminated again. And there was nothing I could do but sit in the contamination. (Dr. Osborne would probably argue this was a good thing.) I spent a good portion of the remainder of the appointment worried about how I was going to prevent the contamination from spreading and how I was going to retrieve my jacket from the coat hook next to the dentist chair without 1) spreading the contamination from earlier, and 2) contaminating it a second time with this new obsessive thought. I plotted that I was going to pretend to forget my jacket, go to the bathroom immediately to wash my hands, and then go back into the dentist to retrieve my “forgotten” jacket. This, however, didn’t work because the hygienist reminded me as I was getting out of the chair not to forget my jacket.

Also as I was getting out of the chair, I stepped on the edge of the platform the dentist chair sits on instead of the flat ground of the adjacent carpet. Argh! My foot has been contaminated again. SUDS went back up to 5. I immediately went to the bathroom where I washed my hands and the sole of my shoe with a soapy paper towel to clean off the contamination. Again, relief.

It was then lunchtime so I went to the pizza place in the lobby of the same building. As I was waiting for my personal pizza the same obsessive thought from the dentist came back up. “I’m just going to eat my lunch and push through it,” I thought to myself. Of course, as I’m eating my pizza I accidentally kick the foot of the chair in front of me. Double argh!! The contamination has spread to my shoe once again. SUDS back up to a 5.

“I don’t want to spread the contamination further. What do I do?” You see, this is a building I will likely be visiting frequently in the future. My dentist is here. My company’s Seattle office is actually moving into this same building within the next month (I know! What are the odds?).

I tried washing the sole of my shoe again in the restaurant bathroom, but they had different kinds of paper towels and soap and that didn’t work as well as the first time. I knew there was a convenience store around the corner and I could get cleaning wipes there (I’d bought them there before). So I beelined to the store and bought the container of 78 wet wipes.

which brings me to where I am at this very moment… sitting in the plaza outside the building and cleaning the soles of my shoes with cleaning wipes.

It’s been one of those days.

SUDs on the rise

No, not soap suds (remember, I’m not washing my hands anymore)! Subjective Units of Discomfort (or Distress). It’s a 0 to 10 scale used in the mental health world to measure the subjective intensity of anxiety, disturbance, or distress experienced by an individual. 0 is absolutely no distress, while 10 is unbearable distress.

I usually hover around 1 or 2. Yesterday and today I’ve been fluctuating between 3 and 6. I find it interesting that I’ve finally started to get my apartment in order and my SUDs level seems to be increasing. I was more comfortable (at least mentally) with multiple trash bags and unemptied grocery bags littering my kitchen than I am now with a clean kitchen. I was more comfortable with six pairs of shoes blocking the entry to my apartment than I am now that they are out of the way.

That’s not supposed to be how this works!!!

Why is this?!!!

I have a couple thoughts…

1. Cleaning all the junk has kicked up a bunch of figurative OCD dust. There was a reason all the junk was where it was. My OCD brain had labeled it “contaminated” and off limits. Touching it or moving it meant that other things would get contaminated. I had to fight through that to get the junk out of the way, but that meant kicking up contamination dust and it is now settling on new things.
2. I don’t handle change well. When spaces, places, or routines change, I’m extremely sensitive to new OCD triggers because historically that’s when I’ve picked up new OCD baggage. And because I’m sensitive and on the lookout for OCD triggers, I find them.

We’ll see if this OCD dust settles and if I’m able to adapt to this change quickly.

Progress

Two weeks ago…

One week ago…

Two days ago…

Today…

Cataloging compulsive and avoidance behaviors – part 1

Cataloguing all of my compulsive and avoidance behaviors will be important because I will eventually need to do exposure to each one of these things. You can think of these compulsive and avoidance behaviors as the “rules” of my OCD, and they need to be broken in order to take back control. I’ve been working on the big stuff in my sessions with Dr. Osborne, but there is also a bunch of little stuff that I haven’t focused on that takes up just about as much time and energy when all combined together. I keep sitting down to record these compulsive and avoidance behaviors in a blog post, but every time I do I get overwhelmed. I think there is too much to record in a single blog post; too many nuanced details I feel like I need to explain. So, what I have decided to do instead is write a series of posts and elaborate on just a few of these behaviors at a time.

So, here goes. Here is Cataloging compulsive and avoidance behaviors – part 1.

• Exponents of three. There are several behaviors I need to complete in exponents of three, meaning I need to complete them three times to make them feel like they’re done correctly. If it doesn’t feel right on the third time, I need to do it six more times so I’ve done it a total of nine times. If it doesn’t feel right on the ninth try, I have to do it eighteen more times for a total of twenty-seven. After that I usually give up (in the future I’ll indicate behaviors where this exponent rule applies by marking them “(x3)”).

The following are all behaviors that are part of my coming home routine.

• Backing into my parking spot at my apartment (x3): car must be parallel to parking line, the ring formed by the back-up light must fall between two spots on concrete wall behind me. If I don’t succeed, I need to pull out of the parking spot and reattempt (x3)
• Getting out of my car: the parking brake must be engaged first, then the steering wheel straightened so that it is perfectly centered, then I shift from first gear into second and back into first again (x3) to ensure the car is in first gear while parked, then I turn off the car and remove the key, then I ensure the lights are off by looking at the headlight knob to confirm it is in the off position and repeat to my self the word “off” three times (x3), I get out of the car and then lock the door manually (x3)
• Checking the mail: key must be inserted into the keyhole in the mailbox perfectly (x3), and door of mailbox must be opened without any of the keys touching any part of the mailbox (if the keys hits any part of the exterior of the mailbox then I have to go get a cleaning wipe and clean that spot because the default for the keys is that they are contaminated and the keys have just contaminated that spot), I must retrieve the mail without touching any part of the interior of the mailbox (if I do, cleaning wipe), then I shut the mailbox and it must shut solidly without rattling (x3), I turn the key and it must not be concurrent with any sudden noises like a car driving (x3), removing the key has the same rule as turning the key but it also must be a smooth removal without the key sticking (x3), then I must stay and look at the mailbox while I count to nine before moving on
• Entering my building: similar to the mailbox the key must be inserted smoothly into the keyhole in the front door without touching any other part of the door handle or… cleaning wipes (x3), the door is pulled open with the key and key only (x3), if I touch any part of the door with my hand I must clean that spot with cleaning wipes, the key must be removed smoothly without sticking at all (x3), then I must step in the door without the door touching me at all
• Riding the elevator: there are spots in the elevator lobby (if you can call it that) where I’m not allowed to step, when I press the button to call the elevator I must press in the center of the button and depress it without the button listing to one side or the other (x3), the door must open and close in exponents of three, I step in the elevator and press the button for my floor (there are also spots in the elevator where OCD says I’m not allowed to step), I must have my eyes shut while the door closes and I must keep them shut for the entire ride to my floor, I must not move at all while the elevator is moving (not even a finger), I must keep my eyes shut and not move until the door opens on my floor, then I can step out
• Entering my apartment: shoes must be removed outside the front door (there are a few pair that have accumulated there, see Unblock Me! post), my hands cannot pass between my line of sight and the shoes that are outside the front door (if they do, my hands get contaminated with whatever contamination is on the shoe) so I keep my hands high at eye level while reaching for the door, once I slide my feet out of my shoes I must not step anywhere outside my apartment, I can only step my socked foot inside the opened door on the interior floor of my apartment

Can you begin to see why these routine things are taking so much time? I would also note that when other people are around I will most likely break these rules because I don’t want to be embarrassed or look like a crazy person. If any of these rituals is interrupted by another person, I will often go back as soon as that person is gone so that I can complete the ritual correctly.