Alessandra Rizzotti, Licensed Therapist, MSW, LCSW, came to NOCD with a solid foundation in CBT and DBT, but almost no background in OCD or exposure and response prevention therapy (ERP). What she didn’t expect was to recognize, partway through her own training, that she’d been living with undiagnosed OCD and body-focused repetitive behaviors (BFRBs) the whole time.
Alessandra joins Dr. Patrick McGrath, NOCD’s Chief Clinical Officer, on the Get to Know OCD Podcast to talk about the training that turned her from a skeptical new hire into one of NOCD’s Life Changer therapists, and the moment she realized her own OCD had gone undiagnosed for years. Below is the conversation, lightly edited for clarity and length.
Meet Alessandra Rizzotti
Dr. McGrath: Can you give everybody a little bit of background about you, and all of the OCD training you did in graduate school that really prepared you?
Alessandra: I’m a licensed clinical social worker. I had a lot of experience with CBT and DBT in my grad school experience, but I never learned ERP. I guess I sort of learned PE a little bit, prolonged exposure, but not in depth. OCD wasn’t really talked about, other than like a paragraph in the DSM. I had OCD as well as BFRBs but didn’t really know what they were, until I came here.
Going from not knowing anything to becoming a specialist, she said, came down to two things: the training itself, and the sheer amount of consultation available to her.
Alessandra: Constant consultation is very rare. That is not something that you would get often after graduating. The fact that I had access to that almost every day was perfect for my brain that likes learning, and I was constantly going to consults. That’s how I felt competent doing ERP, as well as becoming an expert with OCD and BFRBs, and then learning how to help myself, which was really interesting, going through that whole roundabout way of treating myself as well as others.
Becoming a specialist through constant consultation
Dr. McGrath: We run at least 20 hours of case consultation a week currently, so no therapist here is alone ever. We have Slack, and you have access to me and Tracie, our Chief Compliance Officer. How does it feel knowing that you have that in your pocket, available to you as a specialist?
Alessandra: I just feel so supported and held by you all, and you definitely make me feel like I’m not alone. Especially if there’s a crisis, or if there’s anything that I don’t understand very well, because OCD sometimes takes shape in very strange ways that sometimes don’t make sense to the diagnostics. It’s really nice to be able to brainstorm and work with a lot of folks that understand it very well.
Key elements Alessandra highlights:
- 20-plus hours of case consultation per week, available across specialty areas
- Direct access to clinical leadership, including NOCD’s Chief Compliance Officer, around the clock
- The ability to run consults herself, building toward a supervisory role over time
What surprised her about OCD, and how it reshaped her clinical eye
Dr. McGrath: What surprised you about what you didn’t know about OCD, and how did it change the way you do therapy?
Alessandra: At first I didn’t realize that OCD could morph into other themes, like harm OCD and taboo themes, even though I myself had had those thoughts. I think the treatment, although it seems quite shocking at first, ends up becoming quite creative as a modality. I was mostly interested in what are the ways to play with these thoughts that were quite out there and definitely distressing for a lot of people. Using strategies like cognitive diffusion, and learning how to use ACT principles, really helped me learn how to relate differently to these thoughts, and not take them as seriously with Members as much as they were taking them.
Dr. McGrath noted this is a common experience among new hires: therapists often look back on old caseloads and realize, in hindsight, that they’d missed OCD entirely.
Dr. McGrath: Most people describe to us maybe 15 to 20 minutes about OCD in graduate school, and it’s probably a handwashing case, and that’s it. There’s no other description of OCD. So then people leave school with this notion from TV and movies that OCD is just about washing your hands or straightening things. Maybe that affected you in your own life too, as you learned the subtypes and realized, oh wait, you never even knew that was OCD.
That shift in understanding came with a complicated mix of relief and regret, especially looking back at cases from before her training.
Alessandra: A lot of the times the obsessions around relationships, I thought, were just like, oh, it’s me being a teenager, or that person having relationship attachment issues. Sure, there’s elements of that, but when it becomes so destructive to relationships, or it starts to impact how the relationships are functioning, then you have to look at it from another angle, which I hadn’t considered a lot of the time. There were a lot of cases that, for sure, I’ve had guilt around not treating certain things that I can now look back and say, oh, that was definitely that.
Building distress tolerance, not avoidance
Dr. McGrath: And that’s really the reason for NOCD. Stephen Smith’s experience was going to numerous therapists who treated him with general talk therapy, or told him to do compulsions — told him to avoid, to seek reassurance, to snap a rubber band on his wrist and replace thoughts he didn’t like with ones he did. All of those became just safety behaviors that worsened OCD instead of helping it. That’s what I like about NOCD, and I wonder if you could speak about that as a mission for NOCD, to make sure people get the life-changing care that they need.
Alessandra: I think the work that we’re doing is helping people build distress tolerance, so that they can handle really hard situations. It’s not about learning how to soothe through those situations. It’s about building the strength and resilience to get through hard things. I think oftentimes therapy, or talk therapy, or other modalities can be more about, let’s regulate constantly, get you to a place where you’re constantly mindful, breathing through everything. But maybe we need to learn that it’s actually quite okay to have stress and anxiety, that those are normal things to have. OCD isn’t normal, but being able to approach it as though, okay, these are things I can handle, or I can tolerate, that sort of shifts the mindset and helps people get through their thoughts.
Support system and growth opportunities
Dr. McGrath: All of us have cases we may feel a little stuck on. How do you feel supported to get through those experiences here at NOCD?
Alessandra: Absolutely supported, because there’s different consults for different situations. We have a consult for eating disorders, a consult for hoarding, a consult for BFRBs and tics. All those specialties can really help us navigate when the comorbidities are crossing in different ways, and it makes it challenging to tackle both at the same time, or one when it springs up. I definitely feel quite supported in figuring out interventions.
Dr. McGrath pointed out that all of this rigor comes down to one thing: making sure members get life-changing, evidence-based care they can trust, without repeating failed treatment attempts they may have had elsewhere. He then asked whether she gets to voice her own ideas, and what happens with them.
Alessandra: There’s a Slack channel where we get to support other therapists and give feedback. We also get to give feedback in the consults. Now I get to run a consult, so I feel like I get to build that skill. It’s making me feel a little more empowered to offer support to therapists, so that maybe I can get to a place where I can also be in a leadership role at some point. My goal also is to continue developing as a supervisor, and I’ve gotten that opportunity. I think NOCD really cares about helping people feel like they’re growing and changing with the company, because the company’s constantly changing. I even really love that we get to give feedback on the tech. That’s a really cool part of the job too, working with different teams that have different skill sets.
That kind of rigor, Alessandra said, extends all the way back to how NOCD trains and prepares its therapists in the first place.
Alessandra: I don’t think there’s a lot of companies that actually offer that level of rigor, and I think it prepares you for being able to handle different types of cases. I’m grateful for it. I wish that more companies did that level of training. That is what I sought when I was in grad school — I need a good training program, because oftentimes even in grad school, you’re not necessarily getting a good training program on modalities. There’s even a training page, where you can go and take classes outside of the CAMs we do, and we get mentorship. It’s a very special company, and I don’t think a lot of people realize that level of rigor is actually very beneficial for growth as a therapist.
Rewards and community: Cabo and New Orleans
Dr. McGrath: There are rewards for people doing excellent work here. You had a chance to go to Cabo. What was that like, to be somewhere where you’re recognized for excellence?
Alessandra: I was so shocked that that could even be a thing that a company would do for its therapists. I felt so special and so honored, and it was really cool to meet people in person, because we are a telehealth company. Oftentimes people will say, oh, you’re telehealth, so you don’t get to know your coworkers. Actually, I feel like I know my coworkers way better than I did when I worked in a facility, because we are constantly in communication on Slack. We go to consults and conferences together, like IOCDF. But this trip was even more special because we got to really get to know the founders and other folks on different teams.
Dr. McGrath: We also just recently were all in New Orleans together, as a company trip. We set goals, and when we achieve goals, we reward those goals. What was that experience like for you?
Alessandra: Oh my god, that was even more amazing. We had these amazing little get-togethers that we would get to go to. I got to go on a jazz tour with some coworkers. Other folks did a little bayou expedition. We were welcomed by a parade. I don’t know any company that would do something like that. It just felt so special and so thematic and integral to what we do at NOCD, because it was almost like we were having days of exposures every single day, and we got to do them together, and we got to meet each other from all across the United States.
Dr. McGrath agreed it was an amazing time, and said he’s always glad to hear directly from therapists about what’s working and what could be better — pointing to NOCD’s innovation Slack channel, where any idea, no matter how small, gets passed along to engineers who can help build it.
Therapy through technology
Dr. McGrath: As you’ve integrated from therapy that we learn in graduate school, which is generally that one-on-one in an office experience, to now all the technology that you have available, what’s it like to do therapy through technology and with technology?
Alessandra: The fact that we can communicate with our members and inspire them to do homework in between sessions, it’s not so closed off and sterile the way you would experience in a non-tech company. In my experience elsewhere, it’s like, oh, you’re only talking to your therapist to schedule a call. But here we’re like, let’s inspire you to do ERP throughout your life, so that you can become an ERP therapist for yourself eventually. I think it also helps build and strengthen the relationship and the rapport between the therapist and the members. Tech has been the best way to go for me as a therapist. That’s not for everyone, but for me, I have really enjoyed the way it has transformed my ability to be a therapist in a way that’s more helpful to members sometimes.
Advice for anyone considering NOCD
Dr. McGrath: Any final words for people who might be considering joining NOCD?
Alessandra: It’s kind of funny, because when I first got here, I was skeptical. I was like, oh, but it’s a tech company, and they’re new, and I don’t know. I was hesitant, I will be honest. However, once I got involved in the level of training and felt really supported by the staff members, I was all in. So I think just open your mind to the idea. If you’re scared about the training process and how rigorous it is, I encourage you to stick with it, because it will help you grow as a therapist. It will push you and make you uncomfortable, and honestly, that’s a good thing.
NOCD’s mission is to restore hope for people with OCD through better awareness and treatment, and we know the key to that mission is investing in our therapists, to ensure they’re equipped to deliver this life-changing care. If you’re a licensed therapist looking to deliver specialized, evidence-based care and want to see if NOCD might be the right fit, visit our careers page to learn more.
