ERP therapy for OCD treatment with Christina Byington

Dan King:
[0:00] Hello, everyone. Dan here, as per usual, and I am very confident that we’re going to have a meaty conversation today with Christina Byington. She’s the owner and founder of Elevation Behavioral Therapy. Welcome, Christina, and please give the audience the basics on Elevation.

Christina Byington:
[0:16] Hi, Dan. Thank you so much for having me. Yeah, so Elevation Behavioral Therapy is a group private practice based in Denver, Colorado, and we provide teletherapy throughout the state of Colorado. We work with children, teens, adults, couples, and families. And a huge focus of our practice is working with OCD and related disorders. And within that, as I’ve expanded the practice over the years, we’ve also been very intentional with looking at the clinical backgrounds of the clinicians we’re bringing on. And we have subspecialties within that OCD focus as well.

Dan King:
[0:49] So you’re 100% teletherapy?

Christina Byington:
[0:52] Nope. We have an in-person office in Denver, And then we also do teletherapy throughout Colorado.

Dan King:
[0:58] Got it. Okay. And you mentioned OCD. So I’m curious to learn, did this become a specialty of the practice in part because of your own skill

Dan King:
[1:07] set, in part because of the clinicians you found, patient demand? What were all the ingredients that made this a specialty?

Christina Byington:
[1:13] Yeah, great question. So I’ve had the ERP training for 10 years now, exactly 10 years almost to the day, which is really funny. And back in the day when I started my career working in mental health agencies, people were consulting with me for OCD cases, and that was community mental health. And then I joined a large insurance-based group practice, and I kind of became known as the OCD clinician within that group practice. People were reaching out all the time, can you work with this client? Can you help me consult on this case? And I was just absolutely loving that. So then when I started my solo practice, as most group practice owners will say, I never set out to do a group practice. It just kind of organically unfolded. There was just such a demand for it. And I had a waiting list. We were getting a lot of requests. And it was just making me nervous, you know, referring those requests out. So we really intentionally focused on working with OCD and having a big focus on ERP. And then as we grew over time, that has expanded within the practice too.

Dan King:
[2:16] Very cool. And I’m going to ask you a bunch about ERP in a bit. But you mentioned, I want to pick up on something you said just now, which was, it was really fun. What was it that’s so enjoyable about this work in particular for you? If I’m a clinician in a group practice and I’m thinking about how I want to specialize, what’s really fun about it for you doing this work?

Christina Byington:
[2:35] Yeah. And I will say it’s such a specific type of therapy. So you have to really love it. It shouldn’t be something that you just randomly land on. But people really get better. And the treatment is so effective to the point where a lot of my clients will come in for treatment with severe symptoms. By the time we’re wrapping up therapy and they’re being discharged, they’re no longer meeting DSM criteria for OCD. So it’s not like a lot of other therapies where the person is just learning to cope. They really get better and they can live these lives a lot of times almost symptom-free

Christina Byington:
[3:11] or with really minimal symptoms.

Dan King:
[3:13] I’m sure that’s super satisfying to relatively quickly get to that point where you can address root cause. Why is it that with OCD in particular, what is it about OCD that allows you to make such dramatic progress with the right therapy?

Christina Byington:
[3:28] The person is quite literally facing their fears and anxieties. So if someone has a fear of flying aerophobia, we’re eventually working out to the point where they’re getting on a plane and they’re flying. So basically, you’re retraining your brain to no longer be afraid of this thing that you’ve feared for so long. And if we can face that thing that you’re afraid or anxious about again and again, your brain is going to learn, there’s no reason for me to fear this. We’re basically rewiring your brain.

Dan King:
[3:56] And so tell me about the training here. So again, imagine that I’m a clinician and there certainly are folks in the audience that are group practice clinicians or clinicians considering working at group practices. And I’m intrigued by this. What kind of training do I need to do to get good at exposure and response prevention therapy?

Christina Byington:
[4:12] Yeah, it’s so funny the way the whole clinical world has evolved. Because when I did my initial ERP training 10 years ago, I flew to New York, and I was there for days at a group practice in person. And now you can do everything virtual, which there’s just so many more options for it now, which is great. So there’s a lot of online virtual trainings that you can do. I still like the in-person component. I like going, I like talking and connecting with other clinicians. I find it’s a different feel. But if you want to start out doing a virtual training, that could be something that you look into multiple days live online.

Christina Byington:
[4:45] And then after that, I really, really cannot stress the need for consultation. It’s not a training that you just do once and then you’re done. You really need to be connecting with other clinicians and consulting on cases because treating OCD and related disorders is very complicated and very complex. And while you will sometimes see similarities amongst patients, there’s so many different subtypes that you really need to have that consultation piece to be doing it effectively.

Dan King:
[5:13] And learning what I’ve been learning that ERP is really the gold standard for OCD treatment, is it hard to find? Are there very few clinicians that are trained in ERP? Yeah.

Christina Byington:
[5:24] So my practice is unique in that I only bring on fully licensed clinicians. Not to say that there aren’t other group practices out there that do this, but I really haven’t found any other ones, at least in the Denver metro area. A lot of group practices are heavily relying on interns or pre-licensed clinicians. Even with licensed clinicians, there’s you that do it. And what I’ll find a lot during the interview process is some have maybe done a little bit of initial training or have tried some of the concepts of ERP with clients before, but they haven’t really been doing it a ton, a ton. And that’s okay. It’s really the interest and the passion for working with OCD is what I’m looking for. If someone is not really excited about working with OCD, they’re probably not going to be a good fit for my practice. And so I really look for that and the training piece we will provide to you because that can be learned and we can be consulting on cases as they’re moving

Christina Byington:
[6:20] along within our practice.

Dan King:
[6:21] That’s a strong statement that I don’t hear very often. You’re probably not going to be a great fit if you aren’t really, really interested in addressing OCD. So this is, I’m going to presume, at the core of how the practice brands itself.

Christina Byington:
[6:36] It is. And it’s really interesting. Just this past week, I did a poll. I asked each of my clinicians about what percentage of your caseload is OCD or related disorders. And certain clinicians had very high proportions of that. And for example, we have one LMFT and she provides our family and couples therapy. Her percentage of OCD and related disorders cases was much lower than the other clinicians. So it also depends on subspecialties a bit, but I would say working with OCD is kind of the meat and potatoes of what we do. And then in addition to that, you know, we have our sides, right? We have our other things that we see and treat as well.

Dan King:
[7:15] Thinking through just the implications of a world in which group practices make very intentional choices like this, because the norm is you’re starting a group practice, you kind of take what comes in the door. You find clinicians and, you know, hopefully if you have a good interview process, you’re getting some higher quality clinicians, although that too is pretty hard because we have such a shortage in most parts of the country, right? So the general norm is I start a practice, I find clinicians, I try to find clinicians that are as generally capable as possible,

Dan King:
[7:44] and then I take what comes in the door. That’s really the norm. So it’s very, imagine a world in which instead we were intentional about saying, you know I’m going to try to find the best clinicians to help people with very common problems that they tend to have.

Christina Byington:
[8:01] I really take my time with the hiring process. I’m very slow to hire. I’m not in a rush. I find that if people are in a rush, then you end up with fits that are not necessarily ideal for you long term. And I think I’ve been really fortunate because we’re out of network only. We’re able to pay our staff well. I really believe in paying people well, both admin and clinical staff, because they have really demanding jobs and everyone went to grad school with this. And I really want to be able to take care of the people that work for us. And so I think because we’ve been able to pay them well and also develop this really nice community. We’ve been fortunate where we do get a pretty high volume of applicants when I’m hiring. And because of that, I think I’ve been able to really be selective with who we bring on.

Dan King:
[8:48] Do those applicants, do you think, know that at least an interest, if not strong experience in OCD is going to be really helpful in the hiring process?

Christina Byington:
[8:57] I put it in the job description. So first couple lines of my job description, really focused on working with OCD and related disorders. And then I find some clinicians come into the interview process very aware of that and talking about OCD and some are like, oh yeah, I think I saw that on your website. Cool, right? It’s kind of a mixed bag. But one of the questions I asked in the interview, one of my first questions is, what is your experience working with OCD and what is your knowledge of exposure and response prevention therapy? And then that question right there really tells me a lot.

Dan King:
[9:30] Do you find also that the primacy of OCD is really helpful in marketing because typically when you’re getting a totally self-paid practice off the ground, marketing can be very challenging. And so is OCD helpful for you from a marketing perspective that you can really specialize and speak to the needs of a particular group of people?

Christina Byington:
[9:50] Yes, I would say so. I think that there’s been such a demand for it. And we really focus on providing very high quality services. And since we’re out network only. My clinicians have lower caseloads, smaller caseloads. They see a smaller number of sessions per week. And therefore, they’re really able to provide this white glove, very high quality therapy, which has just been so helpful in terms of our group practice. If you want to go to a practice that, you know, it’s a $5 copay, and someone can get you in, and maybe they don’t have a ton of experience, we’re definitely not your practice. But if you want the highest quality therapy possible and a clinician that’s available to see you and has a smaller caseload, that’s our practice. So we really try to cater to very, very high quality services.

Dan King:
[10:40] What are some of the trade-offs here? So it’s, you know, from this conversation so far, to be able to specialize this way, when you combine specializing in a certain condition and you combine the self-pay element, you know, there’s this powerful through line, whereas you say you’re able to

Dan King:
[10:55] attract really high quality talent, you’re able to provide a really high quality service. That all sounds pretty cool. But what are the trade-offs? Like what is harder for you to do? What would be easier for you to do if you had an in-network element in the practice?

Christina Byington:
[11:08] Yeah, I would say probably just our business expenses are higher because every single thing that I do for the practice, I’m so intentional about and I really don’t cut quarters. So I didn’t just get an office. We got a really nice high end. They call it, I don’t know if you’ve heard the stand before, grade A building. I’m like, is there B, C, D? That’s in our lease.

Dan King:
[11:34] Building here.

Christina Byington:
[11:34] Yeah. Right. I was like, oh, grade A. Okay. So we have a really nice office building with a doorman. There’s a gym in the building. There’s a restaurant coffee shop in the building. And when I was touring office space and signing this very lengthy multi-year lease, I’m thinking to myself, what do our clinicians really need to thrive? Well, if there’s a really nice gym in the building, they can go work out in between sessions. They can go grab a coffee. They can grab breakfast or lunch. That’s great. And so I think the level of attention to detail has benefited us in terms of our services. But obviously, you know, our rent and things like that are more costly than a lot of different places that you might look.

Dan King:
[12:14] That makes sense. Is it also the case, you know, if you’re looking for not only really high quality clinicians, but clinicians that have at least OCD interest, if not experience, does that limit your growth potential?

Christina Byington:
[12:26] That’s not something I’ve ever been super concerned about because I don’t want to get super big. You know, I really love our community right now, including myself. We’re a team of nine admin, eight full-time clinicians. We’re going to be a team of 10 here in the relatively near future I’m interviewing right now. But for me, it’s really about quality. And I don’t necessarily think the biggest is always the best.

Dan King:
[12:51] Yeah. No, no, no. I agree with you. The biggest is not always the best. I’m just thinking through all the trade-offs you’ve got here. So, okay, so going to be 10 shortly. That’s awesome. And is there kind of an ideal number that you’re shooting for? You’re going to kind of just make sure to see how things go, grow as you grow, and… Sort of get a feel as you go for what the right size is.

Christina Byington:
[13:12] I would say as of right now, we would be capped at a team of 10 to 11 because of office space. I don’t have any plans as of this moment to expand office space further. Within our office space, we have a waiting room, we have four individual therapy rooms. That feels good, but never say never. I do want to see as time goes on and things evolve, how everything is feeling and going and also just be open-minded to what unfolds.

Dan King:
[13:40] Speaking of what has unfolded, though, you have built something pretty cool pretty quickly, right? I remember when I met you the first time, I was thinking, huh, okay, this has been built quite quickly. It must have been quite a hustle and grind to get to this point as quickly as you did.

Christina Byington:
[13:55] Yes, I do not recommend it, especially people that really value work-life balance. Dan, honestly, it was like 80 to 100 hour work weeks for several years, really, to get to this point, because there was no cutting corners. Every single thing that I was doing, I was just really paying attention to. I was that person that was to my website design team. I’m so sorry, but can we move this line of website copy half a centimeter to the left? I was that person. So you can imagine just what’s involved when And that’s the level of attention to detail. So, I mean, it really has been just paying attention to every small, minute detail within the practice and then proceeding accordingly to get to this point.

Dan King:
[14:42] So your workload is reduced now. Now you have the chance to breathe a little bit.

Christina Byington:
[14:46] Mm hmm.

Dan King:
[14:47] Yes.

Christina Byington:
[14:47] That’s been very nice.

Dan King:
[14:49] I can imagine. I can imagine. Do you see yourself, so beyond OCD,

Dan King:
[14:53] are there kind of specialties two and three? So are there things that you find when it isn’t OCD, the conditions or treatments that are, you know, quite high up the priority list, or is everything else after OCD just sort of a grab bag?

Christina Byington:
[15:07] Yeah, great question. We do a lot of EMDR now. Four out of seven of our clinicians are trained in EMDR. We have a couple more that are really interested and excited about getting trained. So we’re working with EMDR and doing trauma work as well. We have a clinician that’s comprehensively trained in DBT, and she offers a DBT skills group that meets once a week for 90 minutes. And we’ve had really wonderful things come from that. And a lot of our clinicians are trained in ACT. So we kind of complement ACT and the values-based work with ERP. And we find that that’s often an important part of working with OCD as well. And then we have clinicians that, you know, have their own personal background. We have someone who’s really passionate about working with LGBTQ plus folks. We have someone that’s really passionate about working with highly sensitive persons. So within that, our clinicians have their own backgrounds in addition. And that’s where really knowing your team when clients are reaching out to book comes in handy.

Dan King:
[16:08] Now, at this stage of practice, and thank you, that’s very helpful to give folks a sense of beyond OCD, what the practice offers. At this point in the practice is evolution. Are you still seeing patients? If so, how many are you seeing? Or are you fully on the business side?

Christina Byington:
[16:23] Mm-hmm so i actually went on maternity leave i just came back towards the beginning of april we had our first baby late january so what happened with that it actually worked out really beautifully i was seeing a number of patients pre-maternity leave and i hadn’t taken new clients in years and basically i had a talk with each one of my clients anyone that it felt appropriate there was like one person where i’m like nope we’re gonna keep working together but everyone else i said, you know, I’m going to very strategically pick a clinician within our practice for you to work with while I’m on leave. And I just want you to open your mind up to the potential of working with them once I come back from leave. You know, I really picked this person based on feeling very strongly that they would be a great fit for you. So I just want you to be open minded to that. And I think because I was very mindful of picking the fit, and also I’m sure the session rates being at a different price point than my rate as the owner. I think for most folks, finances are a factor. So I think that that played a role as well.

Christina Byington:
[17:26] And I was gone for a few months. And when I came back, a lot of those clients were, in fact, very happy with their clinicians and wanting to stick with them. So now, since I’ve been back towards the beginning, mid-April, I would say I’m seeing, it’s probably about like six to eight a week right now. Thank gosh, because I’ve been able to really focus on the business piece of

Christina Byington:
[17:48] it, because that is a full-time job in itself. And there were times where I’m like, I need to be in three places at once right now, and this is not working. So I think maintaining a small caseload and being able to really run the business and the practice, that’s a really good balance now.

Dan King:
[18:03] We’re able to approach this question of fit because there’s ginormous Silicon Valley companies with huge budgets that have their own algorithmic approach to determining, hey, this client is a fit for this therapist. And I definitely have my skepticism about some of those approaches, but how would you describe your own process beyond realizing, all right, this person has OCD and this person is excellent at ERP. Beyond that, how would you describe the process you went through to determine client therapist fit?

Christina Byington:
[18:35] I think a lot of it is really knowing your clinicians, not just their clinical skill set, specialties, and background, but also their personalities. So knowing this person really needs someone very warm and nurturing. Okay, this clinician within our practice is that person. This person needs someone that’s maybe a little bit more direct and challenges them. Okay, this therapist is the right fit for them. Because yes, we can have these clinical backgrounds and these educational backgrounds, but a lot of it is really based on how the person shows up in the room, their personality, and that relationship. You know, that’s really at the core of everything that we do as clinicians.

Dan King:
[19:16] When I was doing coach training, one of the first questions we were taught to ask clients was, how would you like your feedback on a spectrum of super direct to extremely gentle, extremely diplomatic, right? And you’re right. People do have such, there’s such a wide range of needs and coaching is different from therapy. But I guess in either case, you can have clients that have a wide variety of different needs and personality types.

Christina Byington:
[19:41] Absolutely. Yes, I would for sure agree with that.

Dan King:
[19:44] Talk to me a bit more about DBT. This is one that I see from time to time where I think my experience of it is there’s a lot of practices that really like DBT. There’s a lot of therapists that like DBT. It isn’t necessarily in huge demand. So, you know, a lot of people in the therapy world think Marshall Linehan is great. But does the average patient when they’re Googling search for DBT? Maybe a little less so. Talk to me about DBT, how it’s working in your practice, and do you find are patients looking for it or is it more something that you help them understand they could benefit from?

Christina Byington:
[20:17] Both. I think some reach out specifically for a DBT skills group or to work with a clinician that’s comprehensively trained in DBT. And then some, it’s really the clinician explaining the benefits of the therapy, how the therapy works, how it can serve them. I think really for anyone that’s looking for distress tolerance skills that wants to incorporate mindfulness into their lives and is really working on addressing their interpersonal relationships, which all of us can benefit from those things, right?

Christina Byington:
[20:45] Even very high functioning folks, DBT is really a great fit for that. So we do have folks with BPD that are doing the group, but we have a lot of folks that are seeing us for depression, anxiety, OCD. Maybe they’re just going through a life transition. You know, they just broke up with their partner. They’re going through a divorce and DBT skills is really fantastic for that, too.

Dan King:
[21:07] So you’re hiring a 10th clinician. You’ve got some great systems set up. You’re able to allocate a lot of your own time to the business more and more. What’s next? You’ve decided, you know, you don’t want to grow too quickly. Maybe you don’t even want to grow too much at all, which I can completely respect and understand. So if all those things are the case, what’s next?

Christina Byington:
[21:26] Yeah, I think just really continuing to cultivate this community of like-minded therapists that we’ve created, making sure that the clinicians are really taken care of. Because I think at the core of everything that we do, we need to have happy people working for us, making sure that they have a good work-life balance, making sure that they’re feeling really confident in their cases and the work that they’re doing. And it’s not always about necessarily growing or the next big thing. I think a lot of it is really nurturing what you’ve already built. So that’s really what I’m focused on right now.

Dan King:
[21:59] Very interesting. I don’t know. I’ve certainly spoken to other practice owners that have a limit either defined explicitly or just a general sort of energetic sense that they don’t need to grow. But your answer there was a little different when you said, yeah, I really want to focus on nurturing what is here, right? I think that’s a really thought-provoking answer because as business owners, there’s this natural desire to grow, grow, grow. And there’s something beautiful in approaching sometimes with a mindset of, you know, I’m quite satisfied with what is here and what is here before growing can be improved.

Christina Byington:
[22:37] You know, Jean, I think a lot of it really comes back to values too, because we can hustle and grind and make our practices bigger. But at the end of the day, what do we want our lives to really look like and what do we want to be able to focus on? And I think when you bring up the concept of growing much larger, getting a second office location, okay, well, there’s a lot of things that are going to have to happen to be able to make that happen because I can’t be in

Christina Byington:
[23:01] four places at once, right? So I think in terms of values, it’s really focusing on kind of the here and now and what we’ve already built.

Dan King:
[23:09] I disagree. I have a cloning machine in the back here, so I’m quite confident you can be in four places at once.

Christina Byington:
[23:15] Can I get one of those, please? That would be great.

Dan King:
[23:17] I’ll send, I’ll put the invoice in the mail.

Christina Byington:
[23:19] I love it.

Dan King:
[23:20] I love what you just said too. It makes a lot of sense. I mean, intentionality really is such a key theme in this conversation, right? You know, from the beginning, well, it isn’t as if you haven’t reacted to what’s unfolded. There also is just such an intentionality to everything you’ve built from choice of specialization to choice of clinician to office, right? And so does that always come naturally to you in everything that you do? Or is that something you really cultivated and developed over time, that quality?

Christina Byington:
[23:50] I think I have a strong gut and strong gut feelings with things. And then I think the level of attention to detail, that part does come naturally, but it’s also something I need to check and adjust. You know, I think with being a group practice owner, it’s hard to turn off your brain a lot of the times. So I’m laying at bed at night and I’m like, how am I going to solve this problem? Or, oh my gosh, what piece of furniture am I putting in this corner of our office because I want it to be something really nice. And I’ve already looked at six websites and I can’t decide, right? So I think it’s a little bit of both. I think it’s really listening to your gut and that intuition piece. And then I think sometimes too, just giving it time to marinate on things. Because I think a lot of times business owners can be a little bit impulsive with the choices that they make. And one of the things that I’ve really started to do is if I’m trying to figure out how to work through an issue or a problem, I put my AirPods in and I go workout. I either go for a jog or I go to the gym or a workout class. And moving my body really helps me to be able to think. And I’m speeding up the speed at which I’m moving, obviously, but my mind is kind of slowing down.

Christina Byington:
[24:57] And that way I can really make informed choices versus just making a choice. And I think that that’s really served me well as in addition to everything.

Dan King:
[25:05] Nice, nice. I’ve been playing around over the past couple of years with what’s called the MIQ process, most important question. So when we reach those, sort of business-y moments where there’s a decision to make and you’re really just not quite sure what direction to go in. You can decide rather than sort of impulsively making a decision when you know that it would be worth approaching this from a different angle, but I’m not sure how to do that. When you finish work for the day, you can, and this is similar in a lot of ways to moving your body, I think, to your approach, you can write that question down on a piece of paper. It’s the MIQ, the most important question. You can go to bed making sure to place a notepad right next to your bed. And when you wake up first thing in the morning, just as your subconscious is kind of humming along before you race into action, so often your subconscious will spit out a response that may be so different than you might have expected.

Christina Byington:
[26:00] Oh, that’s such an interesting approach. I love that. Yeah. And it really goes hand in hand with not being impulsive with really kind of giving yourself time to just rest and be and process and allowing the answers to come organically.

Dan King:
[26:14] Yeah, it’s so tempting to take action. I think there’s that part of all of us that wants to succeed now, right? And that part of us diminishes our ability to be in touch with whatever inner wisdom beneath, right, exists. And I think for all of us, there’s always something.

Christina Byington:
[26:33] Yeah, and I think it’s a balance too, because if we’re too impulsive, then maybe that wasn’t thought out and planned out. But if we take too long, then there’s a procrastination element as well. So you need to kind of find your sweet spot as a business owner with hustling, grinding, making things happen, and also really thinking them out and making sure that you’re being thoughtful with your actions. But you don’t want to hold off for too long, because then you’re procrastinating action-oriented items that need a next step.

Dan King:
[27:02] I have this hunch that for most of us business owners, we’re probably in the camp of acting too quickly, probably the balance for so many of us. I speak for myself here, but a lot of business owner-y folks, the temptation to act by nature are so much in that first camp that we can all use a little rebalancing.

Christina Byington:
[27:22] Yes, absolutely. Yeah, it’s tempting to do for sure, especially when you have

Christina Byington:
[27:26] a million things going on.

Dan King:
[27:28] So this has been a very interesting, rich conversation as I knew it would be as we come towards the end of our time together when you’re not building this great practice now that you have slowed down a little bit. What do you do for fun?

Christina Byington:
[27:41] Yeah, well, we live in Colorado in a Denver suburb. And my husband and I have two adorable French bulldogs. And we just had our first baby in January. So a lot of time outside, walking, biking. We love to go skiing in the winter, really just trying to get outdoors and be as active as possible and soak in everything Colorado has to offer. And we’re definitely a family that likes to travel a lot and do a lot of trips. So we definitely try to make that a priority.

Dan King:
[28:06] Well, congratulations on having your first baby. That’s awesome. Congratulations on building such a great practice.

Christina Byington:
[28:12] Thank you so much, Dan. It’s been great talking to you today.

Dan King:
[28:15] Okay, for me as well.