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Foreign.
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Hi, everyone, and welcome to another episode of the get to Know OCD podcast. I'm Dr. Patrick McGrath. I'm the Chief Clinical Officer for NOCD. If you're looking for help for OCD or related conditions, please check us out@nocd.com that's N O C D dot com. William Schultz is back for part two. We had talked about at the end of the last one that there was so much that we'd gone through that we didn't even get through, everything that we wanted to get through. But your story was so fascinating and interesting and just the detail that you went into. So I really appreciated it. So today I wanted to more focus on your work professionally, as obviously having OCD kind of influenced how you approach your work and what you do and what you research and who you collaborate with and all of those things. So just for a little reminder, in case anyone didn't see the first episode, could you just give everyone a little reminder of who you are, what you do, and then we'll get into some more questions around career and research today?
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A
Yeah. Thanks again for having me back, Patrick. It's a real pleasure. I'm William. I'm an OCD survivor, had OCD from 2007 to 2017, did some research, got into the clinical side of things, and now I'm a therapist. And my. My practice in St. Paul, and, and I. I work primarily with people dealing with. With ocd. And I think we had planned today on talking more about some of the research side of things, how that informs clinical practice, things that could be interesting to people who are veterans of the RP or maybe clinicians. But I think we're going to have a lot of fun kicking it back and forth, seeing how some of the ways that I would describe some of the concepts that I'm using with my clients interacts with your long history of working with ocd. Is that about right?
- [02:09]
B
Yes, I would say that that is correct. And actually, I know where I'm going to start already, because you talked about having OCD from 2007 to 2017, which I think might surprise some people, because we of course, talk about OCD being something that's chronic condition. Would you still say you have ocd, or would you say that you figured out how to live with OCD and now it's not really that much of your life anymore? How would. How would you describe it?
- [02:34]
A
I think it's a great question because there's. There's not 100% agreement on what counts as remission from. From OCD. How I characterize it when I am discussing it is my OCD related experiences are a negligible part of my life. I, I still do experience thoughts from time to time, and every now and again, I'll, I'll experience some anxious activation related to my thoughts from time to time. It's nowhere near what it was like when I was in the, in the middle of that process, but it's, it's very easy to handle. But that doesn't mean that it's effortless to handle. Every now and again, I'll, I'll have an experience where, you know, maybe I, maybe I get to a 2 or a 3 and I need to remind myself, hey, this looks a lot like ocd. Probably is. If I do this thing I kind of want to do to feel better, that's probably a safety behavior. So what's my choice here? So it's not 100% gone, but not a big part.
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B
Awesome. Tell us about your work, your research, what you do, how obviously you took kind of what was going on in your life and then brought it into your clinical work and all those things. What's, what's the story of that?
- [04:02]
A
Oh, well, I, I, I'd like to get your feedback on this, Patrick, because there's a number of different things that we could talk about. I don't know if I'll have a chance to talk about all of them, but I'll, I'll throw some your way and then you tell me which it feels most fun to go to.
- [04:17]
B
Let's see which ones we grab.
- [04:18]
A
Yeah, yeah, yeah. So in my professional research, my, my work is focused on what we could call biogenetic etiologies of ocd. And I was so honored and happy when that research got used in the international competency guidelines for adult OCD treatment. In terms of what clinicians need to know about the causal story behind ocd. And the reason that is something that I did was, well, in part because I went through the experience and I was very curious as to, like, why was this happening? But in part because it's such a common question that my clients have when they come to, like, why am I experiencing this? Why does it happen? And it makes sense that that's a common question, because if we know what's causing what, then maybe we can know what we're supposed to do about it. So that's one thing. Another thing that I was hoping we could spend some time on today was metacognitive approaches to OCD treatment. It's a broader subject, but I was really looking forward to getting the chance dive into some of how I describe that to my clients. That's a really interesting area. I think it's a lot of fun. I've had lots of experiences with clients, you know, anecdotally, who have benefited tremendously from this. And it's an evidence based practice, so that's, that's cool too. And then the other thing that was on my mind, Patrick was talking a little bit about the role of commitment in OCD treatment. And the reason that's on my mind is understanding what OCD is, what the, what the treatment looks like. For example, if you're, if you're going to use erp, what ERP is, how it's supposed to work, what that's going to look like in practice. I mean, it takes some time, but it's, it's not like, you know, it's not high level rocket science stuff. It pretty much everybody can grasp it. That's not really where I see people getting caught up and it's certainly not where I got caught up in, in my own OCD experience. What I got caught up in is it's scary, it's scary to do and it really makes it a lot easier to do if you've made the committed decision to go for it. And you know why you've made the committed decision to go for it? Because if you, if you hadn't really committed to the decision to overcoming ocd, it's just going to be a lot rockier road because you're going to find all kinds of reasons not to step into those really tough exposures.
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B
Yeah, you know, I, I get this on the webinar all the time. So I'm actually interested in starting there, if you don't mind. Just on this commitment. And it's scary. How do you motivate people to do this? I have used this phrase sometimes there's an Irish phrase that says only an Irishman can tell you to go to hell and make you look forward to the journey. And I think about ERP like that sometimes that we're going to ask you to do something really, really difficult and hopefully get you excited to do it. Right. And so how do you get people to commit and do scary things? I'd love to start there.
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A
Well, for starters, I wish that I had the foolproof magic way to get someone to commit, because you don't. I'm very confident that. Yep. Don't have the, the full proof.
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B
This interview sucks now. I mean, geez, I thought you were Going to give us the full. All right, well, keep going.
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Any.
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Let's see what you.
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But here are some of the. Here are some of the ways that we can maybe increase the, the, the chances. The, The. The first thing is just making sure that the person is understanding what my clinical assessment is that, yeah, you meet the diagnostic criteria for ocd. This is what OCD looks like. This is what it looks like in your life. This is what it looks like in other people's lives. It's always for people who have been in the dark a long time about what's going on, that is a really helpful experience. And oftentimes putting a label on it gives them a little bit of a hand when they're leveraging that to make the committed decision to step into the exposure. So that's part of it. However, as you and I both know, and any OCD veteran knows, and maybe even some people beginning the OCD world or the OCD healing process know, we do not get a guarantee. And to me, what that means in clinical practice is having conversations, sometimes prolonged conversations, as what it is that would make someone willing to take the risk. Because that's what this is. This is a calculated risk. I would never characterize it as a realistic risk. I would never ask my clients to do an exposure that's realistically risky.
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B
Right? Yeah, nor would I.
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But feared events could happen, whatever they happen to be, even though the chances are probably negligible. And there's lots of ways that that that conversation turns up with people. And one. One example of how that conversation goes is, well, OCD almost never goes away on its own. And one of the things that that means is at some point in your life, if you don't make the committed decision to really go for it and, and really challenge this process, it's probably going to be largely in control of your life until the end. And that's a really sad story because if you get to the end, let's say, you know, 80, 90, whatever, and you lived your life and, well, you were alive and OCD was calling a lot of the shots. My guess is that that would be a very sad realization that, oh, my goodness, I kept saying not now. I kept saying not yet. I kept saying not quite ready, kept saying not quite sure, and month after month turned into year after year, and now I don't really have a chance to live a life without OCD being in charge.
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B
Yeah, I love that distinction between living the life I want to live and living the life OCD wants me to live. Right. That's right. That those are your. Those are kind of the choices that a lot of people feel stuck between.
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A
Yeah. And. And my guess would be that certainly this is what most of my clients tell me is that in a. In a world where they. They live their life in the sense that they're alive and they go through each day, but lots of intrusive thoughts, lots of painful emotions, a lot of safety behaviors, and they get to the end 50, 60 years later, whatever it happens to be. I'm sure that they would be willing to give pretty much anything to get a chance to go back in time and give it a shot, take the chance.
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Say, hey,
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I don't know if I really want to go through the life I just lived where OCD was calling the shots all the time. Maybe that would make me willing to take the chance. And that might not be everyone's decision, of course, but that can be a useful way of looking at it. And it relates to what turned the corner for me in my. My experience where the last three years, I knew I was supposed to do ERP but I just was too scared to do it. And it was something along those lines where I was realizing, like, this isn't. This isn't going anywhere on its own. And it's. Patrick, when you hear me talking about the committed decision, for me, it's about where you're prioritizing OCD treatments in your life. Because if my priority was, well, I really don't want to have ocd, but I definitely don't want to die of rabies. Well, if not dying of rabies is my top priority, well, then I should be doing my safety behaviors, because it's not a guarantee I won't die of rabies, but it increases the chances of it, you know, if I check that piece of garbage, whatever.
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Right, right, right.
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But if my top priority is overcoming my ocd, then I need to abstain from my safety behaviors. But my intrusive thoughts will immediately tell me that this might be the mistake that kills me. And what turned the corner for me is when I was able to not just say, but to enact, well, probably not, but maybe. And if it's the case that this is the mistake that kills me, I'm not going to like that, because why would I like that? But it. But at least I took the chance to bravely confront this thing that was ruling my life, and I can honor that, even though I don't like the outcome. So for me, the core fear was not actually dying of rabies. The core fear was missing my chance to be brave. And once I realized that I actually had the power to be brave tomorrow. Well, it didn't happen tomorrow, but it was a few weeks later, and the intrusive thought showed up exactly like I expected. What if this is the one time you're making a mistake? What if this is going to kill you? And I was very scared, and I was able to say, well, that would be terrible. I would really not like that, be so scary, so sad. Not my top priority. My top priority is taking my chance right now to be brave. And what that means is not being anxious. Of course I'm going to be anxious. I'm not going to do my safety favor. And for the first time in seven years, I woke up the next morning having not completed safety behaviors that day and was astounded that my anxiety was nowhere near what I thought it was going to be. It was still there.
- [15:07]
B
You were still alive and didn't seem to have rabies either, which. Fascinating, right? Yeah. Yeah.
- [15:14]
A
So how I can support clients in identifying what OCD is taking from them, what it is they'd be willing to take that calculated risk for. And it's going to vary for everybody because people's values and priorities are different. But one of those common threats are if overcoming OCD is not a top priority, you're going to kick the can down the road. You're not going to do your homework. You're going to find reasons to continue participating in your safety behavior. So that's kind of what I'm seeing. How does that match with your experience?
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B
You know, I've often used the phrase, in order to be brave, you first must be afraid, because it wouldn't really be brave of someone to do something if they didn't fear doing it. Right. I mean, they would. They would just do it. But to show true bravery in a situation means to face that fear. And in the face of that fear and all of the screaming going on in your head of, don't do it, you're gonna die. Bad, awful, horrible things are happening. To go through it anyway, I. I liken it to the children's book. It's a Sesame street book. It's Grover, and he. And the book is called There's a Monster at the End of the Book. And Grover begs you not to turn the page. And every page, you're getting closer to the end, and he's freaking out more and more until you get to the end. And then Grover says, oh, I'm the monster at the end of the book, Right? You know, just like that was it. Right. And, and I'm going to bet, I'd love to hear from you that most, if not all of the OCD based fears you had turned out to be just like it being Grover at the end of the book.
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A
Well, when you, when you put it like that, Patrick, it reminds me of this. This was one of the most, one of the bravest things I saw in my clients and also one of the most Grover esque. I'm doing some work with a client with some scrupulosity related obsessional content and some core fears about being cast into hell. And we're working our way up the hierarchy. And, you know, we, we start small. His OCD had been around for a long time. Very powerful, very disruptive. We, we do the psycho Ed, we talk about commitment. He's at least partially on board, steps into some initial exposures. We start working our way up. We start working our way up. All of a sudden he's holding on to pictures of the devil in my office. Now he's holding on to pictures of the devil, saying that maybe by holding this picture of the devil, I'm actually secretly worshiping the devil. All right, so scary stuff. But the moment I had in mind was that fateful day when he came into my office knowing that we were reading the Satanic Bible that day. This is near the top of his hierarchy. And so, you know, we check in, he's still willing, we go for it, I start reading.
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And
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maybe 10 minutes into the reading, he looks at me and he says, that's it. And I say, yeah, that's it, that's it. And he think, I thought it was going to be dark rituals and clouds of smoke everywhere. And it's just talking about how you shouldn't let your uncle take your stuff. Yeah, that's it. And he transitioned into remission just a couple months later. And in his mind, the buildup was, was Groveresque.
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Right.
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But when he actually got to it, sure.
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And some people will hear that like, oh my God, you made him do that. No, we, we don't make anybody do things right.
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Never in a million years.
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Never in a million years. And if that's someone's ultimate fear, that I would hear something from the Satanic Bible, okay, then you know what, that may happen in real life. So why not practice that in a therapy session so that if it does happen in real life, you've already dealt with it. Right. But we're not. Sometimes people get this idea from ERP that we're, we're out to just go so above and beyond. And we're, we're really, we're really not. I mean, you don't, you don't. If you're Catholic, like, we're not going to ask you to do a Ouija board because that would be considered a sin in the Catholic Church to do something like that. Now we might say, hey, this store sells them. You can at least walk through it. Right. And you don't, you don't have to avoid that because there's so many other cool things at this store that you would like to buy. But I can't even go in there because there's those types of things. But we're never making people do things in these scenarios.
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A
Of course. And I think you and I are on the same page, Patrick, that I will encourage my clients to participate in exposures after we've collaboratively planned. Never will I pressure, never will I force. And in the context of scrupulosity related fears for some clients, they may never be willing or need to step into reading something from the Satanic Bible. And depending on collaboration and consultation with their faith leaders, we might decide that that's not something that we'd ever want. But in this particular case, we had all the go aheads and that was what the client was willing to participate in. In addition to many of the other typical forms of exposures where one of the things we spent a lot of time on was the scripts where he inconvenienced someone but didn't participate in a safety behavior. And then we talked about what it was like for St. Peter to turn away at the gates of heaven and the immense feelings of sadness and guilt he experienced as he saw his family behind the pearly gates looking expectantly. Oh, yes, yes. But then he gets turned away.
- [21:39]
B
Yeah, there's. There's a great song by a band called Ash and Bloom. They. They're Canadian and. And unfortunately they. I think they've broken up at this point, which is really sad because I really enjoyed their work. But they have a song called Heaven is a Ghost Town and basically no one's in it because nobody can meet the mark to get in. Right. And it's really interesting take on. Here's all these people, you know. Oh, but there was that one day, that one time you had that one thought, right, sorry, you can't get in. You know, and just. Yeah. And OCD is like this arbiter that basically is you broke a rule. So you're. That you're kind of screwed.
- [22:24]
A
Yeah. Yep. And And. And to really help and support the clients, to lean into all the feelings that can come up during scripts like that or exposures like that. Because, yes, anxiety is a big part of it, but guilt is very common. That. Shame is very common. Sadness is a feeling that underlies a lot of these things. Because, look, if it were the case that your whole family was in heaven and you got turned into away, that'd be many things, including extremely sad.
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B
Sure.
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A
In the exact same way that if, you know, you contacted a deadly germ and you didn't wash your hands because you were abstaining from safety behaviors, and then you or somebody you love did get sick. Very scary. I could imagine you feeling very guilty, but it. It's all going to funnel down into, boy, that would be so incredibly sad if that happened. This thing that I spent so much time trying to prevent from happening, and now it actually happened, and supporting my clients and recognizing that that sadness isn't something that we're at war with. It's an understandable response to an event you don't want to have happen. Sadness is the emotion that arises when something that you care about has been harmed, damaged, or destroyed. And for those of us with ocd, we're anxious because we don't want the sad things to happen.
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B
Right.
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Desperately don't want those sad things to happen.
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B
And if they do, we'll blame ourselves for the fact that we didn't do the thing to stop it from happening.
- [23:54]
A
And we have some idea how painful it can be when we blame ourselves like that. So metacognitive treatment isn't just one thing. I would characterize metacognitive treatment for ocd. Any form of intervention that's evaluating the thoughts that we have about our thoughts. Thoughts or the emotions that we have about our emotions. So the way that I'm incorporating metacognitive therapy into my practice with clients is inspired by. By Adrian Wells and Reed Wilson, who both use metacognitive approaches. But let me. Let me throw a few examples your way, Patrick, and then we'll. Then we can kick it back and forth. So I want you to imagine that I'm working with a client whose primary obsessional content is they're going to be struck by a meteorite.
- [24:50]
B
One of my favorite examples, actually. Okay, yeah, great example.
- [24:53]
A
Use it all the time. Now, they're. They know, because they've researched it in detail, that the chances of being struck by a meteorite are very low. As all of us know, very low does not mean zero. And their primary safety behavior by no means their only one. But their primary safety behavior is they stay in their basement all the time.
- [25:17]
B
Layers of things above them. Yes, there we go. Yeah.
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A
Now, it's not. It's not a super enjoyable life to be cooped up in the basement all the time because their life's really become small. Because not leaving the basement means not getting to participate in a lot of things that life has to offer. So it's not that they love it being in the basement. It's just when they compare what it's like for them to be in the basement, even though oftentimes it's not fun. It sure does seem very preferable to what it's like to them to be them if they're outside of the basement, which is extremely scary. Very difficult to function. Function for a lot of different reasons. Now, let's extend the example another step. Friend of this client kind of knows what's up. Calls a client up. All right, man, come on, we gotta, we gotta. We gotta get you out of there. Like, we all miss you. We want you to be with us. Let's. Let's go to the baseball game together. I know it'll be hard for you, but you'll be finer. Whatever other thing they typically say when I'm describing metacognitive elements of treatment to my clients, here's what it sounds like. Let's say that. Let's say our. Our client with fear of meteorite strike is Fred. So Fred gets the invitation from a friend. Let's go to the baseball game. Fred's thinking about being in the stadium, wide open sky above him. Okay. One of the things that Fred is afraid of is if I go to the baseball game, I might be struck dead by a meteorite. And even though Fred knows that the chances are negligible, he also knows the chances are non. Zero and it could happen. And the truth is, that is a scary thought. The idea of being hit by a meteorite and killed when you don't want to die is. That's a really scary thought. And if it were to happen, it would be really sad because that would be it. You wouldn't. Wouldn't get to live or enjoy the rest of your life. But there's another thing that Fred is afraid of, and he normally doesn't have the words for it, even though once I describe it to Fred, it starts to click. One of the things Fred is afraid of is being struck dead by a meteorite. But the other thing that Fred is afraid of is what it's going to be like to be him if he goes to the baseball game, even if he's not struck by a meteorite. Because what it's going to be like to be him if he goes to that baseball game is he's very likely going to experience his internal world going out of control if he goes to that baseball game. He probably is going to have thoughts about meteorites and they probably are going to make him feel anxious. Sure. And he's going to get stuck with unwanted, uncontrollable, distracting and painful internal experiences that really will make it hard for him to enjoy the baseball game really will be quite painful, even if he never gets struck by a meteorite. So one of the things he's afraid of is being struck by a meteorite. But another thing that he's afraid of is the out of control nature of his internal world. And he understandably doesn't like the idea of his internal world going out of control. Because who would like that idea?
- [29:11]
B
Patrick, I'm not a fan myself.
- [29:15]
A
What would it be like if friend says, hey, Patrick, how are you doing? You're like, oh, well, you know, my internal world's out of control in an extremely distracting and painful way. But other than that, just fine.
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B
Yeah. Yeah. Anything we can do to stop that, that'd be great.
- [29:27]
A
Anything we can do to stop that would be fine. And what most of us with OCD do to least momentarily reestablish control of our internal world is a safety behavior. And one of the reasons that we do the safety behavior is because we believe we might further reduce the negligible chance that the unlikely event will occur.
- [29:51]
B
Yes.
- [29:52]
A
The other reason we do the safety behavior is so that we can at least momentarily increase the level of control we have over our internal world. So we can make the unwanted, uncontrollable, distracting and painful feelings reduce or stop at least for a moment and final step. And then I will throw it back to you. When I'm bringing this particular formulation into ERP practice, the way that we're able to frame the ERP practice is, ah, yes, I'm getting practice being a person who does not have full direct control over their internal world. And seeing that I can handle it, seeing that I can continue living my life even though I don't have that complete control and it is distracting and painful. And seeing that the more I practice it, the easier and easier it gets. Until that gray day when all of a sudden I'm able to see for myself, this is easy. This is easy now. Not effortless perhaps, but easy. And. And that's when, you know, that's when I'm characterizing OCD as in remission. It.
- [31:11]
B
It's so interesting to hear you describe it that way. The first book I wrote, I wrote a little stress management manual a long time ago, just based on a introductory talk that I give to the people that I work with. And I. I have a chapter called Control is an Illusion. And I talk about this idea that control is attempted through worry. And worry serves two functions. The first function of worry is if I worry hard enough, I can somehow prevent things from happening. And my mom was great at this. I would come home at night when I was 16, and she would. And my dad would be there too. And my dad would say, is the car okay? And I'd say yes. And my mom would say, are you okay? I'd say, yes. And then she'd say, see, it's a good thing I was worrying about you somehow. Yeah, her worries somehow prevented me from dying in the car accident instead of my excellent driving skills. Of course. And the second part of worry comes out of the idea that if. If we can worry about every bad thing that might happen, then we can propose, prepare for every bad thing that might happen. And then if we're prepared for every bad thing that might happen, we won't need to worry about it anymore. And I always love Tom Borkavec's research in this. And I watched him do a talk one time, and he, he, you know, he did this motion and I loved it. He said, if this is calm and this is anxious, if you're not worried about it and it happens, that's a huge jump. But if you're already worried about it and it happens, you've buffered yourself and prepared yourself for the worst case scenario. And that seems to feel better for people sometimes to be ready for it versus having it happen and having big reaction.
- [32:43]
A
Oh, Patrick. I feel like that is. I. I am resonating with it so hard. I mean, that, that fear of emotional contrast is. It reminds me of Michelle Crask's work. Because what. You know, when she's talking about anxiety and worry, what she was perplexed by was the standard CBT formulation of the relationship between anxiety and worry is that worry reduces the negative effect of the anxiety in a way that's preferable to the anxiety without the. The cognitive cerebral function of the word. But worrying is not a good time. It's not. It's not fun. And Michelle's analysis is exactly like what you reported, which is. But at least there's Further to fall. I don't have to go through such a big swing because I've already cultivated some negative affect by inducing it through the worry. So it's a nasty behavior.
- [33:40]
B
And there was a. I agree totally. A safety behavior. There was another time I took a stand up comedy course. And one of the things that you talk about in comedy are, you know, why are things funny? Because they're unexpected or different things. And so the comedian said one time, you know, he did a skit where he showed up with a skeleton face on and he, his mom opened the door and she screamed and he said, mom, I turned out to be the thing you were most afraid of. I died, you know, and everything. And, and you know, this whole skit, going through it. But he talked to us about, and he wasn't even in psychology, but just, he said this idea that talking about the thing you're afraid of is easier to deal with than the thing you're afraid of too. So why do sometimes people who are so anxious constantly talk about these things? It's maybe it's easier to deal with than the actual event itself. So I think all of this stuff comes into exactly what you're describing.
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A
Yeah, and, and, and I think that we can, we can leap right over to, for example, how Adrian Wells, who was the founder of clinic Cognitive Therapy, would describe a portion of what you described. Patrick was positive and negative metacognitive beliefs. Where for Adrian, positive metacognitive beliefs are I benefit from the worry, so I be prepared because of my worry, or I can figure out this problem because of my rumination. And then he supplements that with what he's characterizing as negative metacognitive beliefs, one of which is my worry is dangerous, so that I'm. These sorts of thoughts are dangerous and need to be stopped. And the other is I can't control that. I can't control my worry. Which is a thought about a thought
- [35:30]
B
and controls an illusion. There you go. Yeah. Yeah.
- [35:32]
A
But it pops up all the time in OCD treatment because I know, as you and Jonathan Grayson have talked about many times, if somebody comes into the office and says I have to do my compulsion, well, we can sympathize with what they mean, but that's probably not true. If I. What they typically mean is if I don't do my compulsion, then I will experience a variety, variety of extremely unpleasant things that I very much would rather not. Patrick, if this is okay, I want to give another example because I think it's going to be. Reinforce this idea of the Difference between what I would characterize as the object level concern, which is whatever the, the content is of the scary story, right? Hit by a meteorite, abducted by aliens, running over someone with your car without knowing it, whatever the story is. And then the process related concerns, which is what I'm characterizing as a loss of control of someone's internal world. So example that can illustrate that is imagine that I'm working with a client and he comes in and tells me, william, nobody seems to understand what's going on to me, but it kind of feels like ocd. I think I need your help, but I also think I'm going crazy. Okay, here's what happened. Okay, well, tell me what's going on. Okay, well, I was at a soccer game with my friends playing soccer, which is something that I very much enjoy. And all of a sudden, out of the blue, I just noticed the image of my uncle. Just there. His image was in my mind. I was like, well, that's, that's weird. Like, I love my uncle. He's great. I have no problems with my uncle. But then it stuck around and I was trying to play soccer, but the image was still there. And so I was like, oh, like this. And I tried to make it go away, and I realized I couldn't. Now, in that particular example, the content of his obsessional content is benign. It. He's not scared of his uncle. He doesn't think his uncle's going to do something bad. There's not a scary story where maybe he did something bad to his. His uncle or his uncle is going to do something about somebody.
- [38:11]
B
It's.
- [38:11]
A
It's not that. His concern is that I'm now experiencing an unwanted object of awareness, and it's getting in the way of me doing the things I want to do in my life. But I can't control it. And if I can't control it, that means it's going to continue to interfere in what I want to be doing. And that's really scary because that is a scary idea. The idea that you never again get to participate in the life that you want because you're always subject to an unwanted object of awareness. So when we're working with clients who have sensory motor theme areas, much of the time it's. It's not. Oh, I'm worried that noticing my swallowing means that there's something wrong with my, my throat. Much of the time it's. I'm worried that I'm going to be having a great dinner with my wife, and then it's going to be ruined because I become aware of my swallowing.
- [39:15]
B
Sure, sure, sure.
- [39:16]
A
And so when we plug that back into the metacognitive formulation I was describing with Fred, the object level fear, the content, the scary story that the person with the swallowing is experiencing is the rest of my life is going to be damaged or ruined because I no longer get to enjoy the things I want to enjoy in my life. But the process is, I am out for dinner with my wife right now and I have lost control over my internal world in a way that's distracting and painful. It's not a hypothetical. It's not a one day I might lose control over my internal world. No, it's. My wife's telling me about the new thing at her job and all I'm thinking of is swallow, swallow, swallow, swallow. And I'm at a seven. This is actually happening. Not one day. Not what if not tolerate uncertainty. No, no. It's really here right now and I can't stand it. And it's so painful and I can't make it stop. So what are we doing in erp? Yeah, yeah, it's. That's scary, that's sad, and it's true. You can't directly make it stop because if you could OC treatment. Be real quick. Yeah.
- [40:42]
B
100%.
- [40:44]
A
Snap our fingers.
- [40:45]
B
Knock it off.
- [40:46]
A
Yeah. What with you thought?
- [40:48]
B
Yeah, come on.
- [40:51]
A
Instead, therapy is. What is it like for me to go to dinner with my wife and not just tolerate awareness of my swallowing? If it shows up, maybe I deliberately hold on to it. Maybe I say, you know what? All dinner long, I'm going to hold that idea. I might not be swallowing right. Or I might get stuck with sensations or thoughts related to swallowing. And I'm going to let those experiences be there even though I don't like them, even though they're just distracting, even though they're painful. And the entire time that those are there, I'm going to practice my psychological flexibility, which is I can still listen to my wife and interact with my wife even in the presence of those unwanted internal experiences. And yes, it might not be as easy as I would like it to be, but with practice, it's probably going to get easier.
- [41:47]
B
If you've heard me and John describe this, both of us have tinnitus or tinnitus, however people say it. I live with this daily, right? And I've lived with this for over 30 years where I don't know what silence is. I. I could not describe what silence is to someone because I, I have lost the concept even of what silence is, because I just. I can't even remember what it was like not to hear the sound that I hear for the last 30 plus years. So I don't go into anything, though, thinking, gosh, I sure hope my tinnitus doesn't ruin this. I just go into life accepting I have tonight and it's going to be a part of whatever it is that I do. And so let's go do it.
- [42:39]
A
Here we go.
- [42:39]
B
Yeah.
- [42:40]
A
And it's what I'm hearing you say, Patrick, is. It's. It's not what you would wish for.
- [42:45]
B
Oh, it sucks, believe me. And it's really loud right now because we're talking about it. So it's decided to scream itself.
- [42:54]
A
Hey.
- [42:54]
B
What?
- [42:55]
A
Somebody talking about me? Let me.
- [42:57]
B
Here I am over here. Yep.
- [42:58]
A
Yeah. And it. It, as you will know, maybe most are, some of your listeners will know it. It is a great point to connect in with one of Jonathan's important insights, which is committing to overcome ocd is committing to get better at living your second best life, where your first best life is the fantasy, where all of your experiences are perfect immersion and harmony with no unwanted internal experiences and no external threats. But your second best life is, yeah, I'm going to go into this conversation and maybe my tinnitus is going to pop up, maybe it's not. And if it does, I'm not going to like it because why would I like it? But I can handle it and I can keep going even though it's a pain. And that's okay. That's one of the cruxes of ocd, which is what makes OCD so rough, because living as if is a very painful, distracting way to live your life. That makes regular activities extremely difficult. So in my ocd, where going outside became extremely difficult, one thing that I was afraid of if I went outside was maybe I'll be unknowingly bit by a bat, thus not get the vaccine, thus die of rabies. Very scary and sad thought. But the other thing I was afraid of is if I go outside, it's a practical guarantee that I'm going to lose control over my internal world in a way that's very distracting and painful and makes it very challenging to do the things I need to do, whether it's meet a friend or go to work or get the mail. And that's not low likelihood. That's happened to me a thousand times, which leads me to believe it's probably going to happen next time. And of course, I don't want that experience. Who wants to lose control over their internal world.
- [45:00]
B
Anyone? No. Anyone? No. No. Okay. Nobody. Nobody does. Right.
- [45:04]
A
And so overcoming OCD from that perspective is recognizing that we will never get direct control of our. Our internal world. But with practice, we can gain very good, indirect, large degrees of control over our internal world that allow us to do the things we want to do with ease, even though perhaps never effortless.
- [45:27]
B
Right. I'm going to take my statement back. Not that it's never because some people like a controlled loss of this. Like a roller coaster or a scary movie or something, or jumping out of a plane. You know, some people put themselves purposely into those situations to have a better bit of that experience, but there's still that feeling of There's. There's a fence around that experience almost. Right.
- [45:49]
A
It's like going to a scary movie. It's. I kind of like to be afraid because.
- [45:54]
B
Yeah.
- [45:54]
A
In the back of my mind, I know it's just a movie, even though I really do feel afraid.
- [45:58]
B
Yeah, totally.
- [45:59]
A
During the movie.
- [46:01]
B
Yep. Yep. William, as always, it's a joy to speak to you and have these amazingly fun guys. These hours go by so fast.
- [46:11]
A
I was gonna say about.
- [46:13]
B
Are we done already? We are already there. Yeah. So I don't mind coming back a third time to talk about other things.
- [46:21]
A
If y' all want to have me back for a third time, I would love it, because this is just an absolute delight to talk about OCD and ways of formulating it and some of the things that get people hung up, whether it's commitment or ifs or what's going to be the best way for me to do it, or the just right time for me to participate in ERP or whatever other intervention we're doing.
- [46:48]
B
Yeah. So awesome. Well, thank you for being here again, and I'm sure we'll see you again in the future.
- [46:53]
A
Sounds great, Patrick. Thank you, too.
- [46:56]
B
And thank all of you for watching another episode of the get to Know OCD podcast. If you like the podcast, you can subscribe to the NOCD YouTube channel. Go to nocd.com if you're looking for help for OCD or related conditions. That's nocd.com we have people waiting on our intake team to be able to chat with you and licensed therapists in all 50 states. And we work in other countries as well. We do take insurance here at NOCD. So again, NOCD.com and remember, everybody, be better to yourself than your OCD ever would be. We'll see you again soon. Thanks.