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- [00:00]
A
A higher level of care really refers to something that requires more support and helps support a person with a different level of functioning. I think if people think they need more than outpatient therapy, right? More than like one to three hours a week, they think they need to go to the hospital. And that's actually very inaccurate sometimes. That may be true, but there's so many levels of care on the in between. How do I know if this is what I need? It's hard for you to be like, okay, I'm recommending myself for residential treatment. I think it really is done in conjunction with a professional.
- [00:47]
B
You've probably heard of ocd, but you don't know that OCD isn't really just about cleaning an organization. It's actually debilitating. It's a condition that causes intrusive, persistent and really sticky feelings and thoughts that can seize on any topic from romantic relationships to illness to spirituality and really anything that matters to you. This can really cause significant anxiety and guilt and shame and discomfort and can make it hard to function in day to day life. If this sounds familiar, know that you're not alone. In fact, 1 in 40 people in the US suffer from obsessive Compulsive disorder, but help is available. I'm a licensed clinical psychologist with 25 years of OCD treatment experience. So I know that these scary symptoms can be overwhelming. But I also know that they can be managed with the right type of treatment. I lead a team of top tier clinical experts at NOCD who are trained in the effective treatment for obsessive compulsive diagnosis disorder. NOCD is an online platform offering specialized, accessible and convenient OCD treatment. My team and I have helped people take back their lives from OCD through evidence based therapies that are covered by insurance. To learn more about OCD and to start effective treatment, head to nocd.com that's n o c d dot com. You deserve to live the life you want to live and not the life that OCD wants you to live. And don't forget to subscribe to our YouTube channel so you can stay up to date on our latest podcasts and webinars. Now, onto today's episode.
- [02:27]
C
Hi everyone. Welcome to another episode of the get to Know OCD podcast. My name is Dr. Patrick McGrath and I'm the Chief Clinical Officer for NOCD. On today's podcast, I'm happy to have a friend of mine, Lori Johnson. Hi Lori, how are you?
- [02:40]
A
Hi Patrick. Thanks for having me.
- [02:43]
C
Absolutely. And Lori, we're going to talk today about higher levels of care. Well, all levels of care, really. But more specifically, what some of the things you and I have really done a great deal in our career is some of the higher levels of care. But before we get into that, it's always interesting just to learn about you and how you got into the profession and what your career has been like up until now. So why don't you give us a little bit of background about your talk.
- [03:08]
A
Perfect. The Cliff Notes. So I'm Lori Johnson, and I've been in the field since about 2009. I initially started in addiction work, and that's what led me to specializing in ocd. So when I was in basically working with adjudicated youth in a lockdown facility, I started seeing ocd. And at the time there was a lot of, like, high. We had like a hygiene closet and you could go and like, check out your brushes and combs and deodorant and all the things. And mouthwash. And, you know, of course it has alcohol in it, so you have to get it out of the hygiene closet. And in the morning, there would be some people that would be like, going back and forth and back and forth and back and forth and like rearranging and recapping the mouthwash and like checking their toothbrush or brushing their teeth. Again, there was it. And I was like, what is happening? Everyone's like, ah, don't worry, you're just an intern. Like, don't worry about that. And it was ocd. And I mentioned that. And I think at the time it was like, oh, this, this is just what happens with teenagers. And I didn't believe it. So I kind of took that experience with me throughout my career and really started uncovering a lot of OCD within treatment and then had the opportunity to work at Eating Recovery center, which there was a ton of overlapping OCD with eating disorders. So I legitimately have worked in every level of care from like psychiatric inpatient lockdown to all the way down to outpatient psychotherapy, one on one iop, php, all of the different levels. So I bring in a wide range of experience around risk and OCD treatment, specifically with exposure and response prevention, as have you.
- [05:12]
C
Yes, we've done a little bit. Let's talk about levels of care. And boy, that sounds kind of technical phrase. We like to use jargony things sometimes in our world. So what do we mean by levels of care?
- [05:27]
A
Care. So levels of care are really for people who need a different type of support. And the. The term that we use and the jargon that we use in this field is higher level of care or heloc. Hlock, A HELOC is a, a mortgage. We don't need that.
- [05:50]
C
You don't, you don't need a mortgage? No. Maybe you do need a mortgage, but maybe, maybe, maybe not today. That's it. Okay.
- [05:58]
A
So a higher level of care really refers to something that requires more support and helps support a person with a different level of functioning. Meaning, let's say, for instance, I'm struggling with OCD or and depression. And because that has gotten so bad for me, I start calling into work. And I am now at risk of losing my job because I have been calling into work. I really qualify for meeting with a therapist more than twice a week. And depending on your area, that number may change and shift because we have different levels of access to care, meaning we may, may or may not have someone in our town or in our region that provides support, specialty care for ocd. And that's what's really fabulous about OCD is that we have someone there who can help. But a higher level of care might not be available. A person may have to travel or take time out of work or take a leave of absence in order to get that wraparound care and support to improve their functioning. So for instance, I may go to the next level of care, which we can talk about. I may go to a level of care and need to be there for a specific amount of time. But what I'm really doing in that program is improving my functioning, improving my ability to feel less depressed or be less preoccupied by OCD, so that I can return to the life that I normally have.
- [07:33]
C
So let's talk about those levels. So our traditional therapy that most people are used to would be the one to two hours a week of treatment that people would have with a therapist. The next up is what we call intensive outpatient programming. Right. Or iops. And these are typically three hours a day for four to five days a week. Other places or states may have different regulations. Some may be able to do two hours a day, four or five days a week, just depending on the number of hours that they have to hit. Is that correct?
- [08:08]
A
That's correct. So there are other levels of care beyond that?
- [08:13]
C
Yes, let's talk about those too.
- [08:14]
A
Commercial hospitalization, which is php.
- [08:18]
C
Php.
- [08:19]
A
Then there's residential.
- [08:21]
C
Well, before we go to residential, I was thinking, I just wanted to say something on php. Yeah. Sometimes people hear partial hospitalization program and think, do I have to stay at the hospital? And no, IOP level and PHP level are not stay in the hospital levels of care, a PHP is a six hour a day program and that's usually five days a week that people will go for that. And then as you were saying, comes residential.
- [08:51]
A
Yeah. So residential is more of a 24 hour care wraparound service. And I think the thing, and you bring up a really great point, Patrick, I think is people hear I need a different level of care or my therapist thinks I need PHP or iop. We throw out all these jargon words and we don't really know what they mean. I think if people think they need more than outpatient therapy, Right. More than like one to three hours a week, depending on where you are, they think they need to go to the hospital.
- [09:26]
C
Yeah.
- [09:27]
A
And that's actually very inaccurate sometimes. That may be true, but there's so many levels of care on the in between that I think many of the people that we treat and many, many of the public, you don't even know. I only know this because I've worked there. It's not common knowledge. So if you hear that you're not doing well, you're like, I'm going to the hospital. Like I had a client once say to me, like, I thought you were going to come in with like people in white coats. That's not how it works.
- [10:02]
C
Right, right.
- [10:05]
B
Residential people do live there.
- [10:07]
C
Right. People kind of move in and stay usually for around 30 to can. I've seen people. 30 to 90 days is not uncommon, unusual, not uncommon for people with that. Why might somebody start at a particular level of care? Right. And how would we differentiate that? Maybe if we start at the top at residential and talk about that from the way down, we can give some people some info. So I personally have opened a residential treatment center for ocd, the Foglia Family Foundation Residential treatment center, which is still going. And we really designed that for two purposes. One, for people whose OCD was so overwhelming that they couldn't function in day to day life. Right. Maybe they were spending hours a day in a bathroom washing their hands or cleaning things, or they were rechecking things over and over so much that they couldn't even go to work or go to school anymore. They weren't able to function in their relationship. We had people who were, you know, driving around the block so much out of a fear that they've harmed somebody. People with significant pedophilic OCD concerns that they basically locked themselves in their homes to make sure that they didn't have access to any children to harm or anything. All that. So you're really Looking at when on the OCD side, when it takes over your life to such an extent that you don't live much of your life whatsoever, residential level of care might be the place to go now. Something to keep in mind. Not all places take insurance, so some might take it and some may not. So that's something you have to do when you make your phone calls to the residential centers. And even if they take insurance, not all insurances will say that they'll approve it, especially potentially if you haven't failed lower levels of care first. Right. So they might say, well, you haven't done a PHP yet, so why would we give you a residential to do if you haven't even tried php? Maybe you could do better at that service. Would you add anything to that, Laurie?
- [12:13]
A
Yeah, I would say that there are other parameters. Usually a therapist is also helping determine what's best. And there also is the autonomy. Like you have autonomy being a client and being a human. And as long as there are no concerns around safety that would determine that a person needs more wraparound support with like a residential versus a php, the least restrictive level of care is the most appropriate. Always. If you that way you have that autonomy. Because in many times in an IOP or a php, people are still able to work to some extent as long as that's beneficial for them. And I think, I'm sure, Patrick, you've experienced this too, is that you're like, how am I going to take care of my kids and I got to go to work and I have to do all these things and I'm going to try to shove in this partial hospitalization program and do it virtually from home and squeeze it all in. What's most effective for your recovery and your treatment journey? What is it that you're needing right now? So is it more support and more real time ability to have support of staff and. Or is it more or. We didn't talk about inpatient, which is beyond residential, where you need more medical oversight for a variety of things like safety or medication, like what is it that you're needing? And I think that alongside your treatment team, your physicians, psychiatrists, therapists, et cetera, and that you're being referred to like it's a conversation to be had. And sometimes you do get to pick between intensive outpatient or partial hospitalization. So we do like to give people the autonomy to make that choice for themselves too because, you know, the sufferer knows what's going on in their own life and what kind of care they need.
- [14:12]
C
Yeah. And typically if you go to a place that provides both, they're going to do an intake with you and they're going to make a recommendation about what they feel will be best. And there are some insurances that won't pay for iop, like Medicare, but they will pay for a PHP for someone. So it just again, depends on sometimes the coverage you have, the states that you're in, the rules, the regulations. So we'll talk today in some generalities, but please know that things may vary depending on the state that you find yourself living in at this time. Correct the difference to me, because having also done PHP and iop, was taking a look at something along the lines of your level of function. Again, if people were working and able to go to work or go to school, we even had an evening IOP program so that people could come after being at school or after work because they were functioning and getting things done. But without some more intensive work quickly, we felt that they would backslide more and then they would need the php. So that was a way for people to be able to get service that they needed, but still live the life that they were managing to live, but not, maybe not totally successfully the way that they wanted to, but at least it gave them the opportunity to keep their job and to stay in school. The other reason we used IOP was a step down from php. When people were really starting to see interference in their life in school and in work or in home functioning, but it wasn't to the level that it had taken over their life. The PHP was the appropriate level of care. We would get people there, they would spend the day with us, they'd get lunch at the hospital. It was part of the work that we did. And again, this was an outpatient section of the hospital though, so they were not on an inpatient. And then after they'd done well and they were ready to start maybe returning to school or returning to work, then we would step them down to our IOP program and they could start integrating back into life while still getting the support of some more intensive work. And then after completing the iop, they would step down back into some more traditional level of therapy.
- [16:28]
A
Yeah, and I think you say a really important word which I think is vital in higher levels of care is integration. The things that a client or a patient is learning in program, you have to learn how to take that back into your life. We provide a really safe environment that's controlled for you to be able to challenge yourself on exposure and response prevention. Do it while you have a Life circumstance, coming up and doing it in that safety. And stepping down allows you to do that without completely like kind of flying the coop or jumping out of the nest and feeling not ready, feeling unsafe in some way, like, oh, I can't do this on my own. I needed, you know, I needed Dr. McGrath to help me every day. You have to learn how to have that independence. So that integration is a really important part of step Down. Now I'll say that knowing that sometimes insurance doesn't pay for step down programming. That's okay. You still have your therapist to support you. But that's the whole point is that you get to do this independently because nobody wants to live in a hospital, nobody wants to live in a program as much as you like us, or as information as you got out of it, you want to return back to your life and be able to do this on your own and independently as well.
- [17:57]
C
Yes, I agree. You know, as much as we like to think that people would love to spend the whole day with us, I think that we've maybe deluded ourselves a little. They really, they do actually want to get back to living their life and not spending all day at the hospital with us. But also I will tell you, the appreciation that we see from people who have done these programs and who have seen life changing experiences from doing more intensive therapy and how happy and proud they are of themselves for doing the hard work so that they can transition back into those individual therapy, you know, one or two hours a week and, and just again live that life that they want to live and how absolutely wonderful that experience is. So that's really exciting for a lot of people.
- [18:44]
A
That is so exciting. I just got goosebumps because I, you know, I remember what that relief was like is we as clinicians and practitioners and therapists, like, we're like, you can do this. Especially with erp, right? Exposure and response prevention is really scary. It is not easy work at all. And sometimes they say to us like, well, I'm already stuck. How are you going to get me through that? This is what it is like to be skilled with very like acute cases of people who really are genuinely like stuck in the trenches and they know that they need to just like do it. But sometimes it's having that encouragement and power to do that. And then at the end of programming or at the end of their resolution or reduction in symptoms, they're like, I can't believe you guys believed in me. Yeah, I can't believe I did it. Like, I thought I was going to be Stuck there forever. So there's a huge level of motivation and that ability to get back to your life. I think also another complaint is groups. People are like, I don't group. I don't want to. I don't want to be around other people when I'm suffering.
- [19:56]
C
Yeah, but that group work can be really transformative. I, you know, I. I always joke, one of the things that always happens in the group is the new member comes in, someone else in the group is talking about their ocd. The new member leans over to the person next to them or messages somebody, like, if it's on a virtual one and says, I wish I had that kind of ocd. And then everybody laughs because they all said the same thing when they started. Group two. There's this idea that a lot of people come in and think, man, any other kind of OCD would be better than mine. And you start to learn that no ocd, no matter what the theme is, interferes in your life. Right. It gets in the way. The theme, it's very specific to you. But if you didn't have the fear that the other person would have. Yeah. You wouldn't care about that fear. But if you did have it, you would feel the exact same way they did. And so you feel about your theme the way they feel about theirs, the way they feel about theirs and the way they feel about theirs. Right. You share that commonality, even though on paper it may look different because you're afraid of A and your B and your C and your D. Ultimately, no, it doesn't matter. You're afraid. And that's the.
- [21:16]
A
Yeah, and I. I think that's a pretty common thing that we hear in the community is like, oh, my. My OCD is so unique. No one's really going to understand. And it's not true. And in fact, even sharing it, many people that have gone through intensive programming have been like, I've never really talked about my OCD before in front of a group to other people. I've never really admitted it out loud.
- [21:43]
C
Yeah.
- [21:44]
A
And it's a really powerful part of group work and processing is that you get to establish relationships with other people who are like, oh, not you. Or who make you feel brave, where you're like, I can't believe they're sharing them.
- [21:57]
C
We even see that at its extreme at the OCD conference, when you've got thousands of people in one hotel together at a conference center, you know, and all sharing their different aspects of what it's like to live with OCD in their lives. So it's huge for people to be around others and to get that support, not just from a therapist, but from other people, too.
- [22:20]
A
Absolutely. And it's like being pulled black in, like, kindergarten as an adult being, like, establishing relationships again. Because before that, I don't really remember trying to create relationships, but you're like, you are a younger version trying to fit in or figure out yourself and disclose this very vulnerable part. And that's not the experience for everyone. Some people have a. A level of vulnerability that they're comfortable with, and they have a lot of support, but I think that can be super challenging. And coming into or being recommended to a higher level of care because you're used to sitting with your therapist, like, chomping on things, and then you're like, group.
- [23:13]
C
What other questions do you see people come up with about these various levels of care and what you do or how to get in or all those things? What. What else comes up?
- [23:26]
A
I think people often say, how do I know if this is what I need?
- [23:34]
C
Yeah.
- [23:34]
A
And I think in a vacuum, it's hard for you to be like, okay, I'm recommending myself for residential treatment. I think it really is done in conjunction with a professional. Or if you. If you don't have a professional in your life, a therapist, a, you know, a psychiatrist, someone who you're talking to about things, a counselor. It's time to start talking about that.
- [23:59]
C
Yeah.
- [24:00]
A
Saying, I think I have ocd. I. You know, I went on the NOCD website, and they reached out to me, and now I'm freaked out. It's. It's time to kind of start looking at your symptoms. How appropriate do you feel in doing all the things that you have? Like, often you can be really worn down by this disorder and being like, I'm tired. I'm tired. I don't want to do that. I'm avoiding ERP work. I am not talking to my therapist about this. I think it's kind of like all the things that you're living with that really no one sees time to start talking about that so that you can determine. This is a pretty big deal in my life, more than I want to admit.
- [24:43]
C
Yeah. We're starting an IOP at nocd, and you're helping to spearhead that. So thank you for that. Why don't you tell everybody about what you're doing and your role here and your team and everything like that?
- [24:59]
A
So what we are hoping to do is, you know, bring this level of care to an ocd, which is a huge honor. I think what happens, and everyone's familiar with the story, whether you're a provider or not, is that look how long it took for you to find someone who specialized in OCD treatment. That is true for higher levels of care. So if you're really struggling, the immediate thought is like, oh, I have to go to the hospital, I have to go to the emergency room, which we didn't even talk about emergency room admits for, or some rural areas. You don't might not have a PHP or an IOP and you might not even know where to go if you are having a crisis, whether OCD related or not. Like, that's not something that you should have to know as humans, but we do. So what we're trying to do is kind of fill the gap because right now with our care level here, we are outpatient therapy, and we can be extremely supportive and we have some support groups and other services to offer for people with O, C, D. But if you have needed a higher level of care or needed just a little more support for yourself in your life, we have to then refer you out of our network and refer you to other places. And Patrick, as you know, it's like throw a dart on a map in the United States and that city, that region may or may not have a level of care in that actual state.
- [26:34]
C
Correct? Yeah, yeah, there are states that don't have it. Right, Exactly.
- [26:40]
A
So what we're hoping to do is expand those services. So right now it's available in the state of Colorado. Anyone who is in Colorado, whether you're a resident or just visiting for a program, we can offer that level of service, and we're hoping to take that state by state and continue to grow those services. So that way, where people are in high need of these types of support that you don't need to wait until you need to go to residential or need to go to the hospital, you can say, I think I need some more support. Talk with your therapist about that and then get an assessment for this program. So we do require that you've had at least eight exposure and response prevention sessions for ocd. Again, that goes back to what we said about least restrictive level of care. If you don't need this, we're not going to make you be here. And if you haven't tried outpatient psychotherapy, then we want you to do that because we think that, you know, you might not need this level of care if you're not impacted by your level of functioning. Also, we'll set for that and make recommendations for level. So even if we're not the most appropriate level or you don't meet the criteria for our program, we're going to get you through a program. So that's our mission here at nocd, is to help treat as many people as we can with OCD and eliminate a lot of those barriers for access to care. Yeah, exciting. It's a lot of work.
- [28:19]
C
It's a lot of work. It's exciting. And like you said, we're starting in Colorado and we're going to build from there. So stay tuned, keep checking in, check out the nocity website to see what we've got. You know, there is always going to be, Lori, some trepidation people have about coming into a higher level of care. What's your advice to families or friends? How might they help to convince somebody that a higher level of care is in their best interest or even for the person who's struggling on their own to make that decision?
- [28:53]
A
Yeah, I think it can be really scary. Again, our, our thoughts go to immediately to hospital lockup. Like, I'm losing my autonomy. It does not need to be that way. It can be a conversation and maybe the conversation ends at yes, I do believe you need that, or no, we don't think you need that at this time. I think the autonomy in being willing to see and look at what is out there can really help you determine actually where you are. It's like, yeah, I do think I need that, or I wish I could have that. And I'm not sure what insurance covers in this. It kind of brings you down the rabbit hole a little bit. So please do not open yourself up to a bunch of unneeded obsessions. But please do open yourself up to a conversation and if that's with your family member, like, hey, I know this is a, a touchy subject. Could we talk about what our safety net plan is? Right. Like if this continues to get worse, what are you open to? And just starting to explore your options. And we know as providers the top tiered programs and what smaller programs are available. So you just start looking and it'll lead you to the Upper Northeast, the Midwest and Texas and California and Washington. Any others to throw in the mix?
- [30:20]
C
Utah, Utah is a big, Ohio's got some stuff going on.
- [30:25]
A
Yeah, you're, you're going to be kind of led to the information that you need. And usually these programs are saying, oh well, it sounds like you might be a fit for over here. And there's this program and that program. We're pretty close knit community and we kind of know each other. Yeah, we do have those conversations, even if they don't end up where you want them to approach saying, hey, your backup plan here.
- [30:51]
C
And the good thing is there is hope out there, right? I mean, there, there are so many levels of care that are available. And like we said, some even take insurance if that helps you to have access to that level of care. And there's even other options out there that we didn't talk about today. There's surgical options, there's medical options, there's medicine options. There's all sorts of things, too, that we can get into in other podcasts. But even, even beyond what we've talked about today, there's other things that are available to help people with ocd.
- [31:25]
B
Lori, anything to wrap up for us.
- [31:27]
C
To give a, a good message to all of our friends listening today.
- [31:32]
A
I think my closing message is that this doesn't need to be scary. Whether you don't like groups or don't want to do this, like, just have a conversation, sure. Going to get some medical and mental health care advice for yourself. And if you're compulsively looking into this, start talking to your therapist about it. Start trying to resist needing to, like, fix yourself. This is really about functionality and getting back to a life, a joyous life, sometimes a painful life, too, but getting back to life, that's meaningful for you.
- [32:13]
C
Good.
- [32:15]
A
So as we wrap up, I just wanted to share more details about the NOCD IOP program that I'm leading. So the intensive program is really designed for those who haven't been responding to exposure and response prevention in a traditional setting, which is outpatient therapy. So we have a minimum of 8 ERP sessions without significant improvement, and that is a criteria for entering the program to meet medically necessary criteria for a higher level of care. So people who have not completed 8 ERP sessions, don't worry about that. We can still connect you to an OCD therapist to begin ERP treatment. It's really important that you have that potential to do those eight sessions or more on an outpatient setting. Right. Higher levels of care are not always covered by insurance, so it can be very expensive. And we just want you to get the care that you need. So we do need you to go through, jump through that hoop to make sure that you meet the criteria for higher level of care. So the program in general spans for three to six weeks. It's available to Colorado residents and also open to anyone who can temporarily come to Colorado during their span of treatment. And it is a virtual program. So we have some flexibility for you to be wherever you need to be during that time. So we have 12 hours a week with you. So from 12 to 3pm Mountain Standard Time, Monday through Thursday, we have a full 12 hours to work on group things, to work on individual erp. We are there as a team alongside of you. And there's some homework outside of the program, but you like really learn how to start integrating this into your day to day. And that's the thing that we know with people who are in need of a higher level of care is that sometimes you have to kind of start and dive right into everything to figure out what you're actually needing in your day to day. So if you want to learn more about the program, you can head on over to the website@nocd.com iop and find out more information. And also if you are ready, you can submit your request and we'd be happy to help you with the next steps in the screening process.
- [34:37]
C
Please know this, that if you have ocd, you're not alone and there are people out there looking to help and thank all of you for watching the get to Know OCD podcast. If you liked it, you can subscribe to wherever you get your favorite podcasts. Or you can subscribe to the NOCD YouTube channel and we'll have it there too. And we'll see you again soon. Bye everyone.