John Hershfield (2:40)

Chief Burns of OCD podcast.

Dr. Patrick McGrath (2:42)

Yeah, that would be funny. We should do that one.

John Hershfield (2:46)

So I. I am a licensed marriage and family therapist who has managed to avoid doing marriage and family therapy for the bulk of my career, and I specialize in the treatment of OCD and related disorders. My position here at Shepherd Pratt is the director of the center for OCD and Anxiety. So we have an outpatient center where we treat folks at that level with. For OCD and related disorders, which you know all about. And we also have a residential program here called the Retreat, an adult psychiatric program for folks with complex psychiatric needs. And I run the OCD programming here as well.

Dr. Patrick McGrath (3:21)

Beautiful building, by the way. Got to tour it. Lots of cool fireplaces that don't. Don't work whatsoever.

John Hershfield (3:28)

They thought they were going to need them, but then by the time they built the building, they had invented central heating. So. Good. It's a very old. It's 1853, I think, is when this institution started, and it's only had six presidents since. So the people who come to run this place for a long time. Yeah, that's.

Dr. Patrick McGrath (3:46)

That's impressive, actually. Wow. That's. That's a long tenure per person.

John Hershfield (3:51)

It really, really is. And I may never get out of here, you know, and that's okay because I love what I do.

Dr. Patrick McGrath (3:56)

When is your run for president, Begin. Of Shepherd Pratchett? When will that take?

John Hershfield (4:01)

I think it's a. It's going to be a while. I got a lot. I got. I got plenty of work right here on my desk before I start aiming any higher.

Dr. Patrick McGrath (4:08)

All right, all right, that sounds good. Well, you know, people know you, obviously, from a lot of the work that you've done through the International OCD foundation, through the books that you've written. But you do come into the field from your own OCD experience, and I think that it might just be of interest for that the one or two people listening to this who don't know who you are. Right. What is your entry into the field that has brought you into the world of ocd?

John Hershfield (4:42)

Yeah, thanks. Thanks for getting straight to the personal right in the beginning.

Dr. Patrick McGrath (4:46)

Yeah. Well, you know, I'm just going to give it away, so why not?

John Hershfield (4:50)

Yeah, yeah, no, it's. Apparently I have OCD. I mean, I'm still holding out for an 11th opinion. But I have been told by important people who I trust that at various points in my life I needed help with this. This condition characterized by unwanted intrusive thoughts and just difficulty kind of wrapping my mind around how to let some things go and when things really difficult for me. In my late 20s, I found some, I got back into treatment and I found some solace in online support groups. And at that time these were these Yahoo. Email based discussion boards. So you'd sure, sure post a message. You know, here's what I'm going through. Some stranger would post a message, oh, I know what that's like. You know, here's some, some tips. And, and so I started reaching out saying, you know, here's my process, here's what I'm learning in therapy. Here's how hard exposure therapy is. Here's, here's what I like or dislike about what I'm being asked to do. And you know, some of it was very compulsive at the time. I'd be sort of talking about like, but why can't it be like this? And I want it to be like that. And you know, kind of compulsing out to people and they'd say, oh, this. I wonder if you're maybe seeking reassurance. Who are you? I don't know you. But then, you know, as I started to get better and was sort of internalizing the tools of cognitive behavioral therapy and ERP and really applying them in my life, I started putting that outward towards the people I was interacting with in these online groups. So I started, you know, giving counsel and advice to, you know, random strangers and finding that it was really quite gratifying. Not only did it help me understand what I needed to understand by kind of articulating it outwards, but you know, it's getting feedback like, oh, that's really helpful, that that means a lot. I got so into it that I started spending, you know, enough time on it. Kind of became the moderator of the group. And you know, through that process, people starting to ask, you know, are you a therapist? Maybe you should become a therapist. And I was going through a, let's say a career drought, so to speak. So I had been an actor before that and I had been working on and off. But, but the acting world is kind of interesting. Like unless you really kind of make it, you have these Days where you're king of the world. You know, you're. You've got your trailer and you've got the food and everybody's being really nice to you and you shoot your scene and you. You give your two or three lines and then you're just let employed again. Right? Nobody cares about you, and you never exist.

Dr. Patrick McGrath (7:17)

Day two. Yeah, right.

John Hershfield (7:18)

It's very, you know, for someone who, you know, struggles with psychological issues, you very. Can be very destabilizing. And so, you know, seeking some. Some more meaning in my life, and thank goodness I kind of arrived at, you know, maybe I should look into becoming a therapist. And in. In California, if you're looking into becoming a therapist at. At a master's level, you can either do a. Typically, either do a social work track or an MFT track. And so I chose a program nearby that would. Had a good MFT track, Antioch University versus Los Angeles. And yeah, just started doing everything I could. I'd make it about ocd. I have paper to write or write it about ocd. You know, project to do. Let's somehow bring it in, make it about ocd. And I was fortunate, you know, after. After graduating to get a gig working for an OCD clinic. So, you know, got trained up there. Then I spent some time working at ucla and they're intensive outpatient program for kids. Then I moved back here to Baltimore county, my. My hometown, and ran private practice for a While, and in 2020, joined Shepherd Pratt and have not looked back. I'm very, very, very fortunate, very grateful for the trajectory it took me. And sometimes I think about, like, well, what's really been the recipe for me for long success with my own ocd. And it might be a little bit different for. For the average person, because for me, I think it's actually thinking about and talking about OCD all the time, you know, so I can never really forget, you know, what are the rules here? Like, what are we really supposed to be doing? Therapists are famous for not applying this stuff to themselves, but because I am working in the field of the condition that I also live with, I think it's. I think it's easier for me to sort of keep it both external and internal, for which I'm really grateful.

Dr. Patrick McGrath (9:07)

I think one of the things that's really cool on that is every year at the International OCD foundation, you're involved in a support group for therapists who have ocd. And the number of people who attend that and who just described what it's like to be in that Room and the fellowship that's created. It's got to be just exhilarating to see all of these people who have come to the other side of OCD and now are giving back to the OCD community.

John Hershfield (9:38)

True story. So I don't actually. I've been to that group a few times. I don't actually. I didn't create it or run it. I think maybe Nathaniel Van Kirk runs that group, but I had gone to a few times, and frankly, I stopped going to it because too many of my former patients were at it.

Dr. Patrick McGrath (9:53)

Okay, that makes a lot of sense. Yeah.

John Hershfield (9:54)

Yeah. So it's full circle.

Dr. Patrick McGrath (9:57)

But what a testament, right, to the work that we do, that now the people that we've treated have decided that this is what they want to do. Also. The work you've done, like the books and various things, are. Are those inspired by your own experiences in your life, or have you found just. There's a deficit either in the literature or in, in people talking about these areas. And, and that's what leads you, because you've. You've gotten a lot of writing done. I, I don't know how you keep a family and do work and write and exercise and do all you do, but I think you've cloned yourself, actually, is what you.

John Hershfield (10:36)

Well, I exercise at six in the morning while watching likes on my. On my. On my phone, on the stationary bike. And, and most of my book writing gets done between sessions. You know, you're supposed to stop the session at 45 minutes, and so that gives you 15 minutes to write, and I'll get around to the progress notes later. I got a book to write. I think most of what I've written is about my patients, actually. I mean, I obviously write from a personal lens, but when I think about the bulk of the material that I've written, it's. It's thinking through just some of the amazing stories of, of courage, of bravery, of. Of audacity to stand up to the OCD that I learned from watching my patients get better. That, that really inspired me. So it. I. I don't. I think it's impossible to not write about yourself. So obviously it's in my own language and only thinking about things, but I, I think a lot of, like, you know, what would drive me to wr. When a family member has OCD or, you know, something specific about OCD and teens or things like that. It's. It's really just sort of watching people who needed those resources and thinking about the things that I've learned from Them and told them that, well, if this was written down, maybe I could spread that message even further than just patient to patient.

Dr. Patrick McGrath (11:54)

And there's a new book, I think you're. I don't know if you could talk about it yet or not. If you can't, that's fine. We will, we will just let people know there's a new one coming, which is exciting.

John Hershfield (12:04)

And my PIN code is. Yeah, yeah, no, I can, I can talk about it. I mean, it's, it's a work in progress. I was literally, while I was waiting for you to sign on, I was like, maybe I can knock out a paragraph, you know, literally working on it now. It's Being a Parent with OCD is the, is the name of the book or the working title anyway, might, might change. It could be, you know, John Herschel's big book of parenting stuff. But so far I'm going to call it Being a Parent with ocd. And again, that was driven from the fact that I've worked with so many, you know, wonderful, courageous, intelligent people whose ocd, you know, really either surfaced at the time they became parents or really blew up after they became parents. Because what happens, right, we always say it goes after the things you care about the most. And when you have a child that becomes such a huge target for the ocd, both from the perspective of, you know, how, how can I be certain that I'm doing everything I'm supposed to for my child to keep them safe? But also some of the existential and moral stuff about like, am I a good parent? What kind of parent am I? I'm a good person, am I a good model for my children? So in, in this book, I'm trying to look at it through the lens of a parent at every level. You know, before you become a parent, when you have a baby, what it's like to have an adolescent, you know, all with OCD and, and how to think about how to take care of yourself with your ocd. Had a lot of patients who just felt like they didn't have enough resources or were ashamed to ask for help. You know, I'm supposed to be a grown up now and be a parent. I shouldn't have this problem of having difficulty tolerating my contamination issues or my harm issues, my intrusive thoughts about the kid and things like that. I am noticing on this particular book, because I am also a parent, that I'm putting a lot of personal stories in here.

Dr. Patrick McGrath (13:45)

Sure.

John Hershfield (13:45)

Mostly funny stories. And you've had my kids ridiculous parenting errors or like interesting things that come up when you're a parent that you don't. You wouldn't normally think about until it's, like, right there in front of you.

Dr. Patrick McGrath (13:58)

So just for everyone. John and I are friends outside of the work environment, so we've hung out and everything. And, you know, I was thinking about today, John, and chatting with you and some questions maybe I hadn't really thought of before asked, you know, what was going to be new. And one of them is, your dad's in the field. He's. He's a psychiatrist.

John Hershfield (14:19)

Yeah, we make him live out in the field. In the back field.

Dr. Patrick McGrath (14:21)

Yeah, he literally is in the field. Yeah, I've seen his office. It's in the field.

John Hershfield (14:26)

For context, I grew up on a farm in Northern, and my parents still live on that farm. And my father is a psychiatrist. And his private practice office is a nice, beautiful office that was made in 1989. It still looks like 1989. And it's. It's sort of built out of the side of a barn. So that's the joke.

Dr. Patrick McGrath (14:43)

Yeah. I think he still has a rotary phone and a fax machine in there, if I. If I remember correct.

John Hershfield (14:47)

Number may start with a letter, actually.

Dr. Patrick McGrath (14:52)

But do you think there was any influence of your dad being in the field at all of you getting into it, or was there at first, you know, like. No, I'm going into acting. Definitely away from that whole thing and then, you know, now coming full circle into the family business, so to say.

John Hershfield (15:09)

I mean, I've been asked that before, and it's impossible to know how people's lives unfold. I knew since I was maybe like 6 or 7 years old that I. That I was very interested in movies and characters and being creative and that I wanted to be an actor. And so I pursued that, you know, you know, well into my adulthood and studied acting in nyu, and then I moved to Los Angeles and was working as an actor there. And it wasn't on my radar in any conscious sense. I did minor in psychology because I was interested in psychology. And, you know, I was sort of always around psychiatric concepts and psychology in some way. I mean, even if it's something like. Even as like a little kid, you know, seeing, you know, paper notepads with the name of some medication on it or something like that, you know, would be around the house, a pen that said Prozac. So it's always been a part of my. Of my world. And one of my friends pointed out that, that I had some sort of knack for Kind of downloading people's problems and kind of, you know, being a good listener and being there for people. And so I guess I've been always been attracted to the idea that a person kind of using their own mind and creativity could reduce the suffering of another person. And through that, I think certainly I've been inspired by my father being a psychiatrist, but it wasn't like, oh, I'm going to go into the mental health field. I really did come into it through my own mental health struggles. Since I've. I've entered this. This field, however, I'd certainly given my father and I a lot more to talk about.

Dr. Patrick McGrath (16:39)

Yeah.

John Hershfield (16:41)

And so it is a kind of. It is kind of interesting how relationships, how familial relationships work, because it's sort of almost like a rediscovery of the father son relationship now that I'm in. In that in the field. And so, you know, maybe I'll write about that one day. We'll see.

Dr. Patrick McGrath (16:56)

Yeah. Next book.

John Hershfield (16:57)

Yeah.

Dr. Patrick McGrath (16:57)

I am my father's son or something. Something like that.

John Hershfield (17:01)

Yeah. He's still. He's still working. I mean, my. My mother wants, you know, he. He loves his work and he's been a psychiatrist literally for over 50 years.

Dr. Patrick McGrath (17:09)

So, yeah, it's great. He's a good man and tells great jokes, by the way.

John Hershfield (17:16)

Famous for telling great jokes. Yeah.

Dr. Patrick McGrath (17:20)

When I do these, there are times that people want to talk about, or even outside of this, where people will say OCD must be kind of like a superpower. Right. I mean, it must be help people be propelled, because you see people who are famous or who are athletes who have ocd. So I like to work on dispelling that myth. I like to say that people are athletes and famous in spite of ocd. Right. Not because OCD was the thing that propelled them there. And I'm wondering your thoughts on that. The idea of you are a successful therapist, you've got this great program, you've got these books that are out. Did OCD help you with those in any way? Or has it only.

John Hershfield (18:12)

It's a good question. It's a good question. I. I think they remember at some point checking in with my longtime therapist, you know, while at the sort of pinnacle of, you know, things are going well in my career. And I was just checking in with them to work through something that was. That was troubling me, and they said something along the lines of, like, you know, OCD has been good to you, and the rage that. That stirred up in me in that moment, you know, towards this person who's, you know, you've been incredibly helpful and, you know, saved. Saved my life in many ways. I was like, nope, I don't think I like sounds bad. Yeah, I wouldn't say it's been good to me. I mean, look, people, certainly some people derive a lot of strength from adversity. Right. From kind of growing through traumatic experiences. I don't think anybody with PTSD would be like, you know, grateful for the trauma they experience, but it. But they might find that the trauma, you know, once more or less resolved, you know, increase their resilience and. Or their willingness to stand up to hard things or things like that. So I think ocd, any, like any other kind of challenge could certainly result in somebody, you know, recognizing that they develop strengths through working through a hard thing. Most of the time when people say OCD helped me, they're talking about character traits that you can have without ocd. You know, fastidiousness, heart, being someone who works hard or, you know, a perfectionist or something like that in a healthy way. So, you know, so does like having something on in the back of my head that constantly tells me there's a book deadline coming up helped me get books written, I guess, in some way, but I could probably write those books without constantly being annoyed by the back of my brain.

Dr. Patrick McGrath (19:52)

Right. People have written books without us.

John Hershfield (19:54)

Yeah, exactly.

Dr. Patrick McGrath (19:55)

Yeah. Yeah.

John Hershfield (19:56)

So, yeah, I, I think that, you know, if your personal journey is. Is one in which, you know, you're grateful for the adversity that you faced because it gave you these new tools, I certainly wouldn't take that away from anybody. But I don't go around saying, you know, thank God I have ocd. It helped me find my calling. Yeah.

Dr. Patrick McGrath (20:12)

Yeah.

John Hershfield (20:13)

I think it gets overlooked too, is like most people don't have OCD. Right. 2 to 3% of the adult population. And in psychiatric terms, that's relatively high statistic, but in mathematical terms it's not. And when you see people who are successful and they talk about having. Having ocd, it can sometimes give the illusion of it being this thing that like, oh, everybody's got a little of it. And look, even these famous people, but those are just, you know, kind of remarkable people who happen to also have ocd. At least that's how I think about it.

Dr. Patrick McGrath (20:47)

Yeah, I, I have felt a similar way too, but it. Sometimes it's difficult to convince people of that. Right. That. And, and, and I'm not out to convince them, oh, no, this or that. But I, in the day to day work that I do, and I would assume in the work that you're doing as well, too. No one's. No one's really thankful for ocd. Right. I just don't. I just don't hear people say, wow, this was. This was the best condition to ever have in any way whatsoever.

John Hershfield (21:19)

I. I think the only way in which I could find an exception to what you just said would, would be if somebody is able to access a more global, mindful sense of gratitude. Like if you're grateful for being alive. And part of being alive is that you have some of these things that have made your life challenging, and one of those things is ocd. In that context, I think it would be fair to say that you are also grateful for OCD because it's part of your. Part of the fabric of your. Of your universe. But that very kind of abstract kind of mindfulness way of looking at it, I think. I think for the most part, I totally agree with you. Why would somebody be jazzed about something that's causing them so much suffering? But they could be grateful for who they became after overcoming, mastering that suffering.

Dr. Patrick McGrath (22:02)

One of the things we haven't talked a lot about here is mindfulness on the podcast, and you've done a lot of work in that area amongst your group of friends. You're famous for going on silent retreats.

John Hershfield (22:17)

Compares a thing talking too much and being silent throughout.

Dr. Patrick McGrath (22:23)

Yes, the juxtaposition is fascinating, bits and starts, but could you tell everybody about mindfulness and what you see its role might be, or in. In ocd, because people will ask about act and mindfulness and those types of things. So I'd be interested your take on that.

John Hershfield (22:42)

My attitude is that the mindfulness for OCD is. Is not separate from mindfulness for everything else. As I mentioned before, the retreat here at Shepherd Pratt is a general psychiatric program, a. An OCD program within it. And so when I'm running the mindfulness group here, for example, I'll be speaking to a group of people, some of whom have ocd, some of whom have trauma or substance use issues or other types of issues. And I'm. And I'm not modifying the message all that much for any. Any of those different conditions, because what we're talking about here is suffering. And suffering is being caused by being lost in thought about the past or the future. And so you're thinking, you know, something bad happened, I can't stand it. I don't like it. I wish it hadn't happened. Or maybe it happened in case of ocd. Could it have had happened? I'm not sure. Right. So that's not you actually showing up to be alive here on earth, present. So mindfulness is a. Is not an intervention. It's not something you do. It's a. It's a perspective you take in which you show up to the present moment exactly the way it is, without judgment and without thinking, like, okay, this really needs to be changed. It's really just looking at things the way they are, like having the experience. So you might be immersed in the past, you know, I shouldn't have touched that thing or looked at that thing or had that thought. Or you might be immersed in the future. This thing's going to happen. What if it happens? I'm afraid, you know, the next thing at this appointment coming up, and all of those things when. When you're sort of inside them and you're not realizing, hey, I'm just thinking here. But you actually feel like you're in the movie. That's where a lot of your suffering is coming from. What. What makes ocd, you know, the. The greater challenge than some other conditions in this regard is that when you become aware that you're lost in thought, it's very hard to just sort of drop it and come back to the present. You usually feel like there's something you have to do, like you're contractually obligated to figure it out or. Or repeat the thing or get that reassurance, and then you're sort of allowed to return your attention to it. So you can imagine somebody who's like, just, I don't know, relaxing and watching tv, and something happens in the show that triggers them, and then they start to think about it, you know, why did it trigger me? What does it mean? What's it going to happen? Whatever. And they don't even know that that's happened. They still think they're watching tv, but actually their mind has completely left the project to follow the story and is now following its own story. And then they become aware, like, oh, I'm obsessing. And to be able to just be like, yeah, I'm not going to do that right now and go back to watching the show. That would be wonderful. But what tends to happen is something along the lines of, let me figure out my sexual orientation in this moment. You know, let me make sure I didn't actually want to hurt anybody, or whatever the obsession might be. Further digging, you know, kind of digging you into this process of being somewhere other than here. Right. Meanwhile, you're getting older, right? So you're sort of missing out on being alive. And where we get a lot of our joy from isn't positive experiences or happy things or exciting things. Those are great. But we get a lot of our joy from just sort of being around when something joyful happens. You know, when you're just sort of minding your own business and then you see a hummingbird and you're like, wow, that bird flies really weird. Right? And they go, wow, that's great. People miss out on so many of those moments because they're lost in thought. So long winded way of basically saying, if you could pay more attention to where your mind is and enhance your ability to bring it back to the present more objectively, you'll find that your life is a lot easier to manage. But what in so doing, you have to only take the risk. And this is where exposure therapy comes in, of letting it go when maybe there's some sense of moral urgency to spend more time with it, to figure it out. Right. Maybe I let this thought go too quickly. You know, maybe I decided to let myself watch this show instead of trying to figure out why I got triggered. And that feels like a moral quandary for a lot of people with ocd. Like, who am I to decide that this is just ocd? This is the battle with most ocd. Right. Because if everybody could just be like, yeah, whatever, it's ocd and let it go, then nobody would need any additional help. Right. So.

Dr. Patrick McGrath (26:44)

Right. Which is also why we don't use that as part of treatment. Just, well, just tell yourself it's your ocd. Because if that worked well, then no one would have ocd.

John Hershfield (26:52)

Right, right. Have you tried stopping it, for example?

Dr. Patrick McGrath (26:54)

Yes. Raised.

John Hershfield (26:55)

Yeah, So I, you know, mindfulness has been very, you know, unlike ocd, mindfulness has been very good to me, you know, and initially I learned about it in a very kind of intellectual way, you know, you know, meditate and feel better and relax or whatever. But. But once I started going to actual meditation retreats and spending a lot of time really kind of training myself to pay attention in that specific way. And I'm not saying this is for everyone or that everyone should do it, but for me there was, there was definitely a process of clouds opening up that, that really helped me to understand the difference between a narrative in my head and just an experience of my senses and my mental objects. And so it's been very helpful for me. And I, and I try to pass this on to as many people as I can.

Dr. Patrick McGrath (27:43)

The other piece you brought up there is something that you and I are somewhat known for together is the moral aspect of things. Where we do a lot of work in the moral scrupulous area. We recorded a three part series that's on the International OCD foundation with our friend Ethan Smith about moral scrupulosity and have done a few talks in the area at various conferences and we'll be featured this year on a panel discussing that as well.

John Hershfield (28:11)

Yeah, looking forward to that.

Dr. Patrick McGrath (28:12)

Yeah, me too. So what is your own interest in moral scrupulosity and what are things you think people don't really know about it but should be aware of?

John Hershfield (28:26)

First of all, I just think it's fascinating because again, part of the mindfulness idea is like you're kind of, it's a, it's a study of the human condition and, and you know, how people, where people derive their morals from, whether it's from their religion or from societal rules or from their family system or just there'd be a. With fundamental human instincts. It's always kind of interesting to get to know someone, to sort of see what's their, their moral frame. And, and for people who struggle with this in, in OCD terms, what's happening is they're kind of viewing moral incongruence. So this, this is, so this idea that they may have done something just slightly off from what they should have done as a kind of contaminant to their sense of self, their identity, their, their, their soul in some cases. And this contaminant can feel unbearable, right, because it's like your self worth is at stake. Right. So it could be something that, you know, human beings being imperfect as they are, would be like, yeah, I guess that's like a minor infraction, you know, like maybe you shouldn't have done that. But for the person with ocd, it just feels much more intense, much more urgent. And so the guilt, and it really is driven, like equal parts guilt and anxiety. The guilt that comes from being triggered when you have moral scrupulosity is so out of proportion to whatever it is that you think you might have done, which in most cases is nothing and in some cases is still essentially nothing just being a person. So I just think it's, for me, I think it's the philosophical part of OCD that's kind of exciting to talk about and work with people and sort of help guide people into. Like, how can we make it so that your life is characterized by less suffering, suffering left your own devices, you're probably going to suffer the most you could possibly suffer because that's how you know you're a good person. Right. How can we do less than that and see if it improves the outcome? I think it's poorly misunderstood. I think it's not exclusive to ocd. I mean, you certainly see it in trauma and in depression and in other conditions it might look a little bit different, but still, this sort of intolerance of human imperfection. And if we could soften that, if we could get some psychological flexibility in there, People always worry it's a slippery slope to being a bad person. But, you know, look how you turned out, Patrick.

Dr. Patrick McGrath (30:42)

Yeah, I, I did okay.

John Hershfield (30:43)

You're all.

Dr. Patrick McGrath (30:46)

One of the things we've talked about too is, is the underpinning of moral scrupulosity behind a lot of the other subtypes. So harm OCD could have a moral scrupulous aspect to it also. Because what will people think of me as, as a person for having done this harm, right? Or this? Or for contaminating someone else or for thinking about harming a child and pedophilic OCD and all these areas, or how will my spouse think of me with my relationship? Ocd, Right. So there, there may be these certain categories where we, we have subtypes of ocd, but there might be some larger catch all umbrellas that a lot of those fall underneath as well. And I think moral scrupulosity would be potentially one of those, those larger umbrella categories.

John Hershfield (31:31)

Yeah, I was go. I would go as far as saying with the possible exception of some of the just right and sensory motor types of ocd, moral scrupulosity plays some role in pretty much every part of ocd. Because like I was saying before, the decision to stop ruminating, the decision to stop avoiding, the decision to not engage in a compulsion for the person feeling that internal drive to do so, that decision to stop is a moral decision, right? It's who am I to put myself first? Well, even the decision to seek help, right? To ask for attention, to ask for treatment. Who am I to be so selfish as to take another person's time to help me reduce my suffering? So I think understanding how to be a person with strong moral fiber, right, who, who really does care about what it means to be good in this world and actually be able to enjoy the benefits of being in this world at the same time, that's, that's the game that OCD is trying to keep you out of. It just says like, you got to be perfect or else you're bad.

Dr. Patrick McGrath (32:41)

And for those I always like to think about, for those watching. And that word scrupulosity sounds weird to you. It. It comes from the Latin scruples. And. And it can be defined almost like a little stone in your shoe, right? Something that's just there and that's annoying and demanding attention. But do you want to really stop and deal with it? You know? And so then think of that as this little earworm thing in the back of your head, sitting there and demanding a little bit of attention. Always kind of digging around, looking for something and. And throwing out those doubts and those. Those uncertainties at, you know, but from a moral side, that's where we would see moral scrupulosity. There could also be religious scrupulosity then, too. And that's where most people, when they hear the term scrupulous, think of. On the religious side of, have I been faithful enough? Have I followed the tenets of my faith to the letter of the law? Those types of things. But there is this moral side, and it could be anything from even. Boy, I should probably wait at the store door again for the next several months, because I think when I left last time, I let the door go too soon, and what if it hit the back of the person's shoe and that injured them? I. I'd like to apologize to them someday. So I'll just hang out at the store and all of my free time, and in case that person ever comes in, I'll. I'll say, hey, several months ago, I. I don't know if you remember me, but you walked past me and I let the door again. I just. I think it might have hit your shoe. And if it did, I. I really do apologize. I hope it didn't scuff your nice gym shoes or something. Something like that, Right?

John Hershfield (34:15)

Just the irony, and this is true of all those cd, is that compulsive behavior, that compulsive confessing and apologizing. You were just demonstrating, right? For the person who's on the receiving end of it, that would be very disturbing, right? That would ruin my day if somebody came up and said something like, to me, I'd be like, I think I'm gonna die today, because there's weird things happening. And that was among one of them. One of the things that's true about OCD is the more compulsive you are, whatever the subtype is, the more you are creating a world that's very much like the world that you're trying to avoid, right? So the classic example is if you want to be Free of illness, you might find yourself having to wash your hands a lot. But if you wash your hands too much, you strip the skin of its protective oils, which makes it dry and crack, which, you know, is how you get getting openings in the skin and infections. What was the point of that? Right, right. And so with. The same thing is true of moral scrupulosity when somebody is compulsively criticizing themselves all day, treating themselves unfairly, punishing themselves all day, in some cases hurting themselves, apologizing incessantly, confessing incessantly, avoiding situations where moral issues come up, they're actually creating a world for themselves where they are angry all the time, judgmental all the time, and making interesting choices, like, you know, lying, for example, because they're afraid they're going to hurt somebody's feelings. Right, right. They're starting to make choices that are incongruent with. With what they understand their morality to be.

Dr. Patrick McGrath (35:44)

Yeah.

John Hershfield (35:44)

And the same is true of religious scrupulosity. Right. You see people who are afraid of having an intrusive thought about their deity, so they're avoiding going to their place of worship and they're not praying and they're not practicing the religion the way they, you know, it's creating distance between them and their faith. So that's. I think some of the magic of ERP is it's about actually bringing you closer to the things that you want and understanding how the compulsions, although in the moment they might relieve some temporary distress, are actually bringing you not just further from the thing you want, but actually closer to the thing you said you didn't want in the first place.

Dr. Patrick McGrath (36:14)

Exactly. You know, I've heard some people with religious scrupulosity talk about it felt like I was worshiping ocd. Right. Instead of. Instead of the deity that I was. I was hoping to have a relationship with. Yeah. That it became the most important thing.

John Hershfield (36:30)

Yeah. And I, I just along those lines is one of the think commonly overlooked compulsions in OCD in general, but particular to moral scrupulosity. You see, religious scrupulosity, too, is self criticism and self punishment. People tend not to think of that as compulsive. Yeah. Right. So. Oh, well, you know, I'm hard on myself because that's going to help me to be a better person. Well, can you provide some evidence of this? Because I've seen you be hard on yourself for a long time and you don't seem to be making any changes. Right. Like, if you can, if you can show me how beating yourself up actually improved Your behavior, then maybe we could have a discussion. I mean, certainly none of the literature on how to raise children suggests that the more you punish them, the. The better behaved they are, you know?

Dr. Patrick McGrath (37:06)

Right.

John Hershfield (37:07)

And no, actually you're teaching them how to evade punishment, how to. How to evade you. So. And not you specifically, Patrick, you're not.

Dr. Patrick McGrath (37:15)

Yeah, I don't. I don't punish. I don't even have children to punish. So I.

John Hershfield (37:21)

But just like, become very attached to their compulsions because it feels like it's giving them the roof that they need. Whether it's hand washing or checking or researching things. I think people can get very attached to self punishment, self criticism, thinking that it's the moral thing to do, when in fact it's the compulsive thing to do. It's actually feeding the obsession. And it's. I think I find people struggle a lot to open up to that idea because self compassion, which is a part of mindfulness, which is really just a part of being fair, is like an exposure. Right. For someone who feels that they should punish themselves because their OCD is telling them that they're bad, treating themselves well is an exposure. It feels very. Can be. Feel very threatening.

Dr. Patrick McGrath (38:05)

And, and you know, I joke about that with the punishment, but one of, One of the ERPs that I talk about with people is if this punishment really works so well, why don't you treat everybody else in your life the exact same way? Right? I mean, if you see them doing things that you find in your OCD to be bad things, go up to them and say, you know, I think you should go punish yourself for that, because that was really terrible, and see if anyone will speak to you ever again for the rest of your life.

John Hershfield (38:30)

Well, so the answer to that is usually something like, well, you know, I always put other people first, right? Because I'm. I don't. Like, I should put myself last because I don't want to be a narcissist. To which my response is, don't you think about yourself all day?

Dr. Patrick McGrath (38:43)

Right, right.

John Hershfield (38:44)

Like, yeah, the OCD is giving you exactly what you didn't ask for.

Dr. Patrick McGrath (38:48)

For. Yeah, yeah. And still demanding all of the things that you're never going to get on the religious scrupulous side. I, I say to people, your deity could show up in our session and say, you're good, and your first reply will be, are you sure? Right? You, you're just, you're just not going to get that level that you really want.

John Hershfield (39:07)

Your deity would be like, this guy.

Dr. Patrick McGrath (39:12)

How dare you doubt Me or anything of that nature. Yeah, yeah. You know, now that you're in the residential side of things, obviously it's a whole new game beyond just the work that we might do in the individual one on one hour or two a week sessions. So where do you see OCD in terms of when it's to the level of residential? Because we've both had that residential side. Are there things you think that people could do earlier on to hopefully not have to use residential? Because as much as we were appreciative of the fact that people came to us for residential and we had a service, we'd also like no one to ever need our services ever again. I mean, that ultimately be the greatest thing ever. So what do people kind of miss out on the levels, you know, Iop PHP on the levels on the way up to residential, that when they have that aha moment in residential, they start to think, boy, I could have done this earlier, but I chose to do these other things instead. Right.

John Hershfield (40:23)

It's a really good question. I wouldn't claim to know the, the answer. One of the most common things I see is people who, who were not given the opportunity to learn how to effectively regulate their emotions. Okay, so whether it's from OCD or another condition, there are things that they find very upsetting and in the only way they, they've learned to deal with that upset is some kind of compulsive behavior or substance use or acting out in, in some way to get away from the intensity of the unpleasant behavior. No one is actually really kind of alerted them to the fact that, that emotional regulation is a part of being able to think clearly so that you can solve your problems, so that that might result in them being treated poorly by their family members or by their outpatient providers, like, oh, this person's unreasonable, or they're, you know, they're always acting out or they're always upset about this or that, or they just won't stop doing this drug or, you know, that's how they like it, you know, and so they end up getting subpar care, you know, and it's not, it's not their fault. And so by the time they end up in residential, they've now spent a lot of time having a relationship with their emotions that's just not conducive to functioning in this world. And so, you know, getting triggered when you have OCD can be incredibly overwhelming. But, but again, you, you could be triggered to depression. You could be triggered, you know, to be re traumatized. You could be triggered to have urges to use a lot of different things can set you off. And if you don't know how to observe and respond and make space for or adjust your emotional world, it's going to overwhelm you and then you're just going to default to whatever it is you've learned early on to do in those situations, which is the thing that's holding you back. I would say that. And, and, and this is a systemic problem. We, we have a mental health crisis in our country, and I think people, for a variety of reasons at the outpatient level, are not getting the type of expert care and attention that they need from the outset. So they might be getting a lot of bad information from the Internet or they might be seeing a therapist who doesn't know a lot about OCD and who's, you know, giving them information that's not helpful. And, and they might have conditions other than OCD that are not being diagnosed or might be diagnosed as OCD when they aren't, or might be ocd, but they're being misdiagnosed as some other thing. So the other thing I see a lot of, besides difficulty regulating emotions here in our residential is poor diagnostic clarification. Right. They kind of have what they think they have, but actually they have something slightly different. If they'd known that earlier, maybe they could have gotten more effective help for it earlier.

Dr. Patrick McGrath (43:12)

Well, that's the whole basis behind nocd and why we exist to try to get more of that out there. Because you're right, you know, Stephen Smith's own experience of going to numerous therapists before he found an ERP therapist, and it led to things like picture a stop sign in your head or snap a rubber band on your wrist or something like that as a way to manage those.

John Hershfield (43:33)

Stop sign over here.

Dr. Patrick McGrath (43:34)

Yeah, yeah. Or yes, yes, just bang, bang your head on a stop sign sign. Maybe that's it. Right. Something like that. Before we go, are there, you've been in the field a while now. Are there little pearls of Hirschfield wisdom that you like to, to give out to people or that you're kind of known for saying and that you want to just have a little platform here to, to give to everybody else who might be new to working in OCD or from, from the professional side or from the, the, the patient member side?

John Hershfield (44:11)

Those are, those are usually things I say and then forget about and then they come back to me later. Yeah, right. I remember a patient recently gave me a feedback that in, in the midst of us trying to sort out how she was going to get through this exposure. It was like, well, okay, so what's going to happen if you do this? Like, well, it's going to be difficult. I said, okay, but it's difficult. But then you're going to, you know, be stronger and then you go do this. Yeah, but I'll suffer in the meantime. And I said something like, well, what's wrong with suffering? And that just stuck with them, you know, like, yeah, these little kind of things where it's like you're just assuming you can't do things, but you're not actually looking at them like, maybe, maybe you can. So I think a lot of what we do is hold hope for people when they're having trouble holding their own hope. And then you kind of eventually kind of pass it off. They can hold their own hope for themselves. I mean, so I say all I'm and go ahead, I'll give you a list of my patients. That would be a crime. And they'll tell you, well, here's one goofy thing John Hershield said. Here's another. Yeah, I think that's part of the work, though. I think that's why I really love working in OCD is we throw people intentionally. We say things maybe not supposed to say or you wouldn't be expected to say because it gets them out of that, that repetitive pattern of like, you're ruminating and thinking and compulsing or whatever, and you're like, what, what, why could you say that?

Dr. Patrick McGrath (45:24)

That.

John Hershfield (45:25)

And now they're looking at their experience from another angle, professionally speaking. I think what sometimes gets overlooked, particularly in the OCD specialty realm, is that therapy is still therapy and your patient is still a human being and that this is about relationships. Right. So I, I, I think psychoanalytic traditions historically did such a terrible job treating OCD that there was this sort of response to like, okay, now we have good evidence based care, we have erp and anything that treats a person outside of a manual that I'm holding right here in my hand is a no go. Like, don't, don't, don't ask about their childhood. I don't want to know about your parents. Just like right here in this moment. You know, I think that's a bit of an overcorrection. And we use overcorrection exposure therapy sometimes, but as a result of that overcorrection. So I think I find some newer clinicians kind of learning how to treat OCD get so sort of stuck in protocol that they forget that the most important thing in the beginning is actually establishing trust with the patient. Hey, you're a person. I'm a person. I'm going to help you because I have, like, some information that you don't have. I'm going to help connect it with the information you do so we can help you suffer loss.

Dr. Patrick McGrath (46:34)

Right. And that rapport is essential if you want someone to share some of their most innermost thoughts or deep. What they think are horrible, awful, demonic, terrible things. And yeah, yeah, it's.

John Hershfield (46:45)

It's hard because sometimes, actually, often we talk about hierarchies. Right. You start low and you work your way up. But the top of the hierarchy for a lot of people is asking for help or telling somebody about your intrusive thought. Right. There's no way to hierarchy your way up to that. You know, once you've said, okay, I'm going to walk into a place that says OCD center on the top of the door. So taking the risk of saying, maybe this is ocd, could be a big violation of your ocd. So it takes a lot of courage to ask for that kind of help, but it's worth it.

Dr. Patrick McGrath (47:18)

Well, and you've proven that, too, in the work you've done on yourself and then in the work you've done in the field. So thank you, John, for being here today and sharing that with everybody. I appreciate it.

John Hershfield (47:26)

Thanks, Patrick. It's really an honor to be on your show. And thanks to nocd. You guys are doing great work helping a lot of people.

Dr. Patrick McGrath (47:32)

Awesome. And thank all of you for watching another episode of the get to Know OCD podcast. If you like it, you can subscribe to the NOCD YouTube channel. And if you're looking for help for OCD, check us out@nocd.com. we'll see you again in another episode in the future. Talk to you soon.