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The OCD Stories
Dr Fugen Neziroglu: When a higher level of care may be needed, and overvalued ideation (#536)
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- [00:00]
A
You're listening to the OCD Stories podcast hosted by me, Stuart Ralph. The OCD Stories is a podcast dedicated to raising awareness and understanding around obsessive compulsive symptoms. I do this for interviewing inspired therapists, psychologists and people who have experienced OCD. Welcome to the OCD stories and welcome to episode 536 of the podcast. And in this one I chat with Dr. Fugen Nezarolu and Fugen is a board certified cognitive and behavioral psychologist and the co founder and Executive Director of the Bio Behavioral Institute in Great Neck, New York. Fugen has published more than 150 papers in scientific journals and authored or co authored 15 books. So it's great to finally get Fugen on. To be honest, she should have been on the show a long, long time ago. She has done so much for the OCD community. So in particular we talk about her rich background in the field of OCD, being mentored by the late Dr. Edna Foer. The dosage of therapy when to level up care Some earliest signs Once a week Therapy isn't working for someone. Intensive outpatient programs, residential treatment, inpatient treatment, medical treatments what an iop, which is Intensive outpatient program should look like. Adapting the IOP to the client's timeframe. We then discuss overvalued ideation, low insight, the need to deal with overvalued ideation to improve treatment effectiveness, motivational interviewing, shame and much more. And thanks to our podcast partners, nocd. If OCD is interfering with your life, NOCD can help their licensed therapists specialise in exposure and response prevention therapy. The most proven therapy For OCD with NOCD, effective treatment that is 100% virtual is available for children and adults with OCD and most members can get started within seven days on average. No hassle, just real science backed help and support between sessions. Begin your journey@nocd.com or I'll put the link in the episode description. So thank you so much to Fugen for her time and expertise. It was wonderful chatting with her. She obviously knows her stuff, which is very much an understatement. She knows a ton, so it was great to get her on. I hope to get her back on again in the future. And thank you to you guys for listening. As always, it means a lot. And without further ado, here is Dr. Fugen Nezarolu. Welcome to the podcast Fugen.
- [02:35]
B
Thank you for having me.
- [02:36]
A
Yeah, it's good to have you on and you are very well known in the community, at least amongst therapists and clinicians. So it's Great to finally have you on. And as we were saying just now, you did voice a character or a couple characters in the audiobook of Blink Blink Clop Clop, which are link in the show notes. So just initially, whenever I get a therapist on or psychologist or psychiatrist, I like to ask them kind of their journey, like, what got them into the work they do and then ultimately ocd.
- [03:09]
B
Well, I was an undergraduate to get into graduate school, actually, and there was nothing about OCD. And Dr. Jose Yuritovaez, who later became my husband, had come from Argentina, and he was trying to bring an Afrina clomipramine into the United States. And Siba Geige, currently Novartis said, oh, there's not enough OCD people. It doesn't warrant us doing any investigation on this medication. And he said, no, that's not true. You just, you know, don't know how many people are out there because they're not asking the right questions. Well, they were not really interested. So we did grassroot efforts. We went library by library. We started what was called the OCD Society pre iocdf. And he finally got the medication for the first clinical trial, which was the first medication for OCD in the country. And I helped was one of the raiders. I got interested in OCD from there and went on to study the belated Edna Foa, who just recently died. And she was my mentor, and she had an inpatient unit, the only one in the United States for ocd. So I went there, studied with her, came back and started the first IOP intensive outpatient program in the United States. Started with OCD and expanded it to anxiety disorders in general, and then started thinking about how ocd, you know, was treated with medications, but that also responds to cbt, cognitive behavioral therapy, and why. So I started measuring serotonin, and by that time my husband had put forth the serotonergic hypothesis, saying there was something perhaps neurochemical that was different in OCD versus non OCD individuals, which turned out to lead to a whole host of areas of research and to the SSRIs that we currently have. We've had every SSRI for about 20 years prior to its FDA approval. But at the same time, I went to study with nfo. I came back, started this IOP program and started measuring serotonin levels with NIMH and demonstrated that we were getting also chemical changes via just purely intensive treatment for our patients. So from there I just continued my interest spread to the related disorders of BDD and hoarding, primarily bd. And that's been my journey and since then for umpteen years. So we won't say how many, you know, you. We all know that the whole world of OCD has drastically changed from two and a half pages devoted to it and the most famous psychiatric book to where we are today. Yeah.
- [06:17]
A
Wow. What a journey. Yeah. And obviously thank you for the work you put in to. To get it to this place. And you know, as you mentioned, Edna Foa sadly passed away recently. What was it like training with Edna?
- [06:35]
B
She was an incredible mentor. I had the privilege of seeing her just two months ago at Northwell Hospital here on Long Island. She was here as a lecturer for ptsd, so I had the opportunities. It's miraculous to see her in person, talk to her for at length prior to her departure.
- [06:58]
A
Yeah. Wow.
- [06:59]
B
Yeah, she was an incredible mentor early in my career, both in publications, presentations and shaping how I did exposures, how I thought and conceptualized problems. An amazing woman who trained so many of us in the field today.
- [07:18]
A
Yeah, yeah, she was. Yeah. Wow. Cool. Yeah, it's a great training to get. So we talked about a few topics. So the first topic for us to discuss is when people aren't responding to weekly therapy, weekly sessions. I'm guessing you'd include sort of twice weekly in that as well. And when to then level up care, maybe to residential or intensive outpatient or something. So what are the earliest signs, do you think that like once a week isn't working for someone?
- [07:54]
B
I think the first thing is to check whether the kind of therapy they're doing once or twice a week is actually the correct form of treatment, because a lot of people have learned the buzzword cbt, erp, so they know they're supposed to do that and they tell the patient they're doing that. Unfortunately, patients really don't know what it actually should look like. They think they're getting it, but often what they're getting is talk therapy and instructions to do certain assign. Well, if the patient could do it in the first place, they would have done it. So telling them, you know, go and touch this contaminated, or don't check your stove or stop thinking about these existential thoughts doesn't really help the person because they don't know how to do that. So the first thing is, are they getting the proper treatment? And how does a client know that whether they're getting the right treatment is to ask the right questions? Are you just reviewing your week or are you in a formal way taught how to challenge your thoughts, which is cognitive therapy? And there's A very structured formal way of teaching you cognitive therapy and then assigning some behavioral experiments which you may or may not be able to do. And if you can't do it, then it's the assumption that the therapist does it with you. The other is exposure and response prevention. And that is where you look at various different situations and did the client actually go out with the person out of the office and practice doing those assignments and situations? If not, and they're not able to do it on their own, the therapist should be going out of the office. So you have to first evaluate what kind of treatment do they get and is it appropriate. Like mental rituals. Sometimes many therapists can take a mental ritual and put it into an in vivo exposure exercise. That just means doing it in your own environment. So you should know should be able to just take a mental ritual and convert it into something that is practicable. So that's one way to see if your CBT is the accurate form. Assuming it is, that it may not be, number of sessions may not be sufficient. So you need more practice per week. So then you say, well, how many times a week were you seen? And then that's where the IOP comes. IOP by definition should be three hours, five days a week. Now there can be modifications obviously to this. It could be two hours, it could be 90 minutes, five times, it could be three hours three times a week. Various different modifications, but it just means the intensity is greater. And what we have is different bands of iop. So it depends on your level of functioning, your quality of life to determine how much more therapy do you really need, what level of IOP do you need? And as I said, that's very much contingent upon depression, your overvalued ideation and how well you're functioning, how distressed are you, what's your quality of life, et cetera. Then if we try an IOP for let's say one to six months and it's not working, I mean, we usually don't go six months. Usually patients within three months do well and then the sessions are decreased. Occasionally when the patient needs like 24, seven, they're very, very severe. They're really unable to even get out of the house. Where we're doing home visits with them in the house, but we're still not getting any movement and, or we've tried different formats, different ways of doing it and we're not getting any fraction. So then we would send them to a residential program. The difference between a residential and IOP is the residential is 24 7. So there's someone on premise 24, 7. Many of them, unfortunately, are groups with some individual sessions. And so they meet together, they're given instructions, but at least there's someone there who can work, you know, work with you. If you're not able to do it, hopefully they'll be able to sit in or do it out there with you. They're usually behavioral associates who do the exercises. So a residential program could cut off the water. They could lock the door to your room. So there are things that they could do, perhaps on an outpatient basis we can't do. Often, coming out of a residential program, they enter into an IOP coming back this way so that whatever is remaining can be worked on at home and in their own environment from residential. You could certainly have inpatient. I don't really see why an inpatient would be beneficial for an OCD patient. But we. There are inpatient programs. I see it if. I mean, again, if you're suicidal, which most. I mean, they have ideation like everyone else, but they usually are anxious people, not necessarily severely depressed individuals. So I don't really see. Because you're now, unfortunately, locked in a unit with people with a whole bunch of different diagnoses. It could be a very scary experience sometimes. Under rare occasions, it might be to modify your medication if there's some concern that you're either not able to take it or if you're unable to take care of yourself physically. You're not able to go to the bathroom, you're not able to eat, you're losing weight in those rare occasions. Yes. It gets you back mobile again, and perhaps then we can work better with you. So it's important. Then there are different forms of treatment. You know, neuromodulation, which is TMS and deep brain stimulation, and those are effective for certain individuals. But again, it's a very small group of people, and you have to have gone through an IOP or residential to qualify for at least DBS D stimulation.
- [15:02]
A
Yeah. Really, really good breakdown. Thank you for that. And so going back to weekly therapy, how do you distinguish whether someone just needs a little bit more time versus okay. No, actually, no matter how long we keep doing this, nothing's going to change.
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B
Well, obviously you need some time in therapy. You know, there has to be some rapport, especially if you're going to give instructions to do exposures or trauma. I would say if you've been in therapy somewhere up to a year and you really haven't made progress, it's time to move on.
- [15:44]
A
Okay. Yeah, good point. So this is more about clinicians, this one. So if I'm looking over this way, it's just, I got my questions there. What are some common mistakes clinicians make when delaying referral to an intensive treatment program?
- [16:05]
B
Well, different clinicians make different referrals, but psychiatrists are more willing because it's usually not within their realm to do cbt. So they're more likely to refer for intensive or weekly or some form of treatment. They may not be as familiar with levels of care, but they know that the person needs CBT or erp, whatever buzzword they want to use. The psychologists usually are more familiar. Social workers, licensed mental health counselors. These days they are more aware. So what I have been finding is that they're referring for Iops when they're not seeing any movement. And what we do at Biobehavioral Institute is really they join the team. So when you make the referral, you are part of our team now. So we don't say we're going to work with the patient alone. You continue to work with your patient, we work with you. We look to see what your contribution could be. Whether it's another day that you're doing the exposures and we're meeting and, or whether it's we're summarizing what we did and you're working on, you know, dysregulation or you're working on some other aspect. You're part of the team because the patient has rapport, usually with the referring person and the connection is really important. So they shouldn't be fearful ever and create another anxiety source. They're anxious enough, you don't have to worry about, you know, having to leave your therapist or someone you feel safe and trusted. So the therapist should, should be, in my opinion, included in the treatments in these programs. And some residential programs actually do a much better job of this than others. So. And IOP programs, I have to also say patients should be leery nowadays. The new word is iop. It went from CBT to ERP and now it's iop. So they're doing catch ups. The Iops, they're advertising for IOP programs, but they're really not doing iop. So consumer be aware that when an IOP is done, it should have individuals going out in the field with you doing treatment one, it should be prolonged treatment, meaning you should have two hours up per day. It could be multiple therapists each having two hours. But if you're doing a six hour program, if you're doing a three Hour program. But you need to know that the therapist needs to go out with you and do things with you. They not talk therapy. And two, it's not just groups. You do not attend groups majority of the time and then come back and say whether you were able to do the exercise or not. No. So if you're looking for an Iop, make sure that they have the capacity to do three hours a day. That's an Iop, every single day. And that the therapist will go out of the office with you to practice the situation in which you're facing your fear. It's amazing. Amazing what you see when you're in the field. You know, the patient reports something to you, but then you go into the home, and then all of a sudden you realize, oh, my God, you know, crossing over into the threshold of the house already is a problem. I have to see step over the saddle. I have to step on in a particular area. I have to put on the slippers, and God forbid, you know, my hand touches if it's a contamination or. You didn't realize that. Yes, the patient told you that they have to wash their hands, but you didn't realize how far they were washing. You didn't realize that they had, you know, these particular, like, rituals around the area, etc. So, you know, you see so much, or you're going out for a walk, and then the person sees what they think is a condom or an underwear. And, you know, and then they're just like, standing back and you go, what's the issue? You were out to do an exposure for something else, but now you're confronted with, I can't walk there. I have to cross the street. Or you go to their house and they can't get out to get into your car, and you're spending a half hour where they have to go back and check things, or they're just lying in one spot thinking and thinking and thinking, what is the worth of life? Why are we here? And they told you that. But they, you know, it made it sound like they're thinking, but they could do other tasks at the same time. And even though they might have told you they can't do a lot of stuff, you didn't realize that they couldn't even move out of that spot in bed. So it's like what people report and what you observe are very different. And things could come up as you're doing something. So the exposure has to be together, and you need to be really alert to what's going on, because even the individual can trick. Trick you. Not because they're trying to trick you, but it's their habit. You know, they just walk around things. They watch, you know, they put their arms close to their side and you go, you know, if you don't see it, you don't know.
- [22:05]
A
Yeah, no, true, I agree. Yeah, absolutely. Going out in the field and doing exposure work is really important. And yeah, whenever I've done home visits, they've been really telling and really helpful and you see how people get stuck, you see the way they live and you can then help them through that. Because I think sometimes it's a tall order to set the homework and then expect them to go do it. And that's why I think a lot of our clients don't do it, because they need that person there sort of pushing them, so to speak, encouraging them
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B
and breaking it down into steps they can do.
- [22:42]
A
Exactly, yeah, yeah, yeah, Spot. Yeah, I agree with that. How do you. Well, actually on that, on the IOP bit, because I have seen historically, not recently, but like more virtual Iops and obviously virtual iops, it's probably better to obviously be in person, but the virtual side of things opens up more access to people and, you know, far to reach places. What's your thoughts on those more virtual iops? Because obviously the therapists, they can go on the fear in the field via like, you know, the phone, but it's not obviously them there in person.
- [23:23]
B
So I think that virtual is helpful. It does get you to access to a lot of places that perhaps you wouldn't have access to. The downside of virtual is you're focusing on one activity. So that's what you're observing. You're not observing the problems that they're encountering or how they're avoiding to do that one activity. So a good example was a patient who has not had anyone in her home for years and she wouldn't allow anyone into her home. So we did virtual, which was very helpful. And we got her to a point where she was functioning a lot better and cleaning up less, checking less. And you know, she would carry her computer or her phone with her and show us, but all we saw her was walking to where the problem was and her touching, let's say whatever it is or, or walking away if it was a door. But we didn't see all the steps until we walked into her home. So teletherapy is very helpful, but if it can be combined, it's preferable.
- [24:46]
A
Yeah, yeah, good. Yeah, good point. And so let's say one of your Patients, Clients. Do you use patients? Is that the word you okay with?
- [24:59]
B
Generally, Interchangeably for patients, yes. So they can get reimbursed.
- [25:05]
A
Yeah. Yeah, true. Okay. So, yes, your patients, let's say one of them needs a higher level of care. Right. And you've got to refer them on. I know, you do it at your. Your center. Right. You have an iop, I believe. Yeah. But let's say you didn't actually know. Let's say you do. You do have an ip, which you do, and you need to tell them all their family and their. That. Look, we don't think it's working weekly. You know, we think you need a higher level of care. How do you have that conversation? Because I imagine for some people they might feel some stigma of, I don't want a higher level of care or I don't want to go residential, or maybe not. Maybe in your experience, people are usually fine with that. But. Yeah. How would you have that conversation?
- [25:53]
B
We don't see that often. They're coming, asking for it. As I said, it's a new buzzword. So people are referring for iop, or the patients are reading about it somewhere or hearing about it. So they're open to it, but patients who might not. And of course, there are occasional patients who have not heard of it. And that's what we think. And that's how we started anyway. I mean, now people hear of iop, but I mean, we've been doing this, don't forget, like almost 40 years. So, you know, more than 40 years. So for us, it's like 4,000 patients later. We've already done this a lot of times, and there was no buzzword for none of this erp, cbt, iop, you know, so in the past, we had to kind of explain why they needed it. And generally patients are actually relieved. And the reason is they're scared. I'm not doing well. What do I do next? Where do I go? The meds haven't worked. If they're taking meds or worked only a certain amount, my talk therapy, or my erp, whatever they want to call it, my CBT hasn't got me where I want to go. Or maybe they did even improve. It's not like you didn't improve at all. But let's say you got to a certain point, but your life really hasn't changed. I think one's goal as a clinician should always be symptom reduction and quality of life. So you don't only aim for symptom reduction. You need to change the person's quality of life. So they're getting some symptom reduction, let's say, in weekly. So it's not like they're not improving at all. Something is happening, but they're not happy and they're scared. They're scared of what their life is going to look like. You know, now they're 25, 27. They've never been with a woman or man or whatever your identification is. And you, you know, you don't know how to go about it. You don't know what to do. Maybe you've never worked a day in your life. You don't have any resume, you don't know how to go on an interview, don't have any friends. You missed all the developmental years or you have few. So how do we get over that? So symptom reduction was minimal. We want to get you to quality of life where you're leading the life you want to lead. So you want to do this fast. You don't want this grip on you. It's torture. OCD is torture. I have patients who have cancer, heart ailments, dialysis. They'd rather have any of that just take away my ocd. It is that. That, in my opinion, horrendous. So people are welcoming another approach that gives them hope to achieve what they want to achieve in this world.
- [29:10]
A
Yeah, yeah, I agree with that.
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B
It's discouraging if you're doing something and you're not getting or the pace is too slow. We have summer programs. We have, like, Christmas break programs. Why? Because people want to continue in college, let's say, but they can't. The obsessions have taken such a grip now they're depressed now they can't get to class. And we have a month, three weeks to get them back to at least a level where they're functioning well. We know that once a week isn't going to do this or you. You're going to lose your job. What do you do? Take medical leave and do this for, you know, a month? Yeah, at least to a point where you can get that it's not a cure. It's not, you know, anything, but it'll get you maybe back to work.
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A
Yeah, yeah, yeah, of course. Because then obviously losing the job is going to create more mental health problems on top of the ocd, Correct. Yeah. Which we don't want. Yeah.
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B
And that's what happens. It's compounding. You know, you lose your friends, you lose your job, you can't make a living. Your parents are taking complete control Then you resent it's just like a snowballing effect.
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A
Yeah, yeah. It's chaos. Yeah. And yeah, I like what you said about, you know, Christmas break, summer break programs, maybe an Easter break program. Yeah, it's, it's, it's good because you're fitting in the time people have, because so many times I'll get referrals for, for people locally that. Because I work with children, young people up to 25, but, you know, they might be in university and then they can't do a lot of the times I have available because it doesn't get clashes with the courses and they don't want to come out or the parents don't want to take them out, which. Fair enough. So, yeah, having those. But we have a lot of what we call half terms in the UK or end of terms, which are like week, two week blocks throughout the year to give kids a break. So, yeah, having like intensive programs within those slots is a really good idea.
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B
Right.
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A
Yeah, right. And is that something you, you like, you have scheduled like, you know, every Christmas we're doing this. Or is it more based on demand, you think actually we need to run a holiday program here or it's an ongoing.
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B
So anyone who calls, you know, we're kind of prepared for the holidays and we're prepared for summer breaks and Easter breaks. And so we're prepared, prepare to take on more people during those periods of time where they need that. And then during the year, when you mention young children, a lot of school refusals that people are seeing, they're trying to get them back to school. And the schools generally have this program of, you know, if they're a really good district in the United States, they may work towards gradually approaching the building, getting into the building, going to the nurse, et cetera, or all of which are great, except if the problem is OCD or body dysmorphic disorder that's inhibiting the person from doing these things. It's not that they don't want to attend classes or they don't like the school or the teachers or have anxiety towards the building or the classroom or feel suffocated. No. It's just they're, you know, obsessing or ritualizing or concerned about their appearance. And so what might, might even be add may not be add, as we know, could be obsessionality. And so even in school refusal we need to look at, because I think a lot of those are social anxiety, OCD and bdd. And unless we treat those three anxiety disorders.
- [33:22]
A
Yeah, yeah, good point, good point. Yeah, I like that. And okay, so let's, let's actually. Is there anything else you want to say on higher level of care before we move on to a different topic?
- [33:37]
B
How important that there is really hope if you're getting the proper treatment and the proper level of care. So I think individuals should not feel discouraged if they're not getting where they want to get to that, you know, it just might mean you need a little bit more. Just like a certain level dosage of medication may not be effective and you have to up it. Why not up, you know, your therapy.
- [34:06]
A
Yeah, yeah, I remember. You're friends with Dr. John Hoffman, aren't you?
- [34:11]
B
Sure. He worked at bio for over 12 years. He's a dear friend of mine. Yes.
- [34:16]
A
Yeah, yeah. I remember seeing him at the Florida ISDF conference a couple years ago and he said that, yeah, we think about dosage of medication, but we don't think of dosage of therapy.
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B
Yeah, yep, I know my biobehavioral people.
- [34:33]
A
He got that from you, did he? Nice.
- [34:40]
B
So Moritz, by the way, was that biotech?
- [34:44]
A
Okay, so that's how they met and then started mbi.
- [34:47]
B
Yes, yes, they both were. They cut. You had to move to Florida and Jonathan was looking to move. So the two of them said, hey, listen, this is what we think. I said, you two are great. Go ahead and do it.
- [34:59]
A
So, yeah, awesome, awesome. So let's talk about overvalued ideation. So firstly, for anyone listening, what is overvalued ideation?
- [35:12]
B
Overvalued ideation is a concept that's very, very important. It's the conviction in your belief. What does that mean, the word ovi? Overvalued ideation was used for reformers, politicians, religious individuals who were passionate about something. They had an idea and there was enormous amount of passion, emotions, affect, attached to that belief system that propelled them forward. That's how the concept started in the 1800s. Overvalued ideation. We have a scale, actually, that people, clinicians primarily can get access to. I think it was published in 1996. And it's 10 items that looks at the conviction of your belief, the reasonableness of your belief, whether other people have this belief or not. If other people don't have this belief, why don't they have this belief? What was the highest level of your conviction or strength of your belief during the week? What was the lowest and was there any fluctuation? And inside is only one of the items which is what do you attribute this belief to? So what we're looking for is how convinced is the individual about this belief? And we take the belief, if I don't check the stove, I am going to start a fire, whatever it might be. You have to break it down. What's the disastrous consequence? Then we kind of assess on those items. The most important is, is there a fluctuation in the belief? So we all know that individuals with OCD on the spot will have a strong belief, right, I have to leave the house. I'm looking at the stove, I'm checking the stove. I can't leave at that moment. I really believe I'm going to start a fire. But an hour later, next day, next week, if I'm not, if I don't have to check the stove, somebody else is doing the checking for me. I don't have that belief. And if you ask me, do you really believe you would have started a fire? They'll say, now, that was kind of senseless. Or, yeah, I know this is senseless, but. So however in the situation they believe it, that's not overvalued ideation. Overvalued ideation is when you believe it and you can't move on. It's close to delusion, but it's not delusion because there's an element of doubt that what you believe is not true. You're aware that other people don't think this way, but you can't. You can't change your thinking. If I challenge it, you can change your thinking if you challenge it, you can't change your thinking. It gets stuck. That's overvalued ideas. And it's a prognostic indicator of how well a person will do in treatment if it's not dealt with. So we did several studies and others have done it as well, using the ovis, the scale, to predict treatment outcome. Even in a study that we did with Fluvoxamine, Luvox, patients who were on Luvox, same dosage, same duration, because it was a trial that we were a clinical trial, we looked at readiness for change, and we looked at overvalued ideation. Those that had high overvalued ideation did not do as well on the Fluvoxamine as they did if they had low ovi. Okay, so the medication also was not able to treat their OCD as well as if they. If they had low in cognitive behavioral therapy as well. If there's high ovi, they don't respond as quickly and as well to ERP because they're not willing to do the ERP or they'll do it. And then they'll undo it because they're convinced their conviction is very strong. So what do you do?
- [39:52]
A
Right. Yeah.
- [39:53]
B
You deal with the OVI first before you start your erp. And that is really motivational interviewing, readiness to give up the ocd, setting up expectations, looking at what one thing, let's say they want to get rid of and why. I want to be able to hug my child. I want to be able to have my child sit on my lap. I want to be able to go back to school, whatever it is. So you work on that for a period of time prior to entering into the exposure.
- [40:45]
A
Wow, you pretty much answered all my questions there. That was really good. And so am I right in saying in other ways, calling this is like low insight?
- [40:59]
B
Yes. Except as I mentioned, insight is only one variable.
- [41:03]
A
Okay. Okay. Yeah.
- [41:04]
B
To. Okay. Because a lot of people are aware that they're thinking the way they're thinking because of ocd. They have that awareness. They're not delusional. They have. They know that it's ocd.
- [41:18]
A
Yeah.
- [41:19]
B
But they think that their thoughts are reasonable, that, you know, other people should kind of think like me. Because they're. Because if you think about it, in ocd, there is an element of truth. Can you start a fire? Yeah, you can start a fire. If you, you know, if it goes on forever and you're on vacation, maybe. And who knows, maybe. Or if the faucet is leaking and you forgot to turn it off and you're gone for a period of time. Yeah, maybe, you know, it could get into the outlets or something. I mean, there. It's not. The probability of these things is like 0.0000.000 on. Yeah, but they're not willing to take that little bit of risk. So therefore, yes, they have the insight. They have ocd, but they think you and I should maybe do a little bit more. Maybe not to the extent that they do it. They'll admit that. But you know what? It might be a little better if we became a little bit more ocd. Like during the pandemic, we all became ocd. Right. Everybody's wearing mask, everybody's afraid to touch things. I mean, maybe we went overboard and. But we started seeing things a little bit more like an OCD person.
- [42:48]
A
Yeah. I mean, I think Covid did help a lot of people understand a bit more the anxiety and the constant threat of fear. Yeah. That's interesting. Trying to think of another question, because like I said, you've answered all mine. So going to motivational interviewing, which Funny enough, I think the, the person that comes to mind for this is Edna Foer. I interviewed her like in 2018 or something. And, and she mentioned motivational interviewing, I believe, back then. So it's not something I particularly do. I haven't been trained in it in my therapy practice. I, I'm, I use ACT a lot, which obviously has the more value side of things. So it's similar.
- [43:36]
B
Excellent. Excellent.
- [43:37]
A
Yeah.
- [43:38]
B
But good for OVI too.
- [43:40]
A
Yes. That's why. Yeah. Whenever I get stuck with a client. Why. I've always called it low insight, but now I call it ovi. I use ACT a lot. But. Yeah.
- [43:49]
B
Can you.
- [43:50]
A
Maybe for my benefit more than anyone else, listening. But motivational interviewing, like, what would that look like with a, with a client? What sort of questions you aren't asking them.
- [43:59]
B
You know, it takes motivational interviewing, actually. It's like looking at pros and cons of giving up your ocd, keeping your ocd. What are the problems you would encounter if you did X, Y and Z? Most often it's anxiety and tolerating anxiety. Right. People are tremendously afraid of feeling anxious and staying in that anxiety state. So kind of looking at, you know, what are you afraid of? What would happen if you gave up ocd? Gave it up, meaning treatment work during treatment to give it up. And what are you afraid of? What do you. What's the reason you would want to give it up? Like I was saying before, like, which comes from value based living. Act, as you pointed out, and act. Where do we ask, you know, what are your values in life and in ocd? What is it do you want? What kind of life do you want to lead? I want to 8 I want to have a child. I want to go back to school or I want to get promoted and I'm left behind all the time. I don't understand why they skip over me each promotion period, whatever. I want to be able to walk freely in my backyard. I want to put my child on my lap. I want to be able to go to a Rangers game. I want to be able to go out to dinner with family. So whatever it is that drives you, gives you purpose and meaning to this life, finding that meaning and using that to help the person do the treatment. Really what we're doing is trying to get the person to do the treatment. Because it's hard.
- [46:13]
A
Yeah.
- [46:14]
B
Although if, I mean, I don't know what your experience is, you could, you know, let us know. But if done while it's humorous, I mean, if you could, if the patient Allows humor into it. And we try. You start laughing at some point because there's a shift in the cognition and the belief at some point, and the person starts saying, I can't believe that, you know, that's not happening. But not to say that they're not going to have the belief 10 minutes or an hour later. But each time it'll be less and less and less.
- [46:51]
A
Yeah, yeah, no, I agree. I try and bring in humor as much as I can, obviously, when appropriate. I'm not doing it in awkward moments. But because, yeah, like you say, if you can get a client laughing and seeing that, oh, my word, this is so silly. Why am I. Why am I thinking this? Then, yeah, you can start that shift. And I always, I always phrase it. I used, like, the upstairs, downstairs brain a lot. You know, you're very logical upstairs brain. It's really your downstairs brain that's doing a lot of this. And, and they often say this is with the high insight. They know their upstairs brain knows that this is silly, but their downstairs brain doesn't. So. And often when they feel that shame, I'm like, this isn't about your intelligence. This is something else. You know, you don't need to have shame here. Right.
- [47:42]
B
But, yeah, that's a good emotion that we don't talk a lot about, which is shame. The amount of shame people feel. People don't report shame. You know, there's all areas of their life that they feel ashamed about, and they don't even want to bring it up to the therapist until that trust is deeply formed. But in OCD and BDD as well, there's the shame of thinking and feeling the way I do. And as you pointed out, every other area outside of those areas, the person is perfectly, you know, capable of everything and anything and solving all kinds of problems and leading, you know, doing everything, quote, as the average person. But in that one area, they're stuck. But yet, you know, that change needs to be dispelled as you're saying, you know, talking about the upstairs and downstairs brain and don't need to feel ashamed.
- [48:57]
A
Yeah, yeah, yeah, absolutely. And I find talking from that upstairs, downstairs place, you can. You can have that detachment where you can laugh about it because you can use that intelligent part of the brain to be like, you know, this is. This is silly. And that's okay, you know.
- [49:14]
B
Yeah, exactly. Exactly.
- [49:17]
A
Yeah. Yeah. Okay, nice. That's, that's, that's all helpful stuff. So we've only got just under 10 minutes left, so I got a couple other questions for You. But actually on overvalued ideation, is there anything else you wanted to mention?
- [49:34]
B
I think that if you're having difficulty doing the ERPs, again, one has to look at why you're having difficulty. It could be that we're taking items that are too difficult for you to do. You know, situations, activities that are too difficult to confront, and we need to break it down a little bit more or. Very often an individual has an ocd, a thought, but the thought is not broken down. Okay, I'm going to stabilize my friend who's sitting next to me, and I had the knife at a restaurant, and I don't want that knife around. So they have the image, they have the thought, but that's it. So what do they do? They avoid either going to the restaurant or sitting next to people, or they avoid knives or sharp objects. So if you break that down, like, how are you going to stab your friend? Right. You have to pick up the knife. How are you going to hold the knife? What kind of knife is it? Okay, so look at the knife. Pick the knife up. Pick the knife up. Okay. Where are you going to aim? Are you sure that that's where you could kill somebody or harm somebody? So they haven't broken it down?
- [51:02]
A
Yeah.
- [51:04]
B
So helping the person break it down and then I think, you know, in terms of helping them get into actually beyond the thought and the image. And then also again, why do you want to sit with a knife? What do you need the knife for? I mean, you could certainly avoid knives. Well, like most restaurants have knives. When you sit down. Well, you can remove it. Yeah, I could, but I don't like knives in my house. Like kind of showing them that. Actually, if it was a specific phobia, you could do something about it. Like maybe if you have an elevator phobia and you don't live in a big city. Well, walk up a couple of flights, you know, I mean, if you want to, that's your choice in life. But in ocd, one of the things you want to do is that it hint it doesn't stay in one spot. Yeah, so that's motivation too, Right? So you're showing them how it impacts their life, because that's how an OCD person is really thinking, well, I could avoid that. Or what's the big deal? I'll just give into it this time. Or no, because that knife is not only there, and it's not only knives, it's sharp objects. And you can't teach your kid how to cut if you can't Hold a scissor next to him or her. It's like it, it generalizes. So that's part of really setting up expectations of why you want to give up your ocd. We were talking about motivational interviewing. Right. So it's part of that setting up expectations and why you want to give it up. Not just doing the exposure. It's not sufficient just to tell the patient, okay, go sit at a restaurant and hold the knife. Okay, I held the knife. And yeah, big deal, you know, okay, I did it. I'm. Not that it's not a big deal, but like, that doesn't necessarily help them get rid of all the different steps. If they saw that, they would also be able to get rid of it quicker because they would realize what the steps are to, to engage in that activity and highly unlikely that it's going to happen.
- [53:27]
A
Yeah, yeah, you're right. Because when we have these worries, we're not we and people, they're not thinking it through step by step. It's just an intrusive thought or an obsession that I'm gonna hurt someone. But it's not. And it might even be a graphic image, but it's not a step by step graphic image for most people at least.
- [53:46]
B
Right?
- [53:47]
A
Yeah. And I imagine getting them to think it out is also kind of an exposure in and of itself.
- [53:53]
B
Exactly. It is exposure. Exactly as you said, you know, Absolutely. Breaking it down that way is part of that whole what you're verbalizing to them as you're having them imagine it and then, you know, putting them in the situation of sitting next to a friend with a knife, but initially actually breaking it down so they see how would I get to that point? And so when they're in that situation, they're thinking, there's no way I'm picking this knife aiming towards the neck that I imagined and you know, the jugular veins and where are, where is it? And will I aim properly? Will my hand shake as I'm doing it? How come he's not. Or she's not going to notice what I'm doing? You know, no one else in the restaurant is going to get up and intervene. And so, you know, it becomes like, okay, this can't really happen.
- [54:43]
A
Yeah, yeah, okay, I like that. And that would be a bit more of the cognitive side of things.
- [54:50]
B
It's, it's. You're usually, you're using it in the exposure, so it would be more like inhibitory learning because you're incorporating all the different elements into it.
- [55:02]
A
Okay. Yeah.
- [55:03]
B
And what I'm finding is that there is now more a change. As I said earlier on, I was trained by ITNO FOA in which we actually always did inhibitory learning, which is incorporating all stimuli into your exposure sessions. And I'm noticing in the residents and trainees that are coming in to biobehavioral that what they're taught is is just actually pure exposure. Holding the knife and just sitting, it's really exposure to feeling anxious. That's what they're doing.
- [55:43]
A
Yeah.
- [55:44]
B
And ultimately it is exposure. But if you incorporate all these elements, you get a quicker and better, more lasting change.
- [55:57]
A
Yeah.
- [55:57]
B
And easier for the patient.
- [56:01]
A
Yeah, yeah, yeah, good point. Okay, so a couple random questions. If you could pick up the phone and call the 20 year old you so time traveling phone, what would you tell her?
- [56:16]
B
Pursue what you did, Forgan. You did a wonderful life. And continue doing it with the same passion as you had then, which I have, and continue forth. And I'm looking into actually new treatment approaches for OCD right now. And maybe when I finalize it, I will get back with you and we'll talk about some new approaches. I still have the same passion and drive. Devoted my whole entire life and career to it. And I would do nothing differently.
- [56:49]
A
Wow. Amazing. What a good thing to say. And then you've got a billboard. You're in New York, right?
- [56:58]
B
I am, yeah.
- [57:01]
A
On that billboard. What do you want written? It could be anything in the world.
- [57:06]
B
There is hope. As long as you get the proper treatment, you will get better. There is no doubt in my mind at all that all OCD individuals will get better.
- [57:27]
A
Yeah, yeah, absolutely. Yeah, I agree with that. And lastly, anything else you wish you could have said or shared today?
- [57:42]
B
Nothing. I mean, I think my heart just bleeds for individuals suffering so profoundly when I know that there's treatment out there. The new OCD newsletter that just came out from the IOCDF was talking about how many OCD individuals are still not getting treatment or not getting proper treatment. And that's very, very sad. For those who may not know, there's the IOCDF that's coming up this July, and for those who can't fly out to Seattle, it is hybrid, many of them. We also during the year have online presentations that people have access to every year, both for BDD hoarding and ocd and access to the whole conference every July through the iocdf.
- [58:41]
A
Yeah, absolutely. Yeah. It's a great conference. Amazing. Well, thank you so much for sharing your passion and your clear expertise. It's been wonderful to connect and speak with you.
- [58:54]
B
Thank you. Thank you for having me. Really enjoyed it.
- [58:58]
A
Thank you for listening to this week's podcast and thank you to our patrons who helped make this episode possible. And if you would like to find out more about Patreon and the rewards and benefits, then there will be a link in the episode description. If you enjoy the OCD Stories podcast and would like to support us, please subscribe and rate the show wherever you listen to the podcast. And thank you to NOCD for supporting our work. If you want to find out more about nocd, you can click the link in the episode description and quick disclaimer Guys, this podcast is not therapy. It is not a replacement for therapy. Please seek treatment from a trained professional and until we speak, take care.