Latest / Radically Genuine / 165. OCD: Why Your Therapy Might Be Making It Worse

Transcript

165. OCD: Why Your Therapy Might Be Making It Worse · Radically Genuine

• Roger K. McFillin, Psy.D, ABPP (00:01.346) Welcome to the radically genuine podcast. am Dr. Roger McFillin. First, I want to wish everyone a Merry Christmas, Happy Hanukkah, and of course a Happy New Year. I've been receiving a ton of emails, comments on my posts, and some consultation requests regarding obsessive compulsive disorder. And I thought this would be a great opportunity to devote an episode to OCD with the understanding that this can be part of a larger series on the condition where I can also interview OCD specialists and research experts regarding the range of OCD presentations and available treatments to be able to talk in detail about what works for whom, why, and what it actually would entail for somebody to recover from an OCD episode. One of the things that I've been seeing on social media is a lot of people professing that they have what's called treatment resistant OCD. And since I come across so many people who've received horrible treatment from people who by no means could be considered experts and are probably overwhelmed by the condition in itself, trying to misapply things they've learned in graduate school or in popular culture to the condition, or essentially just being under the umbrella of psychiatry, I question whether they're treatment resistant or they're just not receiving what is the most effective treatments. So first, if you follow my work, you know that I devalue the Diagnostic Statistical Manual, the DSM, as a valid representation of mental health struggles. Yes, what we label as OCD exists, but attempting to diagnose this as a discrete medical illness based on symptom checklist or meeting a certain category is highly problematic. And I will get into more detail about this when we discuss the various forms of OCD and how it exists on a spectrum. DSM diagnostic labels, they're descriptive. They're not explanatory, which means we don't necessarily know why the condition developed, the context or the function it serves. Roger K. McFillin, Psy.D, ABPP (02:20.472) or even how to just go about helping that person just based on that label. It's not like treating strep throat. In fact, stamping this label and treating everyone the same, I think is the downfall of Western medicine's approach to psychiatric conditions, especially treating mental health as if it's some brain disorder and trying to blunt cognitive and emotional processes with pharmaceuticals. I'll explain later why this approach actually can make the condition worse. Additionally, just the label itself, the name OCD does not allow us to fully capture the range of impairment and distress that's associated with this condition, as we see in popular culture. People will claim to have OCD when discussing certain quirks, idiosynchronicities, you know, like being highly organized, attention to detail, wanting their sock drawer to be laid out. by certain colors, somewhat rigidly adhering to specific routines and potentially even developing perfectionistic standards. Now those behaviors in itself, which may stand out to others as a problem, like if you're in a relationship with that person and you're not necessarily as neurotic, does not suggest that the person who's experiencing them is in struggle or impairment. So, I mean, this is the general problem with psychiatric diagnosis. People do come into treatment, not because their behavior is a concern for them, but it can be a concern for others. And obviously this is the more mild form of the condition and shows how this exists on a spectrum, yet these same people might still receive the blanket diagnosis of OCD and then be treated as psychiatry would treat them or a general psychotherapy would. So what's important to note is that, you know, OCD that we label it certainly exists on a wide spectrum. Many people have been familiar with the term neurodiversity. And this is important for, I think, a society to flourish and function. So for example, as a professor once told me when I was in graduate school, you really want your nuclear engineer to be excessive focused on details. Your accountant should be equally obsessive about the organization and Roger K. McFillin, Psy.D, ABPP (04:46.206) attention to details. And this represents the neurodiversity that exists amongst us. And there's various forms of, you know, personalities that, you know, fit in specific contexts, like that exact behavior allows them to flourish and make a living and is part of their unique makeup. Another note about context. So, for example, a child who has a parent whose behavior is on the spectrum of more attention to detail structure and react strongly when specific behaviors exist, like if your clothes are not put away or your socks are not folded according to color. or even having an organized space or making sure that the fork does not touch the spoon in the drawer. This child who's exposed to this is learning what is important and then how to behave. So the child may develop anxiety around specific rules. We live in a rule-based culture of reinforcement. And so this impact on learning is natural to all of us and reflects the role of environmental shaping. So this can be applied to many behaviors and speaks to contextual factors. So remember a behavior learned that works in one context may not be functional in another. So raised in that neurotic household, following the rules works. Attention to detail with math can get rewarded in school being overly rule-based and structured in various social contexts though could create problems depending. on the relationships you're developing, especially if a friend or partner did not learn or adhere to those same rules. So we must keep in mind why psychiatric labels are just that. And we want to resist the notion of seeing them as a discrete illness that someone has, or just assume these are genetic conditions instead of learned and potentially even serving an important survival mechanism at one point in time. Roger K. McFillin, Psy.D, ABPP (06:57.41) I mean, that's important. Evolutionary biologists will speak to this. And there are alternative ways about thinking about mental health problems now in terms of them exhibiting a form of adaptation to stress, something that could be survival in nature, but when that no longer works or it's adapted into contexts where it doesn't fit, well then distress and impairment occur. versus seeing it as some biological or genetic mishap. But as I said, some of these aforementioned struggles exist on a spectrum and what I described would best be considered some of these situations in a more mild range. The more severe impairment in functioning can create more distress for a person and they can engage in a series of compulsive or avoidant behaviors that become rather time consuming and then make it difficult for the person to adapt and be flexible in life. I mean, this can range from not being able to leave their own home and being so concerned, you know, with contamination and germs that they scrub their hands until they bleed. But the important point here is just identifying all these under the umbrella of OCD can be a problem. And when one doesn't consider context function or the level of distress and impairment, this becomes a fundamental flaw. in conceptualizing, you know, mental health related problems. So the more severe end of the spectrum, one might require clinical intervention and see a mental health specialist. But as I describe, I think if somebody doesn't have the level of expertise or the training to be able to help someone, we can actually exacerbate the problem, make it worse, take something that's relatively episodic. and then turn it into a chronic condition, which I argue is more the norm than the exception. So let's break down how obsessive compulsive is diagnosed in our modern world with the DSM. There's four main diagnostic criteria for OCD. One, has to be, and this is criteria A, there has to be the presence of obsessions Roger K. McFillin, Psy.D, ABPP (09:19.16) compulsions, or both. So what are obsessions as defined by the DSM? So they're recurrent and persistent thoughts, urges, or images that are experienced as intrusive, unwanted, and they cause anxiety and distress. The person likely attempts to ignore or suppress these thoughts or tries to neutralize them in some way. with either other thoughts or specific actions that we call compulsions. And compulsions are defined by these repetitive behaviors or mental acts that the person feels driven to perform in response to an obsessive thought or an intrusive thought, or according to these rigid rules that are developed. And these behaviors aim to... prevent or reduce anxiety or prevent feared events or outcomes. But they're excessive, not realistically connected to what they're meant to neutralize. Like for example, step on a crack, I'll break my mother's back, right? So obviously there's no real association or relationship to stepping on a crack on a sidewalk, but someone who is rigidly fused or attached to the literal nature of that thought, if doing so would create a scenario in their mind where bad things are going to happen. And you see this, like these superstitious-type behaviors can turn into real problems. Criteria B is that there has to be time and interference related to this. So the obsession and compulsions must be time consuming. Now in the DSM, And you notice if you've ever studied the DSM or understand the DSM, it's not like this is strongly researched base. Some of these are kind of arbitrary, for example, like time consuming, taking more than one hour per day. Like why one hour, right? Why is it one hour, not 40 minutes? You know, that doesn't really make sense, but you know, for us in clinical practice, what it means is like how time consuming and how is this getting in the way in your life? Roger K. McFillin, Psy.D, ABPP (11:37.74) And they must interfere with daily functioning social activities or relate relationships. Now, the problem with this is what I mentioned before is you could be in a, you know, not the best match of a relationship. And for example, that person that you're in could be highly critical and it could not be a good adaptive match as a partner. And that creates distress, but you could be in another situation with another person who may be similar to you and the two of you coexist. together. Of course, you need to rule out substance use because you can develop similar reactions due to a side effect of a medication or a reaction to a substance that someone might be might be taking. And then you're supposed to rule out symptoms if they're based on another quote unquote mental disorder. discuss why the DSM is problematic in a second and why that's a problem. The DSM also requires specification. like insight level, good, fair, poor, absent, all the way to delusional, where there's a current or past history of a tick disorder. And then the current level of severity, mild, moderate, severe, extreme. Again, like there's... no really sound boundaries to that, is what also creates a problem in clinical practice. So what's one person severe might not be severe to another person. What one person identifies as extreme is within the normal bounds. And this is what you get when you have a system in trying to construct this and it's construct categorically. And also when people treat OCD conditions who aren't exposed to the range of severity. So it becomes certainly dependent on the person who's making the assessment. It's very subjective, not objective. When assisting with the diagnosis, mental professionals are supposed to assess like the type of obsessions and compulsions present, their impact on daily functioning, the age of onset, the course of the condition. Roger K. McFillin, Psy.D, ABPP (14:01.048) family history and previous therapies or treatments in their response to this. And this is supposed to differentiate OCD from normal worries or ritualistic behaviors, as well as, you know, from other conditions with similar presentations. But that's the problem with the DSM. There's a lot of diagnostic overlap, and then there could be very blurred boundaries on what is adaptive versus what is dysfunctional. So the criticism of the DSM are the binary present absent criteria. Does it not necessary capture the complexity and overlap of symptoms as well as its function, its evolutionary mechanism. And this leads to artificial boundaries between what's normal and disordered. Some major critiques from researchers and clinicians, know, myself included, there should be a more dimensional approach to this versus it being so categorical, DSM uses discrete categories and checklists. It also doesn't necessarily fully account for cultural and social context. So we tend to over medicalize the range of normal human responses to difficult circumstances. And this is largely based on when Western ideas and concepts of mental health. So it doesn't necessarily account for cultural differences in expressing psychological psychological distress. There's many ranges in which people seek to obtain some control in uncertain world. And we risk pathologizing culture. culturally specific behaviors or beliefs. And it's kind of strange, like, because we create these arbitrary boundaries. Like, so for example, if somebody is, deals with the uncertainty and fear of living and they enter into prayer, maybe they pray the rosary compulsively, you know, every day, that's not necessarily seen as maladaptive. Roger K. McFillin, Psy.D, ABPP (16:05.954) nor psychiatric or problematic, and it wouldn't meet the definition of OCD. However, it certainly is a behavior that may be in response to intrusive thoughts. So again, that speaks to the problems with this, and someone can arbitrarily identify a behavior to be abnormal or problematic if not understanding its cultural context or even its value. There's great concerns with reliability and validity with the DSM. Different clinicians interpret the same symptoms differently. Many diagnoses have high rates of comorbidity, which suggests poor discriminant validity. All this leads to misdiagnosis. know, the criteria sets were often developed through committee consensus rather than empirical research. So that's a group of people voting aye. Sure, I see that. Yeah, let's add it in there. And there's not great, as much as they want to identify these conditions to be brain-based, we don't have a very strong biological or neurological validation for any of these disorders, as I've mentioned previously. There's certainly financial and industry influence. You know, the more people that we can diagnose with OCD and the more people that we suggest to them they have a brain-based illness, the more likely they're going to turn to an SSRI or some other drug. in these particular episodes. insurance reimbursement requires clinicians to actually assign a diagnosis. So this is why we see a lot of people diagnosed OCD when it certainly doesn't meet the criteria for it and we have an inflation in diagnoses. we know that these diagnostic labels get mistaken for explanatory causes, right? So person could be, you know, it's really wrong to say, you know, you're, you're in this, you're struggling with these compulsive behaviors because you have OCD. You should never say that, right? It doesn't provide any explanatory value, just like you're not depressed because you have major depressive disorder. Right? So this really leads Roger K. McFillin, Psy.D, ABPP (18:22.84) people to overlook all the very social environmental systemic factors influencing it, how the behavior might be working, how it could be a response to a specific event, how it's reinforced and giving it up can be a problem. When we have people identify with OCD, and we're seeing this more and more in culture, they internalize it like there's something broken within them. And this becomes almost like this self fulfilling prophecy, like they're seeing their themselves through the lens of OCD. My OCD makes me do this. My OCD leads me to behave like this. And there's a real diffusion and attachment to the disorder that gets reinforced by the medical professionals who want to approach these mental health problems like other more objective medical diseases. Roger K. McFillin, Psy.D, ABPP (19:20.576) So again, with OCD, there's a range of conditions that fit under the label. So here are the most common presentations of OCD that we see in clinical practice. And I think people are exposed to this in popular culture, maybe through movies, for example, and they get an idea of it through that experience if they don't know anyone personally or they have not yet experienced them. themselves. And again, this ranges on a spectrum. So contamination and cleaning. So it's that intense fear of germs, dirt or some contamination, which can lead to excessive hand washing even until the skin is raw, a lot of avoidance of things that they perceive to be contaminated like objects and places. And this can be obviously very impairing like seeing anybody like touch doors or other things or even touch another person without extreme anxiety, which really does get in the way of intimate relationships. It could be elaborate cleaning rituals that are time consuming, and a real fear of illness or spreading disease to others. In the early days on the radically genuine podcast, I was really concerned about this happening with the pandemic. And a lot of the misinformation that was spread by our public health officials, that we are creating mental illness. That's not based on sound science, was just a provocation of fear. know, checking behaviors, know, compulsive checking behaviors are another form of OCD that, you know, usually can become very time consuming in pairing. like repeatedly checking locks, appliances, or switches, or turning multiple times to verify if like it turned off the stove, checking that nothing terrible has happened, like something that is common I've seen in clinical practice, someone might be driving. on a road, maybe hit a pothole or something, and then they get the intrusive thought that they ran over another human. And then they have to turn back and check to make sure they didn't. And even if it's, you know, they don't see anything, they could be consumed with that intrusive thought. Other checking behaviors include like seeking constant reassurance about things that they're uncertain about and safety concerns or mentally reviewing. Roger K. McFillin, Psy.D, ABPP (21:45.058) like past interactions or events over and over and over again. Others include like symmetry and like ordering of like objects, like the need for items to be perfectly aligned or arranged, distress when objects aren't just right, like counting rituals while performing tasks, needing to repeat actions a specific number of times in order to feel like everything's gonna be okay, arranging items in specific patterns or sequences. Intrusive thoughts are in itself are a form of OCD. So these could be unwanted, violent, or aggressive thoughts, disturbing sexual imagery, religious obsessions, the fear of like doing something outside of those strict rules and then like believing that, you know, you've offended, you know, you've offended God, or bad things are going to happen to you by a punitive God. There's a fear of like acting and unwanted impulses that often can be like sexual in nature. So somebody, you know, what's quite normal is for people to have, and it's healthy sexual urges, of course, but like that fear of loss of control. You know, you also see people fear of like acting out violently. So like aggressive. thought themselves are intrusive thoughts about violence in their mind and then the belief they wouldn't control it. So actually want to avoid all mental images of that because of the anxiety it's created. hoarding is another one which is related to OCD, the difficulty discarding items due to obsessive fears, collecting items based on like magical thinking specific rules about how items should be organized, distress when others touch remove belongings. Roger K. McFillin, Psy.D, ABPP (23:42.894) common accompanying features, like avoidance of anything that would provoke that fear, time consuming rituals, mental rituals, counting, praying, reviewing, seeking constant reassurance, rigid rules and patterns, high levels of anxiety when rituals can't be completed or you can't check. And this can have obviously impact on daily functioning and relationships. It's also important to note that people can experience multiple types of OCD symptoms simultaneously, and the content can shift over time and usually does. The key feature is not the specific content, but the presence of these intrusive thoughts causing distress, and then the behaviors aimed at reducing that distress. What is probably most important for people who are listening to know is like, how do people get better? for me to provide hope because I don't believe these conditions are a death sentence. People get better when they get the right help, but a major pet peeve of mine in my field is the following. So first, just sitting and talking to somebody about OCD, like a typical talk therapy, is going to do absolutely nothing. So when we say refer people to therapy, what does that mean? Right? You need therapy or you need drugs in the therapy. That means nothing. That gives us no information. In fact, I believe our understanding of what therapy is or what's discussed in popular culture can make the condition worse because you can just feed the cycle of rumination or even like approach the condition. Like it's some unconscious manifestation of some earlier trauma that needs to be brought into conscious awareness like psycho dynamic or analytic methods I Want to be clear that providing the wrong type of therapy to someone who is in a severe OCD episode Should be considered unethical and harmful. I've seen this way too many times in my career like those who Roger K. McFillin, Psy.D, ABPP (26:04.194) become general talk therapists or are somewhere on this psychodynamic humanistic continuum and don't receive the training or expertise to treat some more impairing severe clinical conditions and have become misled themselves about the value of general talk therapies, like these people enter into treating people unethically. Examples of this would be, And this is important to know because OCD is often episodic, which means that there are stressors that may occur in a person's life. And then they return to the OCD as a way of coping with the uncertainty or the desires for control in a life that, you know, may seem out of control. The general talk therapist sometimes assumes that it's that event that provoked it as the problem. So they spend an excessive amount of time. focusing on that stressful event instead of understanding that this is the way the person copes with stress. there biological or genetic components associated? Well, this is how I look at it. I do believe in the concept of epigenetics that environment when combined with genetic vulnerability together can present themselves in some of these conditions. So that's not to ignore the biological aspect of this. I just don't like the way we separate them in our field. Same thing with, and I'll talk more about this, but the same thing with people who now, are talking about our chronic disease epidemics and the role of nutrient deficiencies and environmental toxins and so forth. And the question is, can those provoke an OCD episode? The answer is yes. I believe they can and I know they do. We know certain bacteria can provoke OCD episode. But if we look at... Roger K. McFillin, Psy.D, ABPP (28:26.306) these as responses to stress or signals within the body that have an evolutionary advantage, then I think we're moving closer to therapies that work. So my other pet peeve is the belief that prescribing a psychiatric drug, which most often is an SSRI, where many psychiatrists and prescribing physicians are misled to believe this is an effective and safe option. often without not even providing treatments that are actually effective or exploring maybe other underlying biological causes that might have provoked us like the strep virus, for example, or understanding how behavioral therapy, specifically like exposure and response prevention treatments work and why they work. So there are some caveats here. I want everyone to think of obsessive compulsive disorder to exist on the continuum with the origins potentially serving a very important function, even a survive. survival function. We should recognize the evolutionary benefit of what we call OCD and the ranges of this behavior. For example, those who are able to fixate on specific details necessary to survival, even in an obsessive manner, may have survived longer or saved the lives of their loved ones in periods of war, famine, disease, or mass migration. Those who have missed important details, or lacked the obsessive nature and drive for survival often perished. many people who, another great example of this, and it's discussed in the field of eating disorders, especially starvation, because people who've developed anorexia become extremely obsessive about food and enter into compulsive behaviors. These often get misdiagnosed as OCD instead of seeing this as the biological evolutionary adaptation to starvation. And we see this as probably an evolutionary benefit to... our ancestors who most certainly faced periods of famine and where these food resources were not readily available, especially in wintertime. So when in starvation, we should consume less food and then become very obsessed with obtaining food. And if the starved individual would eat too much when they came upon food, they could actually die. And we see this in the treatment of Roger K. McFillin, Psy.D, ABPP (30:50.912) anorexia, it's called refeeding syndrome. You cannot refeed somebody who is starved and underweight too fast. It would provoke a number of biological mechanisms that could kill them. And if they ate too much at the expense of the other group, people would die. So you could see how starvation and being underweight can provoke a biological mechanism for survival. Biological psychiatry which is typical psychiatry, wants to frame psychiatric conditions as an illness, a disorder, as it's some genetic mishap, and ignore that they exist on a range of adaptation and functionality in response to stressful conditions. I agree, it may no longer serve the individual, but we have to understand the course of the condition and we have to understand context and what may have been occurred before we can adequately treat. So if someone gets the strep bacteria, for example, and then develops OCD, if you treat with SSRIs instead of an antibiotic, I think you're obviously creating harm. Another example is developing obsessive compulsive disorder in response to, you know, assault or another traumatic event. Many therapists wrongly believe that they have to enter into trauma therapy and face and solve the trauma in order to resolve the OCD, OCD, when in fact the developing OCD has become so consuming, impairing and overwhelming that they would never be able to address the trauma effectively. It'd have to start first with helping that person reduce compulsive behaviors, cope with the OCD before you can go back and understand how that person coped with the initial trauma event. Here's a great example of this. A sexual assault survivor, for example, becomes very obsessive about their environment for a sense of predictability and control. Even becoming very vigilant to anything. Roger K. McFillin, Psy.D, ABPP (32:57.806) you know, that's been moved in their environment, like to determine if like someone broke into their home or somebody's there. Checking behaviors can develop in order to make sure they don't miss something because they're very afraid of another catastrophe or something like horrific happening again because their assault was not foreseeable ahead of time. And the person has entered into kind of this self blame mode. which for those who treat PTSD understand, that that's a major factor that maintains PTSD symptoms, like self blame. So like this stuff must be understood in the context of a response to a traumatic event and then see generally speaking that people can enter into what we would label as OCD, but it's certainly providing a survival mechanism, a survival function. So I think it's best for me today, since I'll probably break this up into multiple episodes. please feedback is very welcome in this because I know people have specific questions. And if I'm going to bring on other people, experts, we're going to talk in more detail about how to treat specific conditions. think it's generally speaking best for me to avoid today general terms like cognitive behavioral therapy or exposure and response prevention therapy, or just psychotherapy. And instead let's talk about like what actually has to occur. for people to improve and they get just targeted in different ways depending on the nature of the person and also the nature of the obsessions or compulsions. So there are first, there are two important processes that have to be targeted in OCD treatment that generally underlie many of the OCD behaviors that exist. And that's very important that we must treat the underlying mechanisms, not necessarily the content themselves. And the first is what is called thought action fusion. Roger K. McFillin, Psy.D, ABPP (34:59.31) So I want you to imagine having a thought pop into your head, something that's unsettling, maybe even frightening. Now imagine believing that simply having that thought could make it come true, or that thinking it makes you just as bad as if you've done it. Like a thought of a behavior that is just morally irreprehensible to you, right? So like, for example, you're scrolling social media, And you're watching the news and you're exposed to a pedophile and recent crimes against children. And then the thought pops into your head. And now the thought in itself, its presence there is a reflection in your mind that you could, you know, be that person because you're thinking about it, right? Because you're so attached to the intrusive nature or the the idea that if you think about it, that you could be a pedophile yourself, or it reflects something that's wrong with you. you begin to develop this adversarial relationship with your own thoughts. Like having thoughts of a pedophile is simply being a pedophile. And then you just necessarily, you just go down the path of thinking about it more, because it can't be there. I'll get into that. I mean, this is the reality for many people with OCD. This is what's called thought action fusion. It's a fascinating cognitive pattern where the boundary between thoughts and reality become dangerously blurred. Like the mental fusion really does create a cruel trap for the individual. So someone might have a fleeting thought about harm coming to a loved one and suddenly they're gripped with the, by the conviction that their thought has increased the likelihood that this is going to happen. Or they might experience an unwanted violent image and then feel the same guilt and shame as if they've actually committed violence. It's like their mind has become both a fortune teller and a moral judge. It's turning the natural stream of random thoughts into a source of constant threat and torment. The impact on daily life of this obviously can be quite profound. People find themselves in an exhausting battle with their own minds, desperately trying to control or suppress these thoughts. You can see why they would want to turn to a drug to stop the process. Each intrusive thought becomes evidence of their perceived badness or harbinger of a Roger K. McFillin, Psy.D, ABPP (37:26.028) disaster to come. This hypervigilance only serves to multiply the very thoughts that they're trying to avoid. It creates a self-perpetuating cycle of anxiety and distress. So this is really important. The more that a thought can't be there, the more it's going to be there. And we know this from studies on thought suppression. If I had you, for example, think about a cartoon character in your mind, just in your mind's eyes, see that cartoon character. hear that cartoon character's voice and then I stop you in that exercise and I say, okay, let's do this again, but you're not allowed to think about that cartoon character. Let's say it's SpongeBob SquarePants, right? You are going to think more about SpongeBob SquarePants if you're not allowed to think about it. This is the role of avoidance and suppression, right? And this is why it's so problematic in a lot of mental... health treatments to have somebody view what they're thinking or some internal dialogue in their own mind to be dangerous. We can't create that relationship with a person that they're dangerous because thoughts become way too powerful then. And if you have these intrusive or dangerous thoughts and you're not supposed to think about them, well guess what? You're going to think more. Now it has an obsessive quality. So skilled therapists help people first recognize that these fused beliefs through a combination of cognitive work, you in some carefully designed experiments, like they might guide somebody to really observe those thoughts and not avoid them, to see them from a distance. They might actually even deliberately have them think about dangerous thoughts instead of suppressing them while observing that the feared feared consequences though themselves do not materialize. So this is part of the exposure therapies that exist that are very effective. So people actually learn to sit with uncomfortable thoughts without trying to neutralize them or fight them. Critical component of effective OCD therapies. It's like building a new relationship with their mind, one where thoughts can flow freely without carrying the weight of moral judgment or predictive power. But you have to practice this. It's got to be deliberate. Roger K. McFillin, Psy.D, ABPP (39:48.898) gotta be throughout the day. It actually becomes more of a lifestyle, kind of like brushing one's teeth. Because somebody who has OCD is much, much more likely to get caught up into the content of their mind and judge that. So I am certainly one who was quite critical of our culture and how we have cultivated a fear around our own minds. In fact, I believe This creates more mental problems and more mental distress, cultivating the idea of a mental illness, that what goes on in your mind or what you feel as a symptom of some disease cultivates a consciousness and an attention, which paradoxically will have people judge and turn inward into their own minds. This in itself is problematic. The journey of recovering from this thought action fusion, it's more than You know, just managing OCD, it's about reclaiming a freedom to think about fear and face fear. People who learn to separate thoughts from reality, they can discover a profound sense of liberation. They begin to see that their minds are just simply story generating machines, constantly producing thoughts, and they don't need to be taken so seriously. Of course, this shift cannot happen overnight. patience, proper guidance, homework, daily practice. People can learn to experience thoughts as just thoughts. Mental events can be acknowledged. They can be allowed to pass like clouds in the sky. People can learn to shift their attention back into the now. This needs to be practiced. It's a new relationship to the mind. But what I've found is when you have a therapist who's really good at devaluing this and approaches their life in a similar way and faces fear and doesn't run away from it or suppress it or drug it or avoid it. I think a therapy can be highly effective in cultivating that new relationship to the internal experience. But we condition therapists to be so damn scared of everything. Roger K. McFillin, Psy.D, ABPP (42:14.668) scared of suicide, scared of a person's mind, scared of these disorders. know, so many are just gonna send them off to a psychiatrist because they've been brainwashed themselves that there's something broken in the person's mind, like a mechanic needs to fix it. I personally, I support people to completely diffuse from the content of their mind. Whether you have OCD or not, I suggest starting a meditation practice, mindfulness practice. We can learn and develop skills to detach from the literal content of our minds. And I think it's necessary for it to be, for us to reach our full potential. Unfortunately, as I said, too many mental health practitioners and social media and medical establishments will reinforce the idea that a person's mind is dangerous. We'll even see this in popular culture on movies and television. This is the one reason why I am against the use of a drug that can dampen or dull cognitive processes. There is a frontline treatment for OCD because it reinforces that exact fear that thoughts are dangerous and the person has no control to manage their internal world. In fact, they have to, they have to seek an external treatment like a drug. Roger K. McFillin, Psy.D, ABPP (43:27.596) I that exact process of seeing their mind to need to be controlled to drugs is really, I think, the precursor to substance abuse problems. I cultivate a world with my clients where there is no such thing as an intrusive thought. A thought can only be intrusive if we provide it power and meaning. I also don't think you can solve a thinking problem with more thinking. which is a problem with many therapists. Therapy in itself, becomes an intellectual exercise instead of a skilled practice. You people who struggle with obsessive thoughts, thoughts must learn to think less and be present more. I mean, this can be very challenging process because the person believes thinking is what keeps them safe. In the same way, a worrier believes that they are prepared for a threat or... you know, future problems that exist and they can even feel at least temporarily in control through worrying, the act of not worrying provokes anxiety. So the act of not obsessing from can also create anxiety. People can get addicted to thinking, but remember the brain is plastic and highly adaptable. But if we try to neutralize or dampen thinking with an SSRI or any other drug, even if that is successful in the short term, what you are starting is a never ending battle with your mind. Eventually you're gonna need to achieve, you need a higher dose to achieve the same result. You're gonna need another drug, all at the same time, maintaining this adversarial relationship with your own mind. It's just like why I wouldn't prescribe alcohol for social anxiety. Yes, when people have that social anxiety or a lot of that negative evaluation or judgment, or they get caught up in their own head, You start drinking alcohol and you relax and you don't think so much and you just be, and you might be more sociable. That's why people turn to alcohol. Certainly wouldn't recommend that though, to treat people who have social anxiety. In fact, as you can understand, it's just going to create more problems in the long run. This is a drug effect. Like we don't want to think about this as the way, toward recovery. Some people Roger K. McFillin, Psy.D, ABPP (45:48.718) struggling with intrusive thoughts do everything in their power not to think about them. So alcohol is one thing that they do, smoke weed, take other drugs, go to their psychiatrist, their physician, they get busy, they sleep too much, they engage in a number of compulsive behaviors to neutralize them. But all of this suggests the same underlying problem. Their thoughts can't be there. They're in a battle with their mind. They give those thoughts so much power. If therapy is not targeting this exact process, the person is going to worsen. Roger K. McFillin, Psy.D, ABPP (46:28.962) The second process I think that underlies OCD that must be targeted is what's called intolerance for uncertainty. So imagine spending hours crafting an email and some people do, reading it over and over, consumed by the fear of whether your words could possibly be misinterpreted. For most people hitting send is routine, but for someone who struggles with OCD and intolerance for uncertainty, each decision can feel like standing. at the edge of a vast unknown. This profound discomfort with uncertainty doesn't just affect big life choices. It infiltrates the smallest moments of daily life, turning simple tasks into exhausting exercises in doubt. The intolerance of uncertainty manifests itself in many different ways. A person can spend hours researching minor decisions, repeatedly seeking reassurance about things most would consider settled. or create elaborate systems of checking and double checking just to try to achieve an impossible level of certainty. It's as if their mind is constantly asking, but what if? And then refusing to accept maybe it has an answer. It's like intolerable that they could make a decision without knowing exactly what's going to happen. And this cruel irony is that the more you try to seek certainty, the more uncertainty they seem to find. just creates an exhausting cycle of doubt and compulsion and you're no longer living life. So you can imagine uncertainty as a wave of discomfort that washes over you and when that wave hits, compulsions then act like a life raft for these individuals. They provide immediate temporary relief. But again, temporary. So. Someone might check their work emails repeatedly before bed, desperately trying to ensure they haven't missed something critical. Each check momentarily comes the storm of what ifs, but paradoxically makes the next wave of uncertainty even stronger. I mean, we see this also with people who develop obsessions about their own health, health anxiety conditions, right? Your mind tells you, you might have cancer. You go to the doctor, you get scanned. Roger K. McFillin, Psy.D, ABPP (48:50.05) There's no evidence of any cancer that momentarily makes you feel okay until your mind works on you again. Well, what if they miss something? What if it's developed since the appointment? And then you see a lot of compulsive doctor checking going on WebMD and boom, you're right back in to the cycle of intrusive thoughts and checking behaviors. So every time a person performs a compulsion, whether it's seeking reassurance, checking, mentally reviewing, they're actually teaching their brain two powerful but problematic lessons. First, the uncertainty is dangerous and must be eliminated. And second, that only through these compulsive behaviors can they find safety. It's like building a fortress that becomes a prison in their life. And this is precisely why exposure therapy for intolerance of uncertainty is both challenging, but it's transformative. I don't know any other way to be able to... treat this without exposure therapy, nothing has been proven to be effective other than this. And this treatment systematically targets this pattern through carefully designed exercises designed to break the cycle. Therapists might work with someone gradually delaying checking their work emails, starting at 15 minutes, then an hour, making sure then they can get through an entire evening. The key is they're not just exposing. So into the situation, they're exposing them to the feeling of uncertainty themselves. And what makes this approach powerful is how it directly challenges the function of compulsions. Like each time someone resists the urge to perform a compulsion, they create an opportunity to learn something new. There's a whole field of literature on the inhibitory learning model of fear extinction that has neuroscience backing. If you're a therapist, look it up. especially in how this can be used to effectively treat OCD. Michelle Kraske, inhibitory learning model of fear extinction and applied to OCD. So a person then discovers that they can tolerate the discomfort of uncertainty. They're learning. They learn that bad things don't automatically happen when they're unsure and that the anxiety eventually does subside on its own. More importantly, they learn that they can handle this anxiety without compulsive behaviors. Roger K. McFillin, Psy.D, ABPP (51:10.154) Exposure therapy becomes increasingly more challenging as treatment generally progresses. I do think people need to experience some sense of mastery in the beginning before we build the more difficult exposure exercises. Someone might practice making decisions without gathering excessive information, sending emails without multiple reviews, leaving conversations without reassurance. And each exposure is like a small experiment that tests their beliefs about uncertainty and their need for compulsive behaviors that have become their safety crutch. The most profound change often comes when people realize that their compulsions weren't actually protecting them from the uncertainty in the first place. They were protecting them from a feeling. And this subtle but crucial distinction opens the door for a new way of living where uncertainty can be experienced without the need for escape or resolution. Because let's face it, folks, life is inherently uncertain. You don't know when you're going to die, for example. The goal isn't to eliminate uncertainty or the discomfort that life brings. It's to build the confidence to carry that discomfort while moving forward in life. And I think it's part of the process that makes life even worth living. There can even be positive aspects, seeing life as an adventure in that way. The process of exposure, it's not just enduring uncertainty. It's about changing the relationship with it entirely as people. practice facing uncertainty without resorting to compulsions, they often discover an unexpected sense of freedom. They learn that they can handle the not knowing that perfect certainty is an illusion. you know, there's a strength in being able to say, I'm not sure. And that's okay. In treatment therapists take an almost counterintuitive approach instead of like helping their patients achieve more certainty. which is a hallmark of a bad therapy, happens way too often. They guide them to become uncertainty experts. It's like learning to surf rather than trying to control the ocean. Through carefully designed exercises, people practice sitting with that uncertainty and gradually increasing those doses. They might start with small challenges. Example of this is like deliberately leaving a text message with a minor typo or you make a decision without. Roger K. McFillin, Psy.D, ABPP (53:29.376) seeking reassurance, each small step builds confidence and handling that discomfort. And then you build up to develop these techniques called uncertainty exposures, like they might have someone intentionally leave a voicemail without knowing exactly how it came across, make a small purchase without researching every possible option, except the fact that you don't know if you have cancer, each exposure builds that uncertainty muscle, the ability to function effectively when things aren't 100 % certain. Think of it like developing emotional immune system that can handle the natural uncertainty of life. I've seen this transformation before, it's remarkable, people can learn that they can handle not knowing for sure. They can make decisions without perfect certainty. Really, mean, this journey leads to a profound shift in perspective, in my opinion, from seeing uncertainty as a threat to recognizing it as a natural, even exciting part of the human experience. So those two things are really important. I kind of want to stop there today and just kind of conclude here to kind of describe what my criticisms are of the general mental health field, because the tragedy of OCD treatment lies in a persistent disconnect between what works and what people... actually do receive. While the path to recovery through exposure-based treatments is well documented, countless people find themselves trapped in traditional talk therapy approaches that inadvertently reinforce their symptoms. General therapists, though certainly well-intentioned, often respond to OCD's content rather than its underlying mechanisms. They might spend sessions helping someone analyze the meaning of intrusive thoughts, work on trying to build... Roger K. McFillin, Psy.D, ABPP (55:28.398) self-esteem or to feel better or to prevent stressful experience from happening, which is all impossible, when what's actually needed is a systematic exposure to the uncertainty and fear in itself, not controlling for it. It's kind of like treating a broken leg with meditation. I the intervention may not be inherently bad in some contexts, but when it comes to OCD and trying to address that, you're not facing the core issues and you're inadvertently probably making it worse. This mismatch between what's evidence-based and standard practice means that many people spend years, even decades, cycling through different therapists and approaches, becoming increasingly discouraged while their OCD grows stronger. The truth is important. OCD requires specialized treatment from clinicians trained in... exposure and response prevention or its various forms, including acceptance and commitment therapy until this becomes more of a standard care until more therapists are trained and understand this very complicated condition. Countless people will continue to suffer needlessly and are trapped in a cycle of ineffective treatment that never touches at the heart of the struggle, including that search for a magic pill to control unwanted thoughts. I think this represents one of the more poignant paradoxes that exists in OCD treatment. When people turn to these drugs with the hope of eliminating their intrusive thoughts, they are unknowingly reinforcing the belief that fuels their OCD, that these thoughts are dangerous, that they have to be controlled. And that's not even talking about the range of adverse reactions that people have to an SSRI. God, the idea of giving it to a child in OCD is infuriating and should be, in my opinion, viewed as malpractice. This pursuit of thought control through pharmaceutical means becomes yet another form of a compulsion. Another way of refusing to accept the natural ebb and flow of mental experiences and getting people to face their fears. The belief that we must medicate away our thoughts traps people in an endless cycle of seeking the certainty and control. When we know that healing occurs when individuals learn to let thoughts be thoughts, diffuse from the literal content of their mind, to express them. Roger K. McFillin, Psy.D, ABPP (57:51.552) or to accept them, I'm sorry, rather than suppress them and to carry and face the uncertainty of life rather than trying to eliminate it. This shift from fighting against the mind to learning to live alongside it marks the true path to freedom. No one pill can provide. It's in this acceptance paradoxically that many find relief. They were seeking all along. The most challenging things I'm seeing in clinical practice is adults who were taught to fear their own minds. They had OCD as kids, they went into psychiatry, they took drugs, they fell into the trap. Now they're having trouble sleeping, they're scared of their own mind, and they think the only way to live is to drug their mind away. Much, much harder to treat. So I hope this podcast serves. It's about an, I've talking for an hour here, so there's a lot of information about underlying mechanisms. I hope I'm clear about how standard treatments can be largely ineffective and the way that we talk about it in the medical field in popular culture does more harm than good. And then moving forward, bringing in various experts, we can talk about. how to intervene on various conditions and how people recover and get better. And they do, they really do. But like anything, we know that early intervention is most important. if you intervene ineffectively when someone is young, you're creating mental illness, which is my problem in the current field.