Understanding Real Event OCD: When the Past Fuels Obsession

In this episode, Dr. David Puder is joined by OCD specialist Kevin Foss to dive deep into Real Event OCD, which is a form of obsessive-compulsive disorder where real past experiences become the focus of endless rumination, guilt, and shame. Together, they unpack the symptoms, real-life examples, and how this subtype differs from PTSD, moral injury, and other forms of OCD. The discussion highlights evidence-based treatments like Exposure and Response Prevention (ERP), Acceptance and Commitment Therapy (ACT), and medication options, while also offering guidance for loved ones supporting someone with OCD.

Speaker names marked ? are inferred from speaking time and the show’s known hosts — they are not voice-verified.

• 0:13David Puder?

  All right, welcome back to the podcast. I am joined today with Kevin Foss. He is an OCD expert. He is a clinician in practice. And today, we are going to be talking about something called real event OCD. This is when the past becomes a source of obsession. Some people, I imagine with OCD, really just have a lot of this. And maybe they don't have a lot of the normal hand washing, contamination fears. But let's start it off. Kevin, tell us a little bit about real event OCD. Let's just launch into it.

• 0:50Speaker 01

  Awesome. Well, thanks so much for having me on. All right, so yeah, you gave a really good snapshot of what that is. So real event OCD is a subtype of obsessive compulsive disorder. And we call it real event. There aren't different diagnoses. It's not like a whole separate thing from, as you mentioned, contamination. It's just another way that it manifests. And it's kind of a colloquial way for us to get a quick shorthand to what the types of obsessions are, the general themes that someone is struggling with. So real event, as you said, it's going to be focused on something that actually did, in fact, happen. Whereas, you know, we contrast that with a lot of the other subtypes.

• 1:35Speaker 01

  They're related to things that could happen, that might happen, that if I do this, or if I don't do that, then I'm going to experience some calamity or something I don't want. Whereas with real event, the obsession is about something that did happen. And then a lot of the rumination is going to be about what effect that's going to have on the future, whether or not those values are, or like what value was broken? How do I atone for it? What sort of punishment should I accept or get? And/or the compulsion has to do with trying to eliminate a sense of guilt and a sense of shame related to it.

• 2:18David Puder?

  Okay, so you have a real event. Then you have these obsessions, which are unwanted thoughts, distressing thoughts. Sometimes it's like what really happened, but then sometimes they're questioning. I've had a couple of patients who question if what happened, if more happened, like if they're forgetting some details that maybe like just getting real, like if they're having thoughts like, oh, did I hurt that child, you know, when I interacted with my cousin? Maybe they didn't really hurt the child at all. They didn't touch the child, but they're fearing these thoughts, these obsessions. Is that what we're talking about or is it? How would you, how would you kind of add to that?

• 2:59Speaker 01

  Yeah, and there's, there's, there's, there're gonna be some, you know, a lot of this ultimately, as we're talking about these subtypes, right? At the end of the day, it's all OCD, right? So it's all, you know, an obsessive thought, a what if question, right? What if, if then type of proposition, which leads into a sense of anxiety, discomfort, fear, numbness, terror, whatever you want to call it, an unwanted feeling state, followed by a compulsion to try to undo that feeling or to try to make sure that whatever you're afraid of, whatever that feared story is, never comes to fruition. So there are gonna be some disagreements and some nuances to what fits under this title of real event.

• 3:42Speaker 01

  And, you know, some people will kind of put it into that category of imagining what, you know, what else could have happened. But regardless of all that, yes, so to answer your more direct question, that fear of, one of the compulsions that someone might do would be to, you know, go back in time in their memory and to try to figure out if they're, if something else happened, right? They might recognize, all right, I did hang out with my cousin or whoever, you know, whoever it might be. There could be an imagined story of, well, did I do this, right? I think what, what you're kind of alluding to also is there can be a false memory OCD, which is often attached to real event OCD.

• 4:25Speaker 01

  Real event again is gonna be, all right, I know that I hung out with my, with my cousin and we, you know, I hung out with my cousin that day, right?

• 4:36Speaker 01

  False memory OCD can kind of come in and suggest, well, you know, maybe, maybe you're not remembering everything correctly. Maybe you did something else. Maybe something else happened that, you know, would violate your, your, um, uh, would violate some sort of, uh, value that you have, right? You did something wrong. So in that, a lot of compulsions are going to be, you know, playing that story over and over and over again to try to figure out, was there something else that happened? If I did this, you know, they might have done this. They made this facial expression. I wonder what that means, right? Playing all these out to try to get to a point of confirmation that nothing happened, or get to this place of, uh, you know, confirmation that something did happen so that they can

• 5:21Speaker 01

  take action on it, right? Uh, some of the stuff that I, you know, that I would categorize, you know, as, as really clearly under, uh, real event would be things like, you know, a memory about, you know, maybe cheating on a test in high school.

• 5:35David Puder?

  Hmm. Okay.

• 5:36Speaker 01

  They have that, uh, that memory, like, I did cheat on that test. I know I did, right? No, it's, I know it's wrong. I made that choice. But then the rumination might be about, well, if I cheated on that test, and then if I, you know, if I didn't get that actual grade, gosh, maybe I wouldn't have gotten into the college that I got into. And gosh, if I didn't get into that college, maybe I wouldn't have gotten that career that I now have. So, you know, the long-term impacts of that, you know, can just go and go and go. So that compulsion might be, well, you know, I got, I have to go back and, you know, see if I can find that same test. Like, if I could prove to myself that I did know all the information on that test without cheating, well, I can feel better that, you

• 6:18Speaker 01

  know, I, getting into that college was justified. Or maybe I can go back to find my teacher and just confess to them and say, hey, I cheated on that test, for them to say, you know, that's okay. You're, you're, you're absolved of this guilt and you can move on with your life.

• 6:33David Puder?

  Hmm.

• 6:34Speaker 01

  So, um, I hope that answers your, your, your question, or perhaps it makes it a little bit more muddled.

• 6:40David Puder?

  Yeah, and I think, I think it's like, what is normal guilt regret? You know, versus what is real event OCD? Because I think there are people who do things that are wrong. And they come to my practice and they grow, you know, a new set of values. Or they understand like, oh, I did that thing and that didn't feel good. And then it's like, okay, I have a value here that I didn't even know existed, maybe. And, and then that leads to more thriving in the future. So that's, that's different than necessarily what we're talking about here. And I think it's important to kind of differentiate the two.

• 7:19Speaker 01

  Right, right. I, I wonder for what you're, what you're kind of talking about. And I, yeah, I kind of, you know, see some of these folks as well, where they, you know, they see that they might be, you know, hung up on something or feel guilty about making a mistake in the past. The difference is going to be with OCD is that there is this, it's, it's persistent in the, in the sense of guilt. It's, it, it kind of doesn't let them off the hook a lot of times, right? There can be a sense of, you know, generally speaking, you know, when we, when we see that we've made a mistake, we acknowledge it, we take ownership of it, we try to take some measures to apologize or make atonement for whatever those mistakes are.

• 8:02Speaker 01

  Try to learn from it and then commit to not doing that or doing something different in the future. Right? You know, someone with real event OCD, they're going to go through that process, right? But once they get to the end, their brain says, well, you know, but, but what if it's worse than you actually imagined?

• 8:22David Puder?

  Hmm.

• 8:22Speaker 01

  Right? So then they go back to the beginning of it and then ruminate about it again.

• 8:26David Puder?

  Yep.

• 8:27Speaker 01

  And so on, right? Or it's, they've done the process, but that feeling just persists. So now the battle is, well, what, what do I have to do to get rid of this feeling?

• 8:38Speaker 01

  And get to a sense of confidence and certainty again.

• 8:41David Puder?

  Certainty, yeah. OCD, one of the things I took away from the Pennelle work, you know, episodes, Pennelle, if you haven't listened to those on OCD, he's, he's a leader in the field. I think you respect him quite a bit too, right?

• 8:55Speaker 01

  Of course.

• 8:56David Puder?

  And so he talked about how OCD is the doubting disease. So the doubting does not stop. And I've seen these patients, they'll spend four to six hours a day, they'll spend every waking moment going back.

• 9:07Speaker 01

  Absolutely.

• 9:08David Puder?

  And that's the, that's a huge difference. Like if you have a patient, or if you yourself are listening to this, and you're spending four to six hours in regret, going back in time, with, with a component of doubt, with a component of uncertainty, seeking for certainty, you may have real event OCD. Now, how many of your patients with it have other types of OCD as well? Or do you see people with just isolated real event?

• 9:36Speaker 01

  Both, both.

• 9:38David Puder?

  Okay.

• 9:38Speaker 01

  So we, we kind of expect, and OCD is kind of tricky in this way, is that, you know, it, it finds its way into a lot of other areas of life. And, and the, the real event kind of element of this, remember, as we talked about, you know, real event is not its own diagnosis, right? It's just OCD. And OCD, as you, as you mentioned from your Pennelle episode, it's the doubting disease, right? So there's going to be this, this kind of sense of doubt, this sense of lack of, of trust in oneself, lack of abilities to be able to have that sense of confidence and assurance with, with oneself in these various areas. So you can kind of see a sense of real event OCD showing up in other quote

• 10:20Speaker 01

  subtypes as well, right? So, you know, you, so to that end, yeah, oftentimes there's going to be other subtypes, but it doesn't mean that, you know, if someone has five subtypes, or they just are experiencing real event as an isolated obsession, that, you know, that person is, you know, more broken, or sicker, or whatever verbiage they, they might want to use on themselves. It, what it means is that they have OCD, and they are in this pattern of questioning doubt, reassurance. And what that reassurance does is it goes back and reinforces the idea that I can't trust myself. I did something wrong and bad, and the way to alleviate that bad feeling is by going through

• 11:04Speaker 01

  this ruminative, or reassurance, or avoidance, or ritual cycle.

• 11:09David Puder?

  Yeah, and so reassurance, I think that's an important thing to mention or emphasize. They could ask for reassurance from other people, too. So you may not be the one with real event OCD, you may have a loved one who continually seeks reassurance.

• 11:24Speaker 01

  Uh huh.

• 11:25David Puder?

  And, and is giving reassurance the best way to help them?

• 11:30Speaker 01

  Uh, generally speaking, no, it's kind of a reassurance is kind of a four-letter word around OCD land, as it were.

• 11:38David Puder?

  But that's, that's a very counterintuitive thing, and I think this is why.

• 11:43Speaker 01

  Yeah.

• 11:43David Puder?

  Like, I usually, I'm more psychodynamically oriented, I'm more, you know, transference-focused, I'm more like logo therapy, existential type of stuff.

• 11:56David Puder?

  But for OCD, it's like, I have, I refer these to my OCD experts. Like, because if I, you know, and I've tried working with some of these people, and it's like, if I'm just using empathy.

• 12:11David Puder?

  Trying to find the deeper meanings of things.

• 12:14Speaker 01

  Yeah.

• 12:15David Puder?

  It, it just, they, they still are obsessing four to six hours a day.

• 12:21Speaker 01

  Exactly, and, and, you know, it's, it's, it is, it's counterintuitive, because we as emotional, caring, loving people, you know, we see someone who's in pain, who's obviously struggling with something, we, we want to do anything that we can to make them feel better, right? And it feels like the right thing to do is to say, you know, like, nothing happened, you're fine, right? You're gonna be okay, like, we, like, we can just get over this, like, you're, you're a great guy, you're awesome, you're, like, whatever the verbiage is, right?

• 12:57Speaker 01

  You know, as you said, like, somebody with real event or, you know, another subtype of OCD, they may be spending four, five-plus hours a day ruminating about something. And so sometimes they'll come to therapy, and if someone isn't really attuned to some of these eccentricities and the uniqueness of cognitive behavioral therapy and exposure and response prevention, they're ultimately now just gonna have another hour of ruminating and trying to go deeper and deeper and deeper, which is what they've been doing on their free time already.

• 13:29David Puder?

  Mm-hmm.

• 13:30Speaker 01

  Really, what we're trying to get at here is this disconnection from that pattern. And so, breaking the cycle of compulsion to then get to a place where we can learn to sit with the feeling of discomfort, of uncertainty, and not to get rid of it, but instead to get, to, in a sense, get used to the fact that it's there. And, you know, in this, in the process of doing that, what we often find is the, the subjective discomfort of that does start to come down, but ultimately, through the process of increasing our willingness to simply have discomfort and uncertainty about things that sometimes we're never gonna be able to actually get the answer of anyways.

• 14:14David Puder?

  Yeah. Okay, so let's rewind a little bit. Let's rewind.

• 14:21Speaker 01

  Okay.

• 14:22David Puder?

  So I think, I think we just gotta be, give, give, give some examples, maybe you can give some examples. I think a lot of these things have to do around taboos. And so, in my experience, it could be months before my patient even tells me what's really going on, in terms of the, the events they're going back to, the things that they're concerned about. How often do you see that? How often do they tell you right off the bat versus they hold it in? What kind of things are we talking about?

• 14:54Speaker 01

  Yeah, that's a good question. And I also want to back up a little bit too, and I do want to answer this question. When we were talking about the reassurances that we do, it is important for us, and as a therapist, when someone comes in, I'm not jumping to hardcore exposure day one. There are some things that we can do, and I think we'll get to this part about how you can support your loved one without giving inappropriate and unhealthy reassurances. Because you can give encouragements and assurances that aren't speaking to the feared narrative, right? So I think that's an important acknowledgement. We're not just saying, don't say anything,

• 15:37Speaker 01

  or don't support that person at all. I think there is a way to be encouraging and supportive without feeding into that compulsive cycle. But now that I sidetracked myself.

• 15:49David Puder?

  Okay, let me go with your sidetrack. I love it. So, like, okay, so what is assurance versus what is reassuring?

• 16:01Speaker 01

  Yeah.

• 16:01David Puder?

  Which is part of the compulsion?

• 16:03Speaker 01

  Yes, yeah. So when you're in a relationship with someone, right, outside of therapy, right, you'll see your family member, your friend, and they're coming up to you and trying to seek, quote, reassurance, what we'd be calling it, right? And that reassurance can take many, many different forms. But a lot of times, it's speaking to that feeling of goodness or badness, or is the relationship okay, or did I do something wrong and bad, right? So their question might be about, hey, did I say something yesterday that offended you, right? Well, they're going to come up and say, like, they might not come out and directly say, like, hey, did I say something bad yesterday? But what they might do is,

• 16:48Speaker 01

  you know, they'll say, like, you know, they'll just come up and say, like, hey, how are you doing today? And then really spending a lot of time gauging whether or not that person is like upset with them or angry at them, or say, like, hey, are we good? Or something like that. Just a simple way to try to get them to say, yes, we're okay. And they extract from that that...

• 17:13Speaker 01

  That they're that they're fine, their relationship's fine, they didn't do anything bad, right? When we're talking about, when we're talking about assurances, or we're talking about catching those subtle compulsions, we're trying to pull back on anything that's going to, anything that's going to address that what if, that feared narrative in an inappropriate way, right? And we're not trying to take away that feeling, or justify, or glorify in a sense that doubtful thought. So what that might look like is, instead of talking to the feared story, that narrative, maybe we want to speak more to the feeling itself, right?

• 17:56Speaker 01

  So we can acknowledge, and we can acknowledge that, hey, that person's in pain, right? So, you know, the line that I often give to family members and friends in this situation is, if they, you know, if family members coming up and doing something to try to seek reassurance, we kind of catch you, like, let's say, you know, you were coming up to me and said, hey, you know, you're trying to get some type of reassurance, I'd say, you know what? Look, it looks, it sounds like you're trying to get a little bit of reassurance right now. I love you, and I support you, but I'm not going to answer that question.

• 18:29David Puder?

  Oh, man.

• 18:32Speaker 01

  And it's, it's hard, because we could easily say something that would take that away. You can also say, like, hey, it sounds like you're, you know, it sounds like you're really anxious, but it also sounds like you're trying to get some reassurance, sounds like you're trying to get compulsion, right? You can say, that's really hard, it sounds like that's really scary, it sounds like that's really uncomfortable, right? But we're not saying anything about the content of the narrative, the content of obsession.

• 18:57David Puder?

  Yeah.

• 18:58Speaker 01

  So that'd be a kind of a broad difference between assurance and support, and the reassurance that would be feeding into the obsession. And different therapists are going to call it different things, but generally reassurance is kind of the, you know, general title that we would give them.

• 19:15David Puder?

  Okay. And then, so, we're going into, I think, I think just to give people an understanding of what are some of the common real event OCD types of obsessions.

• 19:30Speaker 01

  Yeah, yeah. So not as a exhaustive list because I know that you know there's we're going to go through and kind of name some things, but they'll be like, you know, someone out there is going to say, he didn't mention mine. It's not what I have. Maybe I don't. It's again, it's going back into this is all all OCD. But, you know,

• 19:49David Puder?

  So you could see how someone would be obsessive about not being on your list, right?

• 19:54Speaker 01

  Absolutely.

• 19:55David Puder?

  Yeah. And if you are, and you're listening to this, you should probably reach out to Kevin Foss to to give you some reassurance that you are indeed on his list.

• 20:03Speaker 01

  And I'm I will provide all the reassurance that you want. You can't see me shake my head.

• 20:09David Puder?

  And and he'll start to help you.

• 20:13David Puder?

  Okay, let's get let's go.

• 20:15Speaker 01

  Okay, so you know, some of the you know, some things that you know, people can experience, you know, it might be like, you know, they they looked at or they maybe have talked to somebody who you know, who's not their partner. And then they might go into their head about like, did I like, did I flirt with that person? Right? Was I on the road towards cheating on that person? Right? Or cheating on my partner? Right?

• 20:37David Puder?

  Or I did, or therefore, I think I did cheat on my partner.

• 20:40Speaker 01

  I did. Yeah, because of that, because of that, that that was infidelity. Right? So now they're going, they might go through a an atonement process with their partner and just and apologize. And you can see how this would go, right? If they're convinced, right? OCD is saying, well, you cheated on your partner. And they go up to their partner and they say, hey, honey, I, you know, looked at that person at the supermarket. I'm I'm so sorry. I I really hurt you. And they the partner might say,

• 21:09David Puder?

  I'm really hurt.

• 21:11Speaker 01

  Well, they might say, I'm really hurt. But they might also go, you looked at a person?

• 21:17Speaker 01

  Oh, okay. Like, that's, that's fine. You looked at like, did you, you know, did you have sex with that person? Did you kiss that person? Did you, you know, grab them in appropriately? No, I didn't do any of that stuff. So you you just looked at them. But remember, the guilt in the individual is overwhelming.

• 21:35David Puder?

  The guilt is, yeah, it would be absolutely overwhelming.

• 21:38Speaker 01

  Absolutely. So even when the partner, again, reassurance, it's fine. I'm fine. We're good. No problem.

• 21:47Speaker 01

  You would think that would clarify some things, but that doesn't speak to this feeling because now the individual might go in and say, "Well, maybe I didn't explain it clearly enough, right? Maybe I did do something more, right? Let me now go back into my memory and see if I did something more than just say hi or just look at this person. Maybe I should go to the supermarket and get their security camera footage just so I can verify that I didn't do anything, right?" So you can see where the snowballs, where the reassurance doesn't happen, or the reassurance doesn't ultimately help from the partner. We now need to help this person sit with that discomfort. I mean, we can keep going with this or go

• 22:31Speaker 01

  through other examples.

• 22:33David Puder?

  I think we should stay with this one. So I'll be, how about I be the patient?

• 22:36Speaker 01

  Okay.

• 22:38David Puder?

  And you be the OCD expert, okay?

• 22:41Speaker 01

  Okay.

• 22:44David Puder?

  Yeah, so I, um, maybe not, maybe not. This would be bad. Like, what if my wife listens to this? And then what if she hears it, only a clip of it, right? And that could be like really bad.

• 22:58Speaker 01

  Are you worried that she's gonna take that line out of context and where you're gonna have said, "I cheated on my wife," or "I cheated on you," and she's gonna hear that?

• 23:08David Puder?

  What if she did, right? What if someone sent her that?

• 23:15Speaker 01

  Okay, okay.

• 23:18David Puder?

  I'm not in person right now. I'm coming out of like the role play.

• 23:21Speaker 01

  Fair enough. Boy, I'll tell you, the conversations and the things that I have Googled and the stuff that I have said as an OCD therapist, and then the stuff that I share with my wife, is wild. So, you know, it's, I kind of say with OCD, you know, anxiety will latch itself on to anything that we can imagine.

• 23:44David Puder?

  Right.

• 23:44Speaker 01

  But we as humans can imagine quite a bit, right? I'm lucky that my wife is also a therapist. She's a psychologist, so, you know, she gets the process.

• 23:54David Puder?

  So, okay, with this type of person, because I've seen this type of thing before, I also think they could go back to confessing, you know? So if they're Catholic, I'm not Catholic, but if they were, they could go to their priest multiple times, you know, to try to confess the same thing. I think historically, when I, when I read about scrupulosity, the, the tales are like, the Catholic priest will eventually say, you're not allowed to confess anything twice, you know? Because they're getting barraged by constant confessing.

• 24:31Speaker 01

  It started to cut you off. That's, that's a really good example of how these, you know, the, these subtypes names start to fall apart because in that, you know, it can certainly be seen as real event, but it's certainly be seen as religious scrupulosity, right? And the, the answer is yes, it's both, right? Somebody may have, may have committed a sin, right? What would be a sin in the, in the Catholic Church? So rightly so, they'd be going to their, going to their confessor, confessing and then doing whatever the priest says, right? But OCD won't let them off the hook just because they did it that one time, right? So they're going to want to go in. Interestingly enough, religious scrupulosity is one of the first places where OCD was

• 25:11Speaker 01

  seen because priests would see somebody coming in and confessing the same thing or confessing things that they might have done, but they didn't actually do. So.

• 25:23David Puder?

  Yeah. And, and, and like, I could see them, they've, they've told me the, you know, citing verses like, if you look upon a woman with lust, you commit adultery. So it's like, it's like, I committed adultery. And it's like they, but the weight of it is, is that intense guilt to the level as if they did, you know, have the affair.

• 25:49Speaker 01

  Right?

• 25:50David Puder?

  Yeah.

• 25:51Speaker 01

  Exactly. But again, we're, we're noticing the difference between, you know, the feelings and the reality, right? The feelings in this don't match up to what actually happened or would be typically justified by the, the infraction, right? Whatever the thing is that was done, right? That anxiety felt so much more intensely and it felt so much more real. Now, the, the person with OCD, I kind of say like they, you know, they, they have these, they're, they're of two minds, right? They have their logical, reasonable, rational side and they have their, you know, anxious side, right? The, the, they have, they experience both. There's a, there's the insensitive OCD joke.

• 26:34Speaker 01

  It was like this, what's the difference between someone with OCD and someone who's crazy?

• 26:40Speaker 01

  The person with OCD knows they're crazy. Again, I know it's thrown around that word, but it's some, these are the words that we use about ourselves sometimes, right?

• 26:50David Puder?

  There's insight into, into the reality of the situation. I know because I've treated very, very complex cases of OCD with schizophrenia.

• 27:03Speaker 01

  Right.

• 27:03David Puder?

  And sometimes you're, I'm scratching my head, am I treating the OCD right now? Am I treating the schizophrenia? And in treatment resistant schizophrenia, it's even more complicated because then they're on clozapine. And is the clozapine causing the OCD?

• 27:18Speaker 01

  Yeah.

• 27:19David Puder?

  And then, or if, is it, if the clozapine's too high, they're more obsessive. If the clozapine's too low, they're more psychotic. And so it's kind of like you're, um, you're, you're kind of in this very difficult balancing act.

• 27:35Speaker 01

  Right, right. Yeah.

• 27:37David Puder?

  And I'm obsessing about that four to six hours.

• 27:43Speaker 01

  I mean.

• 27:44David Puder?

  Luckily, I'm not obsessing four to six hours a day. But it does tie my brain in knots. Yeah.

• 27:50Speaker 01

  Yeah, it absolutely can. And it's, it's, um, you know, getting back to, you know, real event, it can be, it's, it's hard because, you know, somebody is, you know, raking themselves over the coals to try to ultimately do the right thing. Right? And it, it illustrates that they, you know, they're, they are good, they're good people. And that, you know, with real event oftentimes, or sometimes I'll say, you know, they might, they, they made a mistake. They did something they didn't like, they didn't, they did something they didn't want to do, or their values changed and they reflect. They reflect on a time when they did something that, uh, you know, was with it, perhaps within their values then, but is now not.

• 28:35Speaker 01

  And they, they want to make it right. But in order to, in order to do that, they, they just become overwhelmed with a sense that they are this terrible person. And they're just overwhelmed by the sense of guilt and the shame related to whatever that thing is. So that compulsive cycle, it being so hard to get through and so hard to fight against, it, it just feels like it's persisting.

• 29:00David Puder?

  Yeah. Okay. So other examples, just kind of making this more alive to like, give examples, I think helps people kind of root this in.

• 29:10Speaker 01

  Totally. All right. So, I mean, another example could be like, you know, somebody may have made like an offhanded joke years ago, or, you know, put up a tweet, you know, years ago, that, you know, maybe the culture has changed and now that joke is inappropriate.

• 29:28David Puder?

  Right. And now they're, not only have they deleted it, but they also fear that someone took a screenshot before they deleted it.

• 29:38Speaker 01

  Yeah, maybe they did. Or maybe just, yeah, maybe somebody just remembered it. Right. And there's no way you can go back and do that. You can go back and find historical, you know, snapshots in time of what the internet looks like. So maybe it exists there.

• 29:53David Puder?

  That's very scary.

• 29:54Speaker 01

  And so maybe that tweet is gonna resurface. Their boss is gonna find it. Their spouse is gonna find it. It's gonna be released on the news. Right? Hey, you know, you know, Dr. Pooter said this thing a couple of years ago. Boy, how terrible is he? Right? So it can be this fear of.

• 30:14David Puder?

  And then every, everything falls apart.

• 30:16Speaker 01

  And then everything falls apart.

• 30:18David Puder?

  Everything falls apart. I'm gonna lose everything.

• 30:21Speaker 01

  Yep.

• 30:22David Puder?

  Yep.

• 30:24Speaker 01

  Probably.

• 30:25David Puder?

  I've, I've, I've had that.

• 30:27Speaker 01

  Yeah.

• 30:27David Puder?

  Not with the tweet, but, you know, it's like, I've, I've had that feeling, I think. But how do I, how do we differentiate someone like myself who has had that feeling?

• 30:36Speaker 01

  Yeah.

• 30:36David Puder?

  Right? Of concern.

• 30:41David Puder?

  To someone who maybe ruminates about it endlessly. And needs like exposure response prevention to really overcome it.

• 30:52Speaker 01

  Right, right.

• 30:53David Puder?

  Yeah. How do you differentiate that?

• 30:55Speaker 01

  I think it depends on the severity and, you know, as we say in the DSM, right? It causes marked distress. If it's getting to that point where it's causing significant impacts on your emotional well-being, it's impacting your relationships, it's impacting your ability to function in your day-to-day, day-to-day requirements and, you know, just your life, right? And it significantly is, it's significantly different than, you know, the kind of typical guilt that we all experience. You know, having lived life, we are all gonna do and say things that we maybe later regret or, you know, sometimes immediately regret. But, you know, we are gonna do and say things and make mistakes, right?

• 31:40Speaker 01

  But while the rest of us, in a typical way, we'd feel that, we might feel that sense of guilt, that heaviness, and we do our best to apologize or to try to make it right. You know, we can kind of get on with our day without it being, you know, wildly impactful on our day-to-day. Whereas for someone where else it, you know, graduates into this sense of, you know, diagnostically OCD, right? Now, you know, fits within that category. You know, this person is now ruminating about this, you know, for an extended period of time. It's causing them extreme or significant emotional distress.

• 32:20Speaker 01

  They may be avoiding people, places, other responsibilities that they have or to, in service of this feeling, in service of this thought and this sense of guilt.

• 32:32David Puder?

  Okay, but then how, because I'm thinking of like PTSD, like a trauma, like a trauma-like experience could result in rumination, going back to it, nightmares, flashbacks. How is that different than this? Or?

• 32:51David Puder?

  Yeah, how do you differentiate like when you're talking to someone? When do you lean more towards like, okay, you had a traumatic experience? Versus, oh, this kind of seems more like real event OCD.

• 33:03Speaker 01

  Yeah, no, that's a, that's a really good question. And there's going to be a lot of, there's, there's a lot of overlap between those. And, you know, we, we kind of, you know, I think one of the biggest questions we're going to ask is like, where's the anxiety? And like, what's the anxiety story? What's the compulsive response to it, right? Now, also, I think it's, I think it's fair to say that OCD treatment and PTSD treatment is kind of going to be a little similar. There's going to be exposure and response prevention involved with both. Right, there's going to be an acknowledgement of, of, you know, for PTSD, acknowledgement of the trauma, kind of processing through what, you know, the significance of that for that person.

• 33:43Speaker 01

  And then also progressively being able to have that thought, have that feeling or experience that, you know, elements of that event and try to work towards kind of tolerating that feeling or being in that if they're willing, if they're interested in wanting to have those things back in their life. Right, I think, you know, I'm thinking about someone who's like, you know, a veteran who struggles with fireworks.

• 34:05David Puder?

  Yeah.

• 34:06Speaker 01

  Right? So, you know, they might be practicing exposure and response prevention to loud and sudden sounds. That, that does mimic a lot of what we might be doing with, with OCD. So, you know, I'd say there's going to be a lot of overlap between those, between those two.

• 34:23David Puder?

  Okay. That's good. Yeah. I, um, I think of trauma as like something, often in the midst of a traumatic scenario, there was an element of dissociation or like this profound near-death experience. Whereas a real event OCD.

• 34:44David Puder?

  It could be just things that, almost like a moral injury? No, not moral, but see, moral injury is, I would put in a separate category as well. I don't know if you've thought about like moral injury. I had an episode on that with a vet, talking about like when he went, when people go through things that really push them past what they want to do morally. Like sometimes then, then they kind of have this different type of trauma that occurs to them, like a moral injury trauma.

• 35:19David Puder?

  Yeah. Do you think, do you think in categories of moral injury as well? And differentiate that from real event OCD? Cause when I think real event OCD, I'm thinking doubting. And I'm thinking going back to the event to try to make sense of it in a, in kind of a more compulsive way. And all the compulsions that follow. And, and the person is more of an OCD type of person. Like they're more, they may have had other obsessions throughout and compulsions throughout their life as well.

• 35:48Speaker 01

  Yeah, yeah, exactly. Yeah, they're, they're oftentimes going to have other, other elements as we, as we talked about. But I think you, you, you pointed out something really important in this is that there's, there's going to be, you know, more of an emphasis on the impact of that event on other areas of their life. And it's going to kind of be, it can kind of go into this extreme sort of bizarre

• 36:13Speaker 01

  story, right? Like what's going to be the impact of this one event, right? Going back to like, you know, did I cheat on that test? Right? They recognize that they did cheat on that test. But it's now, what is, what is the long-term impact of that? And how do they, how do they stop that thing from happening? Or how do they ultimately just feel better from it, even if it's a temporary, better, right? Temporary relief. So that, that might be one of those, one of those.

• 36:44David Puder?

  And so for, for the examples that you've given, like going to the supermarket to check the video footage.

• 36:50Speaker 01

  Yes.

• 36:51David Puder?

  For something like that, does the person, cause I could also see that kind of a little bit psychotic, right? Like, does the person, if it was psychotic, the person would be doing it in a sense of.

• 37:04David Puder?

  There would be no insight that what they're doing is anything like a compulsion.

• 37:08Speaker 01

  Right, right, right. And that's kind of that, you know, the fixity of beliefs, right? How certain are they in their thought where it then kind of graduates into a delusion? Versus, or do they have that kind of mixed insight where they have that, you remember that that logical part of their brain and their fear irrational part of their brain? Right? How much, like, which side is getting the microphone in their life? Right? And is there, you know, if there is too much, or there's a significant lack of insight, that's going to be a slightly different approach, right? It's gonna be, if there is, if someone does have a little bit of insight and can kind

• 37:50Speaker 01

  of experiment with and play with that idea that, you know, maybe the thought that they have is overblown, is irrational, you know, doesn't make sense, and yet that anxiety is still speaking really loudly that it is vital and important and true, you know, then that's where you can kind of put a wedge in between those two and try to pull the microphone away from that illogical side of their brain and have that rational side speak, even if it's a quiet little voice. But that can help to break down the, you know, the importance of that story, the rationale of that story, so that perhaps they can practice exposure and response prevention. And it gives them permission to then say, maybe this story

• 38:34Speaker 01

  isn't correct. So if it's incorrect, if it's inaccurate, well, maybe I can, maybe I don't need to do anything about it. Maybe I don't need to go look into it or keep apologizing for it.

• 38:48David Puder?

  All right. So let's talk a little bit about exposure response prevention. What are some of the go to things that you usually start someone with?

• 38:57Speaker 01

  Yeah, yeah. So- Exposure and response prevention is going to be part of the gold standard of treatment. It's going to be the main thing that OCD therapists are going to want to do. What we're doing with that is we're progressively getting closer and closer to whatever the fear is while resisting anything that would undo, neutralize, or help to avoid that feeling, that bad feeling, right? So when we're working with someone, we're going to try, we're going to first start by building a hierarchy of all the things that trigger their anxiety, right? Situations, places, people, ideas, activities that tap into that sense of anxiety.

• 39:40Speaker 01

  And then we're going to rank that from easiest to hardest. And generally speaking, we'd start with the easiest stuff and start exposing them to that and then working their way up. A really basic idea of exposure and response prevention, I think about like maybe a fear of spiders, right? Is like if someone has a fear of spiders, we wouldn't start by getting a tarantula and putting it on their face, right?

• 40:06David Puder?

  You would never do that to me, by the way.

• 40:08Speaker 01

  Challenge accepted. But so we'd start, like, we might just start with writing the word spider, right? We might just write, we might start with just writing the letter S if that is going to be kind of activating. And then again, it's exposure and then the other part, response prevention. The response in this is the compulsion, it's the avoidance, it's the neutralizing behavior. So we'd write S and then we wouldn't get rid of it, look away from it, we wouldn't try to think about something peaceful and safe, we wouldn't think about squishing a spider. We'd sit with the thought and the feeling, right?

• 40:48David Puder?

  Do you ever think about having a reality TV show and doing this?

• 40:51Speaker 01

  They did, they did. It was called Obsessed.

• 40:54David Puder?

  It's called Obsessed? Oh, man. I just don't watch any TV anymore.

• 40:58Speaker 01

  Yeah. Interestingly, my own supervisor was...

• 41:02David Puder?

  Oh, really?

• 41:03Speaker 01

  Yeah, it was one of the therapists. And they did exactly this. So they helped someone in the show, you know, walked them through their process of, you know, through exposure and response prevention. It's...

• 41:14David Puder?

  So let's talk about plane flights, fear of plane flights.

• 41:19Speaker 01

  Let's do that.

• 41:20David Puder?

  So what's the, let's say they've tried VR, they've tried...

• 41:28David Puder?

  Specifically, the turbulence is what gets them?

• 41:32Speaker 01

  Okay.

• 41:33David Puder?

  And the fear of death and going to hell?

• 41:37Speaker 01

  Sure.

• 41:37David Puder?

  Okay.

• 41:38Speaker 01

  Makes sense.

• 41:39David Puder?

  So what would you start?

• 41:42Speaker 01

  All right, so with, so for anybody out there who's, who has a fear of flying, there's a program called SOAR, S A, wait, S O A R. That is, it's a great program specifically designed for fear of flights. But for someone who may not have access to that, again, we're gonna, if we're just in the response, exposure and response prevention phase of treatment, you know, we're gonna look at, we're gonna make that hierarchy of like, what is it about flights that trigger their anxiety, right? Different elements of it, right? So it might be, you know, they were gonna put down on that list, all right, the turbulence, right? They're gonna put down, they're gonna put down the thought of dying and going to hell, right? Which is his own whole can of worms, right?

• 42:26Speaker 01

  They're gonna put down all the sounds that they might hear, right? So they're gonna put down this whole list, and then we're gonna put it in order. And then we're gonna start with the easiest stuff, and then start, start exposing. So like, some step in that would, would likely be, you know, just watching videos of, of flights.

• 42:45Speaker 01

  This would be a relatively easy exposure, right? So we're gonna pull up videos on YouTube of airplanes taking off and landing, totally fine. But in that, it's gonna be likely triggering some, you know, emotional anxiety response. And then we're gonna turn our attention towards that, make space for it, notice where it is in one's body, and resisting the urge to try to look away from it, to neutralize the feeling. And what we find, what we learn is that, that the, the subjective discomfort of that will slowly start to come down.

• 43:17David Puder?

  Now, do you do like, with behavioral therapy, my understanding is it's kind of like, before you do the experience, it's like, okay, this is what I think is gonna happen? Maybe you write that down, and then you do the experience, and this is what actually happened? And then the discrepancy between them? Do you ever do that sort of thing, where you get them to look at the discrepancy before, before the behavior, after the behavior?

• 43:41Speaker 01

  Yeah, there's an approach called the inhibitory learning model and it includes that as well, where you anticipate what an exposure you're going to be in.

• 43:51David Puder?

  Okay.

• 43:51Speaker 01

  You think about what you're likely to feel, what you're going to want to do, and you also identify what compulsions you're going to be avoiding doing. And then you do the exposure, right? And in that model, you're going to look at, you're going to kind of look at two things. One is going to be, what was the actual outcome of that exposure? And then through that, as you kind of mentioned, it's, how does that differ from what the feared expectation was? What was surprising about it? What stuck out? What was different? And then you build on, what can you do differently next time? How can you kind of amp that up or take one step further? The other avenue of that is looking at how, like, were you able to handle the anxiety? Just the discomfort in that process, right?

• 44:36Speaker 01

  So did you, not, did the anxiety come down, but were you able to sit with that discomfort for longer than you imagined it? Sometimes it's, you know, I can't, you know, I can't be in a room with a spider for, you know, more than a minute.

• 44:52Speaker 01

  Let's try a minute and 10 seconds.

• 44:55Speaker 01

  And what that does is, at the end of it, they go, I didn't, like, I thought I was going to run out of that room at a minute, but I was in there for a minute and 10. That's amazing, right? Nothing bad happened, it didn't kill you, it didn't bite your eyeballs out, whatever the fear is. Great. But next time, well, let's try a minute and 20. Right? So you're extending that out.

• 45:14David Puder?

  Let's not do that.

• 45:16Speaker 01

  Really? Okay.

• 45:17David Puder?

  No, I'm joking. I'm joking.

• 45:20David Puder?

  No, let's talk about the real event OCD, though, because I think it's like, so we have the idea of the basic, like, we're progressively going through more and more distressing, higher levels of anxiety things. So with real event, like, what is the list? Is it things that actually happened that we're writing in the list? And you're writing like a hierarchy of the most distressing, the least distressing?

• 45:43Speaker 01

  Yeah, that's a great, that's a great question. So, you know, let's go with, I mean, let's go with the cheating example, sorry, the cheating on the test example. If you want, we can go with the supermarket example too. But let's say it's the school, right? So it might be, you know, you could think about somebody might be anxious or be triggered by things that remind them of that time. It can be things that, you know, locations. It could be the high school. It could be the name of the teacher. It could be the test, the kind of test that they were taking, right? It could be, you know, almost anything with that. And then, you know, if it's, let's say it's the, just the idea of their high school is kind of activating because it kind of brings up, you know, this whole story.

• 46:26Speaker 01

  So we might start by looking at pictures of it online, right? We might move to, you know, drawing pictures of it. We might move to, I like to do what I call environmental exposures, which is make it so that it's impossible to get away from whatever your fear is. So we're going to picture, we're going to print out pictures of their high school and put it all over their room. It's going to be the home screen on their phone or the background of their computer. So they're going to constantly see it.

• 46:51David Puder?

  Okay. So if it was this fear

• 46:56Speaker 01

  Yeah.

• 46:56David Puder?

  of this girl that you met in the supermarket, who is very attractive, you would recommend printing out pictures of her and putting her all around the house?

• 47:06Speaker 01

  Possibly, yeah. That may be one of those things. If it's seeing this person or maybe seeing someone like this person, right? You might, you might do that, right? Now, that does get into, you know, an ethical question, which we can, which we can also talk about with that. But yeah, it might be the supermarket. It might be, we're going to go to the supermarket every day, right? Because it's, being in that supermarket is going to bring up all that sense of, you know, anxiety and guilt and all that stuff. Great. So we're going to allow that feeling to be there and say, you know, this is my, you know, this is my alarm system going off and it's too sensitive in this place. So I'm going to walk up.

• 47:44David Puder?

  How do you differentiate like being a stalker? You know?

• 47:48Speaker 01

  Yeah.

• 47:48David Puder?

  And printing out pictures of this girl that you got off the video?

• 47:51Speaker 01

  Uh huh.

• 47:51David Puder?

  Thing versus and going back to the place where you met her?

• 47:57David Puder?

  To try to interact with her potentially again as a behavioral experiment?

• 48:00Speaker 01

  I mean,

• 48:01David Puder?

  To being like, you know, not a stalker and.

• 48:04Speaker 01

  Yeah, yeah, we're I'm not I'm not here to advise stalking. So no one get any ideas, y'all. But, um, you know, but it that that's that is where, you know, some of that the ethical questions come in when it come when it comes to comes to exposures, right? Are we doing things that are, you know, violating someone's rights, violating somebody's autonomy? Are we taking advantage of somebody or is the exposure that we're doing hurting somebody anyway? And, you know, we're not gonna, I'm not here for that, right? I there are wild stories out there that you might hear horror stories of exposure and response prevention. But, you know, if it's if it's if it's the idea of a certain person.

• 48:44David Puder?

  Yeah, and I'm just I'm just being I'm being playful, but I think I think I'm just.

• 48:49Speaker 01

  It's I I hear you. And these are conversations that are never ending in the OCD community of how far do you go in exposures? Um, I mean, two, two great examples of this. So I know you're being playful, but you know, for anybody out there who's hearing this, who goes, man, I read, I looked on Reddit and people were describing their exposures and that's crazy. I'm never gonna do that. Like, examples are, you know, eating Skittles off toilet seats.

• 49:17David Puder?

  Okay, that's not too that's not too weird.

• 49:20Speaker 01

  That's not too weird for you. This is what this is what Dr. Pooter is doing in his free time.

• 49:25David Puder?

  No, not doing that.

• 49:27Speaker 01

  Okay, so.

• 49:30Speaker 01

  So that's something that somebody might read and go like that's I'm not doing that, right? But the question is, is it necessary, right? Is it required to to to get success and treatment and freedom from OCD? Is that required? Now, another example for religious scrupulosity, I love talking about religious scrupulosity. Is that, you know, I've heard examples of people therapists advising clients tear pages out of their Bibles. Right? If they're fear of blaspheming or offending. Now, as I don't think I oh, no, I don't think I confidently would never advise somebody do that in any faith for any, you know, for any reason. I think that I think that would be a disrespectful move. And I think it's I don't think it's necessary for exposures, right?

• 50:16Speaker 01

  Or, you know, taking that that Bible page and, you know, wiping your butt with it. Related stories like that. So there's, there are things that, there are things that could, like, is it a good exposure? It's a great exposure, but I'll never suggest it.

• 50:32David Puder?

  Well, it's, it's a, I think, I think it's culturally insensitive to someone's values. And I think that's where it's, there's, it takes some nuance, right? Like, if someone was having scrupulosity for us out of a spiritual background that I don't have, I'm not going to try to violate their spirituality.

• 50:57David Puder?

  I think, I think you can, you can work around it, right? That's what you're saying.

• 51:02Speaker 01

  Yes, absolutely. And, you know, let's go with, you know, maybe somebody, you know, sinned or blasphemed or said something, you know, let's go back to that, like tweet, right? They made an inappropriate, you know, joke about, you know, their religion when they weren't actively religious. And now they're more religious. So now that that tweet is, you know, a terror in their life, right? Well, you know, we, we do have to acknowledge that it was said, right? That we don't, but ultimately there's, we, we need to first start with cutting down on any of those compulsions that somebody might do to continuously apologize or continuously atone for whatever that thing is that they made a mistake for, right? But as an exposure, I'm not going to then say, all right, as an exposure,

• 51:47Speaker 01

  all we're doing is active blasphemy, right? We're going to live at the risk of blasphemy, which is what you and I do on a regular basis anyways. And everybody else does. So we're living life as an exposure, but the response prevention is resisting scrutinizing oneself, like playing through their whole day. Did I blaspheme? Was this blasphemy? Did this, did this qualify as that?

• 52:16David Puder?

  Yeah.

• 52:16Speaker 01

  Right? So resisting those compulsions.

• 52:20David Puder?

  So, okay, blasphemy, like, give me, give me an appropriate exposure. Let's say the patient says, you know, Kevin Foss, I fear that I may have blasphemed God and therefore I've done some unforgivable sin and therefore I'm going to hell.

• 52:38Speaker 01

  Okay, so depending on the place in therapy, like one thing we may do is a script or a cognitive exposure. So with that is, or it's magical exposure, excuse me. What that would be is we're going to write out a story of somebody's worst fear actually happening and actually coming to fruition. And this is something that we use a lot in real event OCD to kind of play out this story. Right? So we'd be writing a story about somebody blaspheming, you know, somebody blaspheming in one way or another. And then writing out what the consequences and the impact would be. So maybe it is, you know, they said or did something and then they made God upset

• 53:19Speaker 01

  and that they lived their life and maybe they have, you know, subtly bad luck throughout their entire life or, you know, or up to their lightning bolted immediately. But maybe they die and they go to hell and, you know, God specifically says, "Hey, remember that thing that you did when you were 20? Yeah, it's because of this." Right? So we play out that story and we write that story out. And then we reread and reread and reread that story until the subjective anxiety of that starts to come down. Now, notice in this, we're not saying, you know, "God provides forgiveness and recognizes that I make mistakes and I repent for it and everything's fine and I avoid hell." Right?

• 53:55David Puder?

  That's not what you write out. You don't write that out.

• 53:58Speaker 01

  Correct. We are not writing that out in this exposure. We're writing out the worst case scenario because it's going to be activating. Right? But we're also acknowledging it's a story. Right? It's playing with that thought that's in your mind and activating that sense of anxiety. We're showing your brain then that you can have this thought. It's a thought about blaspheme. It's not writing a story with, you know, riddled with blasphemy. It's saying, "Well, maybe I did." And then that is going to likely trigger someone's anxiety. We sit with that feeling. We notice where it is in our body. We make space for it and over time, our body starts to tolerate that story and kind of becomes bored with it.

• 54:42David Puder?

  Yeah. Okay, but what is the difference between that and someone just on their own, going back through the story and seeking for certainty?

• 54:52Speaker 01

  Ah, right there. We're not seeking certainty in this story. We're not trying to get, we're not trying to get comfort. We're not trying to get confidence that we need to do anything about this. We're just simply saying, here's this story. Here's this, here is this stimulus that's going in my head that activates my sense of anxiety. Right? It's, I'll, you know, put it, let's put it in a different way. What's your favorite food?

• 55:19David Puder?

  Choc, dark chocolate.

• 55:20Speaker 01

  Dark, in what form?

• 55:23David Puder?

  Uh, eighty-five percent dark chocolate. Single source, single origin.

• 55:28Speaker 01

  Bar?

• 55:29David Puder?

  Bar, yeah.

• 55:30Speaker 01

  Okay.

• 55:32David Puder?

  Oh, like with, with coffee would be the best, like a good Americano.

• 55:36Speaker 01

  Okay, so let's say you have, so I want you to just have that chocolate for every day, for every meal for a month. The first couple of days are gonna be awesome.

• 55:47Speaker 01

  By day thirty, you're like, I just want anything other than my favorite thing.

• 55:53Speaker 01

  Right?

• 55:54David Puder?

  Okay.

• 55:55Speaker 01

  We, we habituate, we tolerate, we, we, we, you know, we habituate to the excitement of that. It's that in reverse, right? It's, we're having this story, we're playing it out over and over and over again, to the point where eventually our brain starts to become bored with it. And we can get used to, we can get used to almost anything, pretty much anything.

• 56:17David Puder?

  You know what I think about? As I think about the men, and it's usually men that have this job, that go down into like sewer systems in those suits.

• 56:25Speaker 01

  Yeah.

• 56:25David Puder?

  You know, where like literally they can't see.

• 56:29Speaker 01

  Yep.

• 56:29David Puder?

  Cause they're surrounded by shit. And it's like, how do they do that? Because that is like, have you seen videos of guys that do that? And it's just like, what?

• 56:40Speaker 01

  Oh, yeah, yeah.

• 56:41David Puder?

  How is this guy even doing it? He's going down there, he's got his wrench, he's gonna open up this thing, unclog this thing, or something like that.

• 56:49Speaker 01

  Yeah.

• 56:50David Puder?

  It's like, oh my gosh.

• 56:52Speaker 01

  It, I mean, that's a fantastic example that we can get used to anything. Now, I bet he doesn't say, you know what I love doing? I love crawling down in the sewer and just be covered, head to toe in poop. It's my favorite thing that I do. I love it.

• 57:09David Puder?

  No, he would say, I love the paycheck that I get at the end of the day. So I can go home and take care of my family with my paycheck. That's what he would say.

• 57:18Speaker 01

  He probably does, right? And he probably would say, and by the way, we're talking about here is actually, there's a whole other avenue called the mastery model, which is kind of describes this is where we call kind of just gross OCD, where it's not like a feared story, just something just feels gross, right? That's a whole nother conversation. But it's kind of this idea that like, we don't love it, but we do it. I mean, as a parent, you know, how, how many times did you get poop on your hands from your ridiculous pooping child? A lot.

• 57:50David Puder?

  Countless.

• 57:51Speaker 01

  Countless, and at no point did you say, this is great, right? But we, and if before that, if someone said like, hey, by the way, you're going to have a little human and they're going to poop all over you. How do you feel about that? We'd probably go, I'm against it, not for it, right? But we get used to it, not because, but through the process of just showing up and doing what you value, you want to care after your child. You do your value. And in the process, you got used to the thing that's bad. I'm, I'm in LA. We have traffic all the time.

• 58:24David Puder?

  Hmm.

• 58:25Speaker 01

  I don't love it, but we get, but it's part of life. You get used to it, right? You're in Florida. How is, how's the humidity?

• 58:34David Puder?

  You know what I did to overcome this? I built a sauna.

• 58:38Speaker 01

  No, you didn't.

• 58:39David Puder?

  And I use the sauna every morning. And so when I get in, when I get to my lunch break, I actually go outside at noon in Florida all year round now. And I sit outside with my lunch and I eat in the heat and I love it. I totally changed my mindset, but it's that, I'll tell you what, the first, the first 10 times I did the sauna was not fun. But my body is like adapted.

• 59:04Speaker 01

  Yeah, that's exactly it, right? So it's it's so interesting to find that that we we can get used to so much stuff. And with, you know, in the case of OCD, somebody's terrified of X, Y, or Z. And they can get they can get to that point where they, you know, they kind of like the idea of something. That's going to be terrifying to a lot of people. And we, you know, the vast majority of folks who, you know, go through treatment, they don't end up loving the thing that they're deathly afraid of initially. But they get to a point where they go, it's just a thing. It's just a thought. Real event, it's they can the idea is we're trying to make space for and learn that we can sit with the uncomfortable emotions, the uncomfortable, that sense of uncertainty.

• 59:48Speaker 01

  And instead of engaging with that feared story or the shame, they can disconnect from that and reengage with life as best they can in enacting their current and most important values in life. I know it's such a therapy thing to say, but it's kind of saying, I made this mistake. It's in my past. It sucks. I don't love it. And I'm going to do my best right now to do something different, to be the person I would like to be. And make space for the reality that we're going to make mistakes again because we're human. And that's what we do.

• 1:00:25David Puder?

  OK, so here's a here's a question for you. At what point do you say, OK, now I'm going to recommend this person get on medication? Like you're working with someone. How often? Like, what are the markers that you have that this person is going to need medication for a time? Or what are the what are the like? If we're working together with a client?

• 1:00:47Speaker 01

  Yeah.

• 1:00:47David Puder?

  At what point do you say to me like, hey, I think we can go down on the medication?

• 1:00:52Speaker 01

  Yeah, it's a good question. It's a good question. Well, so as I'm not a psychiatrist, I'm not going to pretend, I'm not gonna, I refer out for that. Now, meaning I don't want to say you need medication because I don't want to make that call and say, hey, Kevin, that ridiculous person said I need, you know, I need medication. All right. So getting back to that. My markers for that are often going to be, you know, if we're, if we're in treatment and we're doing the process and we're, you know, working up the hierarchy or we're trying to make some headway and we just kind of hit this wall, or it's, you know, they have this, you know, overwhelming sense of unwillingness to continue pushing in the process. And I've exhausted every tool and idea that I can think of. You know,

• 1:01:36Speaker 01

  I might say, you know, maybe you want to consider medication for this because for some people, that can be the missing puzzle piece in treatment. Now, medication is, you know, there are going to be people who are on medication and still struggling in treatment. There are people who are not on medication and they're thriving and doing great. Right? So I don't think it's a magic pill necessarily, but I also think it's one of the tools in our toolbox. So when someone gets to that point where it feels like we're, you know, just beating our head against the wall and not making a whole lot of progress, you know, I might encourage them to go chat with their, with their psychiatrist about medication. And then, so your other question is when they come down. So if we're, you know, if

• 1:02:18Speaker 01

  they're on medication and we're doing treatment, they're doing really, really well, you know, we're kind of getting to the tail end of their hierarchy, we might talk about like pulling down on medication, right? If they, so they can make a choice, right? It's, it's up to them. If they want to stay on medication because they say, gosh, my life is just more functional and better on medication. Great. Live your dream. But if they say, my ultimate goal is to get off this medication, then under the, under the, the guidance of their psychiatrist, they're going to pull it down a little bit and we're going to keep doing treatment. We're going to keep doing exposures because that anxiety might now be a little bit higher. Right? So we want to continue reinforcing what they've been doing as they've been on medication and showing themselves, yes, I can have, I can still do this thing,

• 1:03:02Speaker 01

  though it might feel a little bit uncomfortable, I can still do it. And then it comes down, we still do exposures to the point where, you know, the goal would be to be off medication, showing themselves that they can still engage their life, resist their compulsions, tolerate uncertainty without medication. That would be kind of the arc of that.

• 1:03:19David Puder?

  Great. Okay, we're gonna wrap it up because I'm gonna get to dinner here with my kids. Any, um, any kind of final thoughts, any things that you didn't say that you'd want to say?

• 1:03:31Speaker 01

  Oh, boy.

• 1:03:31David Puder?

  I know, we, we could have covered a lot more. I, we could probably keep going for another three hours.

• 1:03:36Speaker 01

  We probably, we probably could. I mean, I know we didn't talk a lot about, um, kind of the process of shame and guilt. Um, and we see, you know, we see a lot of that shame being that bad feeling when we've done something bad. Shame being that bad feeling when we are something bad and.

• 1:03:51David Puder?

  Guilt, I've done something bad, shame, I am bad. Is that how you see it?

• 1:03:55Speaker 01

  Yeah, it's like this core sense of self. What I, you know, what I, for that, just very briefly, is I try to encourage folks to shift their shame language to guilt language. Right? So their shame language is I've, I'm, I'm ruined, I'm screwed, I'm bad. Right? Instead, we want to talk about guilt as, all right, I, I acknowledge that I didn't do something that's within my value system. I made a mistake. And I'm gonna own it. I'm gonna make atonement for it if possible, if reasonable. And then instead of beating myself up and continuing in this cycle of disengagement and shame and, um, uh, isolation. I'm gonna go pursue life and, you know, pursue life and try to make a different choice in a similar situation in the future.

• 1:04:40Speaker 01

  So I'd encourage folks out there, you know, if, if they're experiencing real event OCD, boy, you know, go chat with an OCD therapist, talk about what's been going on. And, you know, there's, there's recovery, recovery to be found in this process and, and getting your head out of the past and starting to live your life in the present.

• 1:05:00David Puder?

  Yep. And I think my final, my final word would be, if, if you have a patient that's not getting better, that's ruminating four to six hours a day, and you feel stuck, and you could be trying things.

• 1:05:16David Puder?

  That have worked for most of your clients. But unless you get some specialized training, exposure response prevention, send them to a specialist, you know, I think these are the clients that if you decide not to treat these clients, that's fine. But learn how to refer, find someone in your area. I have a couple. I have Kevin Foss as one of them. LA area.

• 1:05:44Speaker 01

  LA, Orange County.

• 1:05:46David Puder?

  LA, Orange County, California. Where else do you have a license?

• 1:05:51Speaker 01

  Montana, and I can meet with folks online in Florida.

• 1:05:55David Puder?

  Okay. And do you do any like coaching as well? Like if someone from another country was like a clinician and they wanted to learn more about this?

• 1:06:05Speaker 01

  Absolutely. Yeah, happy to do that. I also have a podcast where the focus of it is a question and answer based. It's question and answer based, so folks message me questions about OCD and anxiety disorders and I yammer on about it for about a half an hour or so.

• 1:06:22David Puder?

  Awesome. I would love to come on sometime.

• 1:06:25Speaker 01

  Absolutely. Let's do it.

• 1:06:27David Puder?

  Let's do it. All right. Thank you so much. Have a great day and we'll leave it there for now.

• 1:06:31Speaker 01

  Thanks so much for having me on.