Comprehensive Obsessive-Compulsive Disorder (OCD) Treatment Guide: Evidence-Based ERP Approaches and Best Practices for Clinicians

In this episode, Dr. David Puder dives deep into the world of Obsessive-Compulsive Disorder (OCD) with renowned expert Dr. Fred Penzel, who brings over 43 years of experience to the table. Together, they explore groundbreaking approaches to treating OCD, including Exposure and Response Prevention (ERP), cognitive restructuring, and embracing uncertainty. Dr. Penzel shares fascinating insights into the neurobiology of OCD, the cycle of intrusive thoughts and compulsions, and effective strategies for lasting recovery. Whether you're a clinician seeking best practices or someone navigating OCD, this episode offers a wealth of practical tools, compelling stories, and hope. Uncover why OCD is called the "doubting disease" and how evidence-based methods can break its grip. This is more than a podcast—it's a roadmap to understanding and overcoming one of the most challenging mental health conditions. By listening to this episode, you can earn 1.25 Psychiatry CME Credits. https://www.psychiatrypodcast.com/cme-program Link to blog. https://www.psychiatrypodcast.com/psychiatry-psychotherapy-podcast/episode-228-comprehensive-ocd-treatment-guide-evidence-based-erp-and-cognitive-strategies Link to YouTube video. https://www.youtube.com/watch?v=flP_z4XByk4

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 Dr. Fred Penzel. He is an OCD expert who has been on my podcast before. He specialized in OCD about 40 years ago, I think I remember you telling me when a professor said it was 43, when a professor said it was too hard to treat. And you had this kind of gumption, you know what, I'm going to try to figure this out and try to treat it. And I've appreciated corresponding with you and hearing some of your wisdom. And I thought I would have you back and really focus in on one specific aspect of OCD, which is kind of the doubt and the need for certainty.

• 0:56David Puder?

  And I've had a couple of these patients that it seems almost like that's the pure, there's a pure aspect of it where then they almost like develop more doubt about the treatment, you know, or like doubt about the doubt. So I wanted to get your take on this and have a dialogue.

• 1:16Speaker 01

  I think it's useful to note that in the 19th century, OCD was referred to as the doubting sickness or the doubting disease. And I think even back then, they recognized, you know, what one of the central features of it was actually doubt and guilt, actually, are two of the two of the main features that you see in OCD. But the doubt is crushing, really, and it's, it can apply to anything, basically. It can, it can, it seems for some reason, which we still don't understand, to attach itself to whatever bothers a person the most or whatever gets their attention most easily.

• 1:59Speaker 01

  Maybe it's just that people think a lot of things and only certain things stick because they really are matters of concern to that particular person. But yeah, doubt is, and it's a doubt that cannot be resolved. But what happens is it drives people, the only thing that can overcome doubt that's that powerful is trying to get like perfect certainty about things. And of course, we know that we live in a world where perfect certainty doesn't really exist. Uh, certainty is, is, uh, and, and even where people think they have certainty. I, I tell people, it's like your, your brain's been out of Teflon and the, the certainty just sort of slides off and slips away, uh, essentially. So, so even when people think they can be

• 2:44Speaker 01

  certain about something, within a short time, they're now uncertain about it again and, and the whole process starts over. It's like a vicious cycle, uh, basically.

• 2:56David Puder?

  Yeah, it, it is a vicious cycle and it seems like people go back to memories in the past, like that maybe they have a doubt, like was I an evil person in this moment? You know, and so they go back and they replay this event and that, that replaying of the event, would that be the compulsion, would you say?

• 3:17Speaker 01

  Yeah, any, any attempt to relieve the anxiety caused by the OCD, which is, you know, the uncertainty is what's causing the anxiety, uh, basically, because it's anxiety about whether the person either harmed someone else or harm came to them in some way or both, uh, basically. So, so, uh, it, it, a compulsion is, it can be, you know, any of those things. Uh, it can be a mental event, that's something that person does strictly in their head, or it can be an observable physical, uh, compulsion as well. But compulsions, I like to say that, uh, compulsions are lousy solutions to the problem of having obsessions, uh, basically, because they don't work, basically, since, since perfect certainty is impossible,

• 4:01Speaker 01

  they're doomed to fail. They can, they can never work. A person might get a little relief for a short term, but OCD doesn't care about that. OCD just kinda can sweep aside any certainty or reassurance or anything that the person gets. OCD is sort of, uh, immune to that, uh, basically. So, yeah, people review past events. They, uh, watch, uh, either videos of events or they, they take written notes and study them over and over again, or they sit and play these things in their heads over and over. But, but, uh, they're, as, as they get more frantic in their attempts, that certainly isn't an aid to memory and now they're, they're even more uncertain than when they first started studying these things.

• 4:43David Puder?

  What do you think like, okay, like, let's, let's give an example that's a little extreme. Like in Crime and Punishment, Fyodor Dostoevsky's character, you know, gets kind of this obsessive, ruminative thing about, you know, the murder that he committed. So this is, this is maybe a little bit different than like someone with obsessions with something that is a little bit more dubious in like moral nature, right?

• 5:11Speaker 01

  Well, yeah, it's, it's usually situations that are sort of ambiguous where it's not really clear what happened, where the person was unsure to begin with and just started to, you know, surmise what, what had happened. They came up with different possibilities and probably, you know, they, they tendencies to latch on to the worst one, basically. So, you know, yeah.

• 5:36David Puder?

  Have you had patients who come to you and they, they believe that their, you know, their intense doubt is around some moral action? And maybe like with Raskolnikov, you know, he, he murdered someone. So this was an actual action that probably guilt was normal. Is that, is that something that presents to you or is it, is it always different than that?

• 6:01Speaker 01

  Well, again, that would be a sort of an unambiguous situation. So, you know, the person might ruminate on the fact that they behaved badly, but they wouldn't be ruminating on whether they did it or not. No C D. It's, it's like a perfect example is I have people who, you know, they go driving in their car and they go over a bump in the road and they immediately say, oh, how do I know I didn't run somebody over? Maybe I did. It's, it's quite possible that I did, but I didn't go back to check or anything. So now I'm a hit and run driver and responsible for somebody's death. And, and then they may actually drive back to check and walk all around and drive by numerous times and, but they don't see anything. But of course, the O C D isn't satisfied with that.

• 6:44Speaker 01

  The O C D will say, well, maybe they took the body away or the person rolled under a car nearby that was parked or, you know, all kinds of possible explanations, but, but they never really get to the bottom of it. They'll go home and listen to news reports. They'll do all kinds of things and, and of course they won't get certainty because again, we do not live in a world of certainty, basically. Everything is pretty much, I tell everybody. Things are pretty much up for grabs in this world, you know, you can't, you can't be 100% certain about most things.

• 7:18David Puder?

  Okay, I want to further get into this because the scrupulosity aspect of OCD is so interesting to me. It's like, how do you delineate like normal moral guilt that maybe they should feel guilty about versus scrupulous guilt?

• 7:35Speaker 01

  Well, okay, for one thing, which is typical of most obsessions, is that no matter what the person does, no matter who they talk to, no matter what they read, no matter what advice they get, they can't resolve it. It never goes away. And also, these things tend to be, they tend to be worried about things that most people wouldn't even worry about, basically. They would either say, oh, it doesn't really matter, or that's ridiculous, or they'd shrug it off, or somebody would give them an explanation and they'd be happy with that and go, wait, but in OCD, you don't see that. Person keeps, keeps at it and at it and that, and it can go on for years, basically. And the things that people do in response to it are generally not normal.

• 8:17Speaker 01

  Let's say if it's on a religious matter, what they do to deal with it is not generally proper religious observance either. It can be very extreme. It can go, you know, it tells them that no matter what they do, they haven't done enough, or it isn't good enough, or it doesn't count, or nothing can make up for what they did. And, and, you know, it can be quite severe, especially with the religious ones, because, you know, many people, they, their fears of going to hell, or, or being permanently damned, or, or, you know, things like that. And this, this is what drives, you know, these, these attempts to, to somehow resolve that and say, well, no, I'm really a good person. And this is also an additional thought that hits people with these things, which, which is,

• 9:01Speaker 01

  and it's another sort of OCD double whammy, basically. It's, it's like the idea that, well, if I didn't do these things, or, you know, why am I thinking about them? Because if I didn't do them and it was an issue, I wouldn't be thinking about it. So it becomes like sort of circular logic, essentially, you know?

• 9:20David Puder?

  Yep. I had, I had one patient, I'm going to change some details, of course, as I always do. But he deeply feared that he had molested a child. And so he would go back to every memory of him interacting with a child. And he would, he never, of course, molested an actual child. But he feared that he would have, or he could have. Not that he would have as if he wanted to, but that he fears like, well, what if I did, but I don't remember it? Right?

• 9:53Speaker 01

  Yeah.

• 9:54David Puder?

  Is that something that you've seen or any?

• 9:56Speaker 01

  Oh, yeah, very common, very common. All these thoughts are usually preceded by the phrases, how do I know or what if? You know, generally, those are kind of giveaways I tell my patients. But, but, yeah, the OCD will pick on anything like that, that the person thinks is, you know, immoral or bad in many cases. And they will keep going, but the problem is memory is also not that accurate. As time goes by, you know, details get blurry or we're not sure about whether we remembered things correctly. And then the OCD steps in and says, well, you can't really remember what happened, but you did it. Even though you can't be sure, it's, it's, you know, you definitely did this and, you know, you're gonna, you're gonna suffer for it in some way.

• 10:42David Puder?

  Going back to the scrupulosity aspect. So you find that they do things that are not normally within their religious practice. Can you give some examples of like what we're talking about?

• 10:53Speaker 01

  Oh, yeah, people will, they'll invent their own prayers, for instance. They'll make up all kinds of religious rituals. They'll constantly apologize to God. And, and, you know, things like, like this, that you don't normally see in, in, you know, that aren't recommended as normal religious practice in, in whatever their religion is. I've even had people feel that they've, they've violated codes in religions that aren't even theirs.

• 11:23Speaker 01

  Which is how extreme this can become. So it's, it's, uh, there's like no limits to what OCD can do. It's, uh, it's like, I, I call it the disorder of a thousand faces, uh, basically. So, so, but scrupulosity can be, uh, very, um, uh, excruciating. In fact, it doesn't only affect people who are, who were normally very religious to begin with. I mean, it certainly can affect them, but it can even affect people who, who weren't terribly religious to begin with and, and, uh, who, who aren't that strong in their beliefs, but it'll still tell them the same kinds of things. Uh, so, so, uh, yeah, you see this quite, it's, it's a very common theme, uh, basically. Uh, I've, I've seen, uh, people do, uh,

• 12:06Speaker 01

  I, I remember I had someone who stopped going to religious services because this, they got this thought, uh, whenever they were praying, that the thought came to, oh, how do you know you're really praying to God? Maybe you're really praying to yourself. Maybe you think you're God or you wanna be God. And then, uh, so they, they couldn't go to religious services anymore because they thought, wow, you know, I'm gonna get punished for thoughts like this. This really breaks the rules. So that, that's one kind of thing you see. I've had people get like morbid thoughts about God. I had a, a person who was constantly tortured by the, the thoughts that, I hate God and I want, I want God to have cancer. I mean, these are, you know, not kind of typical, uh, thoughts that people have, but, but they were just as excruciating as if, you know, it was just a normal, everyday thought.

• 12:52David Puder?

  Do you, do you find that as people like, like if the compulsion is to go back to the memory and sort of like rework the memory, go through the memory step by step? And sometimes it's almost like they want to insert or change the memory or like add to the memory or like it within the fantasy they, they, um, yeah, do you, do you know what I'm talking about?

• 13:12Speaker 01

  Uh, yeah, I don't see that so much. Again, what I see more is people just trying to verify in their own mind, what happened to get it absolutely straight and then to try to be able to hold on to it, but they can't hold on to it. It, it slips away. So, so they never, you know, it's, it's like, uh, uh, an endless task, basically that could, it's something like an itch that you can't scratch.

• 13:36David Puder?

  Yeah, okay. So, so, okay, like, so you're getting them to sit in the doubt. What do you tell them to get to get them to just sit in the doubt?

• 13:47Speaker 01

  Well, we we do. First of all, I think if we begin any therapy, you really need to do a good round of like psychoeducation, basically. So so what I first try to do is really teach people what the nature of OCD is, what they can expect from it, what it requires to get better, and why we have to do the things that we do. Because I, you know, I don't believe in asking people to do things if they don't understand why they have to do them, because I want them to be partners in their own treatment, basically. I'm kind of that way myself. If you ask me to do something, I'll say, well, you know, why do I have to do that? Or what's the the importance of it?

• 14:21David Puder?

  Okay.

• 14:21Speaker 01

  So that's the first step.

• 14:23David Puder?

  So can we can we play this out? So I'm coming in, and I'm the patient. So just take me through what you would normally say.

• 14:29Speaker 01

  Oh, gosh, that's that would take a whole session in it.

• 14:33David Puder?

  Would it? Okay.

• 14:34Speaker 01

  Well, one thing I do give patients, it's called, it's a document I put together years ago. It was I made it for my new patients. It was called How to Succeed in Your Twenty Five Tips on How to Succeed in Your Behavioral Therapy. And and it became kind of popular, actually. I didn't realize it at first, but the OCD Foundation actually has it on their website now. And a lot of therapists have told me they give this to their new patients also, because it spells out all the basic principles and ideas so that I want everybody to start with the same body of knowledge, basically, so that they they're informed consumers. So so, you know, so I explain to them,

• 15:15Speaker 01

  it's sort of in a nutshell, that OCD is very paradoxical, that all the things that they thought were going to help them in the past, like compulsions, only made them worse, and that all the things that they thought were going to make them worse, like the, you know, facing the thoughts and the situations, will actually make them better. And and I explain to them that the only way to overcome a fear is to face it. You can't run away from or escape fear, because it's it's an internal experience. You can't run away from what's inside your own mind, basically. So we don't try to do that. And I say, we can't control thoughts either. So you can't push a thought out of your head, or sometimes I tell them, I say, we can't turn off. The faucet, uh, basically. So since we can't control thoughts in that way, what we can do,

• 15:57Speaker 01

  we can control our response to the thoughts because I tell them that you may not control what pops into your mind, but you can't control how you react to it and what you do about it. That I said is totally under your control. OCD can't make you do compulsions, although people think that at first. I say, no, you came up with the compulsion as a way of managing the doubt and the anxiety. And then you practiced it hundreds and maybe thousands of times to the point where it became so automatic that it feels like, uh, OCD is making you do it, but it's not. I say, anything, you, you've learned something and anything that you learned that way can be unlearned. It's not hardwired into your brain. So you can, you can unlearn it through practice, uh, basically. And this is, this is how I view it, uh, basically.

• 16:40Speaker 01

  So I tell them, uh, the goal, since we can't escape or avoid, the goal is, and I love this word in regard to it's coexistence. I say, you have to learn to coexist with the thoughts to be able to say, okay, I can have that thought, but I don't have to do anything about it. It doesn't, it's not important to me. I don't, I don't have to act on it in any way. Ultimately, I mean, that's the ultimate goal. That's not the earlier intermediate goal, but that's what we're going for, uh, basically to be able to live with those thoughts. And, and, and we're, we're trying to, overall, we're trying to build tolerance. We're trying to increase the person's capacity to experience these things without, again, you know, having to do compulsions. And, and one, one other thing I like to tell them, I say, the anxiety is not the problem. The compulsions are the problem. The compulsions are what are going

• 17:25Speaker 01

  to tie your life up in knots, uh, basically. The anxiety, if you stop doing compulsions, that means you're staying with the anxiety and ultimately you're going to get over the anxiety. But if you think the anxiety is the problem, you're just going to do more compulsions. So, so, you know, I think the, the, I try to make it very clear why we do what we do and, and how it's supposed to work. And I tell them it's, it's a work in progress. It's a, a gradual process. Nobody, you know, builds up their tolerance immediately. It's like any training program. If you wanted to learn how to play a sport or play a musical instrument or anything like that, you would have to practice regularly and, and intensively. And, and then, you know, you would become good at whatever it was and that. I like the old saying, habit is overcome by habit.

• 18:09Speaker 01

  So we develop new habits to displace the old ones. And the less they practice the old habits, the weaker they get. And then stronger the new ones become, and it becomes easier to resist and react appropriately to these things. So that, that in a nutshell is what, what I tell them.

• 18:24David Puder?

  Okay, so what if the compulsion becomes repeating the things that you've talked about as a way of dealing with it, you know? So it's like, you need to sit with the, you need to sit with the doubt. So repeating, you need to sit with the doubt, becomes the compulsion.

• 18:41Speaker 01

  Well, interestingly enough, you know, I give people homework to do every week on their own, therapy homework. But every homework assignment, the first three items on their list never changes. It remains the same throughout therapy and even after therapy. And the three items are, number one, as we say, try to agree with all obsessions. Let them be there, and agree with them. You know, in other words, stay, stay with the thought, let it be there, say it's true. And the second point we tell them is, we say, do not study or analyze the thoughts, only agree. Don't, don't try to figure out what they mean, or where they came from, or, or anything else about them. Just say they're true and leave it at that, okay?

• 19:22Speaker 01

  And the third point we say is stay away from all, all reassurance, basically, to, to not seek reassurance from other people, or from yourself, or in any other way. So again, they're, they're staying with the anxiety. And I tell them, I say, you know, treat all these situations where you get thoughts, or your anxiety comes up, treat them as opportunities to practice. Don't say to yourself, oh, why did that have to happen? To even say, okay, this is giving me a chance to work on this now, and, and I'll get better if I face it the way I'm supposed to, essentially. Now, we do give other homework in addition to that, but I call those three our, our permanent assignments.

• 19:58David Puder?

  Okay. Okay. So then what if the person, like, it becomes a compulsion to go back to your handout and read it over and over again?

• 20:07Speaker 01

  Ah, well, then we tell them, obviously, to stop doing that, and, and to instead tell themselves that they don't really understand the information, and it won't be able to help them, and they're never going to get better because they're untreatable.

• 20:22David Puder?

  What?

• 20:25Speaker 01

  But that works.

• 20:27David Puder?

  Okay.

• 20:27Speaker 01

  It's actually, people report they feel when they, when they start agreeing with the things, they think they're gonna get worse. But many people report to me and say, no, I felt sort of like a sense of relief, like I could let go, I didn't do anything.

• 20:39David Puder?

  So, so that, that's good. So I have had patients with OCD who say, I feel like I'm going to get worse. And that's like an obsession of theirs, right? That they're like not getting better, that they're gonna get worse. So you would have them agree with that. I am going to get worse?

• 20:52Speaker 01

  Yes, absolutely. OCD, it's interesting. It's the, I, I believe it's the only disorder that really attacks its own treatment. That it tells people, you don't know how to get, you don't know how to do the treatment, you can't get better, nothing can help you. You probably don't have OCD and, and so on. All these things to get a person discouraged almost and to want to give up. Uh, because it, it tries to make them feel hopeless in a way. Again, it's just part of, not everybody's, but many people's OCD. And in my 25 tips, I actually warn people to expect that that may happen to them.

• 21:25David Puder?

  Okay. So like, let's say they have some moral scrupulous thought, like I'm a, I'm a pervert.

• 21:32Speaker 01

  Right.

• 21:32David Puder?

  Uh, or something like that. And then, so this, this, this example, this guy who goes back to his past, which, um,

• 21:40David Puder?

  uh, you know, it, it becomes like a thought over and over, right? Do you, so does number one try to agree with all obsessions? Do they, do you tell them to agree with that?

• 21:49Speaker 01

  We work up to these things, basically. You know, we start kind of gradually and, and build up, keep raising the bar.

• 21:56David Puder?

  So what would be a gradual, like what would be gradual for that? Cause that seems like.

• 22:00Speaker 01

  Well, we, we first, we approach the idea that, yeah, there are people who molest children. They're, you know, really nasty individuals. Uh, they should be separated from society and locked up and everything. And then the next thing we go is, uh, You know, there are many people among us that we don't even know they're like this, but they are. And then we move on to say, maybe I'm like that. And, and from there we say, yeah, I very well could be like that. And then I'm probably like that and even move up to, yeah, I'm definitely like that. And I definitely did these things and, and all the rest that goes along with it, basically. So it's, it's a gradual escalation of what we do.

• 22:40Speaker 01

  We, you know, obviously if we hit the person with the worst stuff immediately, we're going to scare them away from therapy. And then a lot of beginner therapists unfortunately take people too far at the beginning because they're so zealous about getting people recovered that they push people over the edge. So then they, they lose their patience.

• 22:59David Puder?

  Okay, so, so let's say they, they believe that they um did this, to this horrible thing of the past, right? And so now they, they're saying to themselves, I know I, I am this type of person, right? That would, that would harm, let's say harm women, like I am a person that would specifically do this malevolence towards women. Okay. So now they're saying that that's true. What if they have a, like a self-concept now that's like, kind of, it's hard for them to hold that. Like it's, it's, you know, it's like their idea of themself doesn't have the.

• 23:37Speaker 01

  See, one of, one of the hallmarks of OCD again is that these thoughts are what, what we, the person recognizes that this is not them, deep down. In other words, one of the, the term that they usually use, a technical term is that, that the thoughts are ego alien rather than ego syntonic, meaning that the person says, this is, this is not who I am, which is why it's even more disturbing because it, it makes the person even more puzzled as to why they're getting the thought to begin with. Which which is, you know, what's even scarier, basically. So I've I've in all the years I've been doing this, and I've been doing this for a long time now. I have not seen that happen with people, but I have seen people lose their fears as a result of staying with it.

• 24:20Speaker 01

  It is this is Zen saying I always like, which is that facing what you fear is a way of getting closer to the truth. Problem is, people never stay with these things long enough to observe what really happens. They're too busy escaping. So so what happens ultimately, if they stay with it, the thought, you know, it persists. But then after a while, it kind of peaks off and then tends to subside. And then the person says, wow, you know, if I just stay with this, it's going to get better. If I take the the initial discomfort, there'll be less discomfort for me down the road. But I have to, you know, wait patiently for that to happen.

• 24:57David Puder?

  Okay, so like, let's say, um.

• 25:01David Puder?

  Oh, wow, okay. So it's like you haven't really seen people. I I think you both say if you bring it on too quickly, the person will leave treatment. But also, um, there's a progression in sort of like, um, progressing towards like this idea of like, you know, try to agree with all obsessions. So like, let's say the obsession is like, I think I may have murdered someone.

• 25:30David Puder?

  You know, like, and that so would the what would be the progression to to agree with that?

• 25:36Speaker 01

  Uh, again, you know, that there are murderers among us and, uh, you know, anybody under the right circumstances could commit murder and, uh, maybe I actually am capable of that. And maybe I did do it and and then we move to I I did do it. Or first I'm capable of it and then yeah, I probably did do it and then yeah, I really did do it, basically. And the interesting thing is, as I say, the further on we go, it becomes harder and harder to evoke anxiety in people. It takes more and more. And by the time we get to the end of the process, people say, how do you know when you're recovered?

• 26:18Speaker 01

  And I say, well, when we can't come up with any homework assignments to get your anxiety going anymore, when we can't bring on the anxiety, no matter what we do, then we say you recovered because the thoughts no longer have any impact on you. And you can let the thoughts be there and coexist with them without having to tie your life up trying to deal with them.

• 26:40David Puder?

  Okay, so let's say they're spending six to eight hours obsessing per day. Do you add homework on top of that six to eight hours?

• 26:50Speaker 01

  Well, first of all, the homework is going to give them something to do instead of just sitting there and obsessing. It's going to give them some, we're trying to give people tools, basically, as things that they can actually use to help themselves. And we try to treat it very comprehensively. We try to hit the OCD from many different directions. There are writing assignments, there are recordings they make and listen to, we watch videos online, we read articles, we go places that might evoke the thought and, you know, take part in activities that may bring on the thought. So we try to, I tell people, we're trying to surround it and hit it from all sides so that you're confronting this thing and you learn, again, that the answer is to face your fear and that you

• 27:34Speaker 01

  can't escape and avoid it, that that's impossible, that you're trying to do something that you'll never succeed at. So we're going to do something we can succeed at, basically. So that's essentially what we're trying to do. But we want to really, I tell people, the goal is zero compulsions, no compulsion, which is attainable. It really is. We can't, I don't promise zero obsessions. I know you're probably going to get thoughts. It's a chronic disorder and we can't just, you know, medication may lower the level of thoughts somewhat, but even that's not a cure. It can't stop the thoughts entirely as a rule. So, in fact, I tell people, the purpose of medication, and they usually ask me about it, is to help you to do the therapy.

• 28:16Speaker 01

  Because it gives you an assist in the therapy and the therapy is ultimately what really changes you at all.

• 28:22David Puder?

  Yeah, I talk to people about that as well. I think it's the same with like, yeah, social anxiety. It's like, maybe a little medication allows you to socialize, but then after socializing for a number of years, now you may not need this medication, right? Okay, so, so break this down. Specifically with the doubt, like what? And with the scrupulosity writing assignment, like, give me an example of like what that would be.

• 28:50Speaker 01

  Uh, well, well, first thing I do is I have people write, especially for directed sentences, 25 times a day. Like, you know, I could murder somebody. For instance, write that 25 times per day. And, and it sounds kind of simple minded, but a lot of my patients tell me that's one of the most effective assignments, interestingly enough. Then we ultimately move on later in the therapy to having the person themselves write their own worst thought of the day 25 times. I let them decide what the worst thought is. And, and in addition, I give them directed topics to write two-page compositions on and then record them into their phone and listen to them six times per day as a rule.

• 29:30David Puder?

  Okay, and the compositions are like, what, well, give me, give me an example.

• 29:35Speaker 01

  Oh, you know, how

• 29:36David Puder?

  Two minutes.

• 29:37Speaker 01

  Like, like, one kind of composition might be, uh, uh, how I can't be sure that I didn't murder somebody, or what it was, what, why I really like killing people, or how I plan to commit my next murder, or, or things like that.

• 29:52David Puder?

  What if the FBI gets a hold of that, that, that plan to murder, you know?

• 29:57Speaker 01

  Well, so far, this never happens. So I, I, I feel the odds of that are, are rather small.

• 30:02David Puder?

  I'm seeing my doubt, my doubt's kicking in. I'm like, like

• 30:07Speaker 01

  Well, if somebody asks me, if a patient asks me, I say, I don't know, maybe they will. I tell them, don't, don't come to me for reassurance, because I'm not going to do that either. I'm not going, I'm not going to participate in compulsions with you.

• 30:18David Puder?

  Okay, so give me an example of like how they want you to reassure. And how therapists often reassure.

• 30:25Speaker 01

  Well, for one thing that, you know, they'll, sometimes they'll just ask about the treatment, say, oh, am I, am I really going to get better? Can I recover? Is there any hope for me? Uh, you know, things like that, or, or is the therapy really working? You know, stuff like that, uh, is one kind of reassurance. Another one is they'll, you know, they may ask me directly about the topics, you know, they say, well, you've heard everything I have to say. Do you think I did that thing, you know, whatever it was? And I'll say, I don't know, maybe you did.

• 30:51David Puder?

  Okay.

• 30:52Speaker 01

  I'll even say, yeah, you probably did do that. And, but you know, the funny thing is, instead of like freaking out, the person will just sort of look at me and smile.

• 31:00David Puder?

  Ah.

• 31:02Speaker 01

  They know exactly what they're doing and they know the answer they're gonna get, so.

• 31:06David Puder?

  Now, now, before you say that, do you, do you preemptively warn them like, hey, I'm not gonna reassure you because that's part of your compulsion?

• 31:13Speaker 01

  Yeah, that's part of our, our introduction, basically, is that I, I don't do compulsions with people. And that includes reassurance and, and in fact, I'll instruct family members to not reassure them either. If they, like, they're, they're not supposed to ask for reassurance, but if they slip, the family member is supposed to say, sorry, I'm, I, I'm not allowed to discuss that with you.

• 31:32David Puder?

  Okay, so the, the, um, so if this person has family, like, what, how do you, how do you engage the family to not reassure?

• 31:41Speaker 01

  Well, pretty much the same way I, I instruct the patients to not ask for reassurance. I explain, you know, how harmful this is and what enabling is. And if they really want their loved one to get better, uh, they're not gonna participate. I say, you know, if your loved one was a, uh, was an alcoholic, you wouldn't go out and buy a bottle of vodka for them. I said, so this is really kind of the equivalent of that. So we're not, you know, you, you, either, you know, like they say, either you're part of the solution or you're part of the problem.

• 32:09David Puder?

  Okay. Do you, do you meet with families? Like, do you, will you meet with the?

• 32:13Speaker 01

  If the patient agrees, yes.

• 32:14David Puder?

  Yeah.

• 32:15Speaker 01

  In fact, a lot of them want me to because they want, because the families often don't understand what's happening and they want me to explain. And that's usually a great relief, uh, to family members because, you know, I, I not only explain the nature of the disorder and why they're seeing what they're seeing, but also, uh, why the person has to do the therapy. Because, you know, most people aren't that acquainted with behavior therapy and, you know, they see the person doing these homework assignments. It may look pretty weird to them if they're not familiar with it. So I explain what they're going to see and what that's gonna be like and, uh, how they can help and also how they can hinder.

• 32:50David Puder?

  Okay, what are your go-to articles you have them read? Like, what is that about?

• 32:55Speaker 01

  Uh, well, on my website, I have several dozen articles about all different types of OCD. I started out many years ago writing like a series of articles on the nature and the treatment of different types of OCD, basically different topics you're likely to see. So by now, I've got quite a few. In fact, I just wrote one on, it's not on my website yet, but it's in the OC Foundation newsletter about obsessions about suicide and all, which nobody ever writes about and which really throws a lot of therapists off track.

• 33:27David Puder?

  Okay, so what is the obsession? What are they saying to you?

• 33:32Speaker 01

  Oh, the thought is, oh, I'm gonna kill myself, or maybe I really wanna kill myself. But they'll get like, almost like an urge, like saying, yeah, I'm gonna, I've gotta go kill myself right now. Or if they're cutting something with a knife, they say, how do I know I couldn't take this knife and cut my wrists? Or all kinds of, and then again, as with other obsessions, the person says, well, if I didn't wanna commit suicide, why am I thinking this? But they have no history of suicide, and they're horrified at the idea of it, and would never wanna commit suicide. But it's the idea that they can't stop thinking about it that really sends them, basically. So again, we have to teach them that, yeah, you're gonna get thoughts about killing yourself, and you're gonna have to learn to coexist with those thoughts, because we can't just simply shut them off. So that's what we do.

• 34:15David Puder?

  So let's say you have like a medical student who's having these obsessions during a rotation, and they're just like, I cannot focus. I cannot focus, Dr. Peter, help me. Help me figure out how to like, you know, like what? Do you have them sit with the doubt and sit with the uncertainty and not do the compulsion while they're on a rotation on life?

• 34:40Speaker 01

  Well, sure, because, you know, what can they do? You know, people have jobs, they have things they have to do. They can't just stop in the middle and do therapy. So, yeah, I mean, they can still, in their head, agree with things, even if they're in the middle of something else. And also, I tell them, I say, look, you know, we're not gonna get this under control overnight. This is a process. It's a retreat. Training, basically, and it takes time to retrain yourself because you trained yourself to do compulsions. Now we've got to train you to do the opposite. Basically, so, so, you know, I tell them, don't expect overnight improvement. I said, but if you take care of your daily goals with your homework, eventually it will, it will add up to something and, and the larger goals will be taken care of if you take care of the daily goals.

• 35:24David Puder?

  Okay, and what if, um, what if there's certain, you, you talked about going places that might evoke the thought?

• 35:32Speaker 01

  Yeah.

• 35:32David Puder?

  To what, what kind of places are we talking about?

• 35:35Speaker 01

  Uh, well, for instance, I, I have a patient who can't walk across bridges or walkways because they get the thought that they might want to jump off. Basically, and kill themselves. So we have them do just that. We have them walk across these things. Sometimes they can't do it all at once. Sometimes I'll have them just walk out a little way on the bridge of the walkway and then come back. But then each week, we try to go further and further. And, and ultimately they can, you know, go all the way across the back and then they learn, okay, I can think this thought, but I'm not necessarily going to do anything about it. But they have, you can't just tell them that. They have to see it with their own eyes. Basically, they have to learn through experience and this is how you overcome any fear. Like we said, you have to face it. If you, if you look at anyone

• 36:18Speaker 01

  that ever overcame a fear of anything, okay, you'll see that they did it through facing that fear one way or another. But they could, they couldn't run away from it.

• 36:28David Puder?

  What, what if you had a patient, like say they had OCD at baseline, they've had like hand washing in the past and then something traumatic happens, right? And then the, the obsessions get centered around the trauma in like a new way. Like, for example, let's say they were, um,

• 36:45David Puder?

  they, they were sexually assaulted. And so now, anything around sexual assault, anything in the news on sexual assault, any people, any of that brings up this kind of like idea in their mind that like, oh, I may be sexually assaulted in the future. Right? It seems like a trauma, but it has like a very obsessional component with their compulsions. Now they have new compulsions of going back. Going back to memories where they maybe were walking in places, trying to remember, like, were they sexually assaulted during that time? And so forth, like, how would, how would you approach that? Because you have both OCD and the trauma, right? Mixed.

• 37:24Speaker 01

  Yeah, yeah. Well, sometimes you have to make a judgment call as to, you know, what you want to work on first. You can't do everything at once. Clearly, I mean, that would be, you know, there's not enough hours in the day or, or enough homework you can give someone to do it all at the same time. If, if the PTSD was bad enough, you'd go for that first, basically, so that the person could then settle down and do the behavior therapy. But, but interestingly enough, exposure therapy is also an approach to treating PTSD, and I have used it on quite a number of occasions. And, and in there, we actually have people make recordings of the event and listen to them and, and listen to them daily.

• 38:06Speaker 01

  And then each week, we revise them in terms of, as they're listening to these during the week, they usually remember more memories and more sense experiences and things like that. And then we keep building that into the next recording. And we keep going and we keep going. And, and people start out, you know, being upset at first when they listen to these things. But it's very interesting, because as the weeks progress, the person, you watch them actually responding with less and less upset as they listen to the recordings. And finally, you know, they, it, it seems to aid into putting these, these experiences back into, like, long-term memory storage, you might say, instead of being at the front of their, their thought process. And, and when that's more under control, then I would say, you know, you'd have a very good chance of then working on the OCD.

• 38:51Speaker 01

  But, and, and with, along with PTSD, you know, parts of PTSD, sometimes we also, again, as in OCD, we have people go places and do things that evoke, you know, later on in the therapy, we don't do that right at the beginning, but, you know, that evoke, you know, again, thoughts of, of whatever the incident was, and, and confront it in some way, and, and that actually helps.

• 39:13David Puder?

  Okay, so I hear you kind of, you're doing this recording, composition things. Are you doing that with them? Are you recording it in session?

• 39:21Speaker 01

  Yeah, I give them the topic and then they write, it's two pages usually because that works out to a a two-minute recording, which is what I've learned seems to be pretty effective. So, so we have them write it, so I mean, I'll, I'll have them bring it in and play it for me. And listen, if I think it's good, I'll tell them if I think it needs amending or it needs additions or things like that, I'll tell them that also. But, you know, I tell them, I say, this is part of learning to be your own therapist, basically, because ultimately, you know, you're not going to be in therapy forever and eventually you're going to be out there on your own and you have to be able to handle these things yourself and use the tools that you learned in therapy. You have to, like I said, you have to be your own therapist because I like to say the getting

• 40:04Speaker 01

  well is 50% of the job and staying well is the other 50%. So you better have those tools and use those tools on an ongoing basis since we don't have to cure OCD at this point in time, it's chronic.

• 40:18David Puder?

  So, okay, so do you find that people with OCD, they have to continually kind of change the way that they, what they're recording, based on like new levels of obsessions and compulsions that pops up throughout their life?

• 40:34Speaker 01

  Oh, absolutely. In other words, if a recording, I tell them to listen to recording until, over the course of several days, it's really boring, basically, because I say you can't be bored and scared at the same time, essentially. So then we have them upgrade the recording to a new level and we keep doing it. Eventually, we may reach a level where the person says, you know what, I can't, there's nothing I can make up as a recording that's worse than what I've already done. And we know that we've pretty much exhausted the topic and usually at that point, it really doesn't bother them very much at all. So that's what we're aiming for here. We're trying to, I tell, I say, we're trying to make you obsession-proof, basically.

• 41:13David Puder?

  So, so there, so the, okay, with the moral scrupulosity, for example, so what you're saying is that they'll have new kind of obsessions that are even worse.

• 41:23David Puder?

  And you have them kind of integrate that into new recordings?

• 41:26Speaker 01

  Sure, you, you can't ignore them. So yeah, you have to work on, on whatever comes along. I, in fact, when it, when it comes to obsessions, I tell them to always expect the unexpected, because you never know what new obsession might be around the corner. So you, since you can't prepare for every obsession, you have to prepare your tools, basically. And, and all, all OCD is basically treated the same way. So we don't, you know, different themes are not generally treated with different therapies. The same principles apply to all OCD. So that, that's what I teach them. And I say, if you understand the principles and you know how to use the tools that are in line with those principles, you're going to do very well. You're going to, like I said, you're going to be your own therapist.

• 42:08David Puder?

  Okay, like, let's say, let's say you had a patient who had this obsession that something bad was going to happen to their son. Okay. And maybe their son had some illness, but he imagined it would get worse and worse and worse. And

• 42:21Speaker 01

  Right.

• 42:22David Puder?

  his son would end up dead. So walk me through what that would look like with this kind of like agreeing with the obsession?

• 42:31Speaker 01

  Well, we, we talk about, you know, people, you know, how some people have particularly serious illnesses and then some people, you know, that could really damage them. Then we have, we move on to some people have fatal illnesses. And then we say, maybe your son has a serious illness and maybe your son has a fatal illness and, and definitely has a fatal illness. Your son's going to die. There's nothing you can do to save him, blah, blah, blah. You know, we, we go the distance. We try to come up with the ultimate confrontation here, basically. And when a person can tolerate that, you know, what, what else can OCD do to them, basically? When a person can face the worst of the worst without getting anxious and, and being able to say, okay, like, you know,

• 43:14Speaker 01

  I can be with that thought, but I don't have to do anything. Then they're, they're good, basically. Now they're managing it. It's not managing them.

• 43:24David Puder?

  Okay, and so when you, when you talk about the progression, like, how long do you start with this idea of some people have a particular illness that may damage them?

• 43:35Speaker 01

  You know, it varies with, it varies with the patient, basically, and their reaction to it. If, at the, like, I'll have them listen to something, say, for a week, and they come in and I'll say, "Well, when you listen to this, does it still bring up any anxiety?" And, and they'll say, either they'll say, "No, I'm pretty bored with it, I don't care, I'm ready for a new," they'll even tell me, they say, "I'm ready for a new recording." They do, they, you know, because they want to get better. But, but otherwise, or they'll say, "No, I think, I want to stick with this one for a while, because I think there's still something in it, and I, I feel like I need to work with this some more before I move to the next one."

• 44:09David Puder?

  Okay, so, okay, so then, what is the, the two-minute write-up in this scenario? What would they be writing up? Like, what would, what would they be telling the story of?

• 44:20Speaker 01

  It depends, it depends on the thought, basically, you know? I, I let them determine it, because they're, they're more familiar with what's going on in their head than I am, basically. They know what, I, I say, "You, the OCD gives you all the material you need to make this recording, just use what it's telling you."

• 44:34David Puder?

  Do, do you think this would work in someone who doesn't have OCD, who just has maybe anxiety?

• 44:40Speaker 01

  Uh, possibly, possibly. Uh, you know, it depends, you know, whether they're just a generally anxious person, or they're anxious about something specific.

• 44:49David Puder?

  Well, let's say it was specific. Let's say this person with their, with their kid, maybe they're not OCD, but they have this deep fear that...

• 44:57Speaker 01

  Yeah, I think, I think it would work, I believe it would work.

• 45:01Speaker 01

  I, I, in fact, I sometimes use this with people with other type, like, even in, like, I've done it with people with fears of public speaking, or, or social anxiety, or, or even with phobias and things like that, so, so, yeah.

• 45:16Speaker 01

  Yeah, I, I, I think it would, it would work, because, again, you, like we said, you know, facing what you fear is a way of getting closer to the truth. You, you, again, you, you, you wear these things out, you, the person just gets tired of hearing it, you know? It's, it's like, they say, "Oh, you know, enough, enough already, I've, I've, I've heard it, you know." A psychologist friend of mine put it very well, he said, "The treatment," he says, "is like watching a horror movie a thousand times."

• 45:42David Puder?

  Hmm.

• 45:44Speaker 01

  Which I think is, you know, it's kind of a, a good, uh, image for that, basically.

• 45:51David Puder?

  So you have them like, okay, so you have them like, say that the obsession is true, that this will definitely happen.

• 45:58Speaker 01

  Yeah.

• 45:59David Puder?

  And then you have them record a two minute, sort of like, story of that happening.

• 46:05Speaker 01

  Yes.

• 46:06David Puder?

  And then maybe over time, that story changes and you have them re-listen to it until they're like, I'm listening to this thing and I'm, I'm really bored and I, I just don't want to do it anymore. It's just really boring. Is that the goal?

• 46:22Speaker 01

  Or if there's still parts of it left, we'll, we'll make another recording.

• 46:27Speaker 01

  You know, an even worse one, if we can. If we can't, that also tells us something. That's kind of diagnostic in a way, because now we know we've gone the distance with that particular thought.

• 46:37David Puder?

  Okay.

• 46:40David Puder?

  And I guess I'm like, still confused, like, if the person is confused on if it is true or not, and it really does change their perception of themself, right? Like, if, if they did hurt someone, maybe they did hurt someone a little bit, or that maybe they could have hurt someone, but they didn't hurt them. Or, you know, like, but they're, if, if they assume that they hurt the person, like, that makes them out to be a bad person. So is, and that labeling of themself as like, a bad person, like, is, is that something that they're labeling?

• 47:11Speaker 01

  Um, well, only, they would only assume that that's so if they could verify that, that what happened really happened. But it's, it's always a matter of doubt. Remember, we're talking about the doubting disease. I mean, if a, if a person has like, you know, all kinds of outlandish thoughts that they hundred percent believe, now we're talking about a delusion. We're not talking about an obsession anymore. An obsession is, is a doubtful, repetitive, negative, intrusive thought, basically. So if it, if it meets those criteria, then I, I, as I say, I've been doing this for, you know, four, more than four decades now, and I've never seen it change anybody's perception of themselves. In fact, if they really believed they were bad, they probably wouldn't be struggling against the thought. They'd just say, okay, well, I'm bad. That's me. That's, that's,

• 47:55Speaker 01

  I accept that, you know, that's who I am. But, but it's not, that's why they're going to these lengths to, to prove that it didn't happen, because they don't think that that's them. It's, it's, as we said, it's like ego alien, if you want to use that, that term, basically, that old psychoanalytic term, that it's, it's not. It's not native to them. It's not who they are. Uh, it's like, in fact, a lot of people say, you know, it just came to my head one day. I don't know where it came from. It just started or sometimes it's not even the result of something that happened. So, so, uh, eh, no, I've never, again, eh, you know, I've heard people bring this possibility up before, but, you know, people, in fact, eh, when people first start therapy, they'll say, well,

• 48:39Speaker 01

  isn't this going to convince me that I'm that person? Or I, and that I'm a really bad person. And I say, you know, and I tell them, I say to me, I said, I said, yeah, I'll reassure you about this. I won't reassure you again because I'm not in the reassurance business, but no, it's, it's gonna, it's gonna have the opposite effect. And, and you're, you're eventually going to get tired of hearing it. So, so it doesn't, it doesn't, um, it doesn't seem to work that way. I mean, I've never, believe me, I, if I, if I saw that happen, I would have abandoned the, the approach years ago. But, but eh, eh, people get better. They don't get, they don't get worse. And, and eventually people will say, you know, I, I, in fact, I'll give you a good example. I had a guy who had, uh, thoughts about murdering his, his girlfriend.

• 49:24Speaker 01

  And we, we did everything to confront the idea, yeah, you're gonna kill her. We actually had, uh, she was in on it too. She knew what his thoughts were because he had told her and she was very understanding. So we actually have her take part in homework. He would sit next to her while they're watching TV, holding a big knife uh, in his hand and, and for part of her, she had homework to say to him, please don't kill me.

• 49:44David Puder?

  Oh. And, and what, and what would he say? Would he say to her, I'm gonna kill you?

• 49:50Speaker 01

  Um, not so much. Well, I didn't, I didn't really do that so much, but I had him, you know, holding and using implements that he could have used to kill her around her and in situation. But the interesting point of all this is that when we got to the end of the therapy, he said, you know, he said, you have given me every opportunity to kill my girlfriend that if I really wanted, if I was really gonna do it, I would have done it. He said, but I, I've approached this ev- every possible way. He said, and he said, I see now that, you know, it was just an obsessive thought and I'm, I'm not gonna do it. So, so he was able to it's pretty much live with the thought. Eh, you know, even if he still had the thought, he could say, well, you know, I tested this out fully and, uh, I'm just not gonna do it. So that, that was the convincer for him.

• 50:37David Puder?

  How would you, like, what if this was like a very passive guy who has kind of like a difficulty in being in touch with his anger? And he'd kind of disavowed his anger towards his girlfriend, you know, that he had, and it was coming out with these kind of extreme thoughts? Like, is there, in your mind, kind of a more, you know? Yeah, is that, this is, this is obviously a different problem than what we're talking about, but I could see you kind of see more of the OCD. I may see more of people who have like a hard time being in touch with their anger at times, too.

• 51:12Speaker 01

  Well, for the purposes of OCD treatment, I would say, yeah, you know, you are angry and you are containing this anger and eventually you're gonna let it out, eventually you're gonna kill this person and do all kinds of other awful things. I've had people who even had worse thoughts where they thought they were potential mass murderers and all, and we work on that. I have them, you know, read biographies of mass murderers and watch videos about them and read stories and, you know, tell them how they're gonna be. I have them do compositions and recordings on how they plan to become mass murderers and how they're gonna carry out their killings. And all, I mean, we hit every aspect of this, and by the time we get to the end of it,

• 51:54Speaker 01

  they're just like, okay, you know, I've had enough with mass murderers already, I'm tired of hearing this.

• 52:00David Puder?

  So by the end of it, they're not, they're not the Columbine kids that you were treating before?

• 52:08Speaker 01

  Yeah, yeah. You really see like a transformation in these folks. I mean, and I'll tell you another thing, which is that I don't just, it's not as simplistic as just trying to change people's behavior. I tell people, I say, along with changing your behavior, you have to change your beliefs, you have to change your, I call it your philosophy of things, the view that you take of things. And I say, it's your beliefs about uncertainty, your beliefs about risk in life, your beliefs about anxiety and internal experiences like that. And we work on changing that along the way, too. We don't just, it's not just as simple as behavior change, because if you change your Behavior, but you're still thinking the same ways. You could easily slip back into symptoms again. So I say, if you really want to stay well.

• 52:53Speaker 01

  You you have to regard these topics i- in a whole different way than you have. Before and and so we we work on that as well. So I I don't want to make it sound like it's all behavioral. It's there's cognitive aspects. To it also where we challenge the person's beliefs about uh. This comfort and about anxiety and about uh uncertainty in life. And and get them, you know, again, it's like the the twelve step thing where you you change what you can change. And you accept what you can't change. Basically, and that that's what we try to work toward.

• 53:23David Puder?

  Okay, so yeah, break that down a little bit more like the um. Like, let's say someone says, well, but in most areas of life, I am very certain.

• 53:34David Puder?

  And and so why I why can't I be certain about this as well?

• 53:38Speaker 01

  Well, I I explained to the number one, nobody can predict the future, no matter how certain they think they are. And number two, I say, we we can't even predict what's going to happen five minutes from now. In life. So how can how can you, you know, this kind of statement is illogical. Uh, basically, you know, you may think. That everything's certain, but you know, things can happen uh. In in a blink of an eye that change everything. It could be uh. Sitting at a stoplight in your car and somebody rams into you uh. With with their car and now you're like a you're physically disabled and and damaged. Person. I mean, how could you have foreseen that, for instance, or or becoming ill with. You know, some kind of physical illness that you couldn't foresee. And also I say, there's no. There's no certainty. In fact, my favorite Zen author, she says, if if you're looking for certainty, you're you're on the wrong planet.

• 54:21Speaker 01

  You know, and I I agree with that. I I don't think there is very much certainty. We can. Make kind of rough predictions or educated guesses. But we we can't be absolutely certain about anything. Life, I've been around a while now. Life life has taught me. That that you you just can't anticipate everything that could possibly. Happen in like good or bad. Basically.

• 54:42David Puder?

  Have you have you seen uncertainty as well in like domains of like relationships like I'm uncertain that my boyfriend loves me type of thing?

• 54:49Speaker 01

  Oh, oh, yeah, that can be a big one in OCD too. And, and, you know, again, what I explain to people is, is again, it's on a philosophical level is that you life doesn't, the universe is not set up to give us everything we want. And then you can't, there are no written guarantees in life, no matter what you do, or no matter what you undertake, there's no certainty that it's going to work out, or that you're going to get what you want. We go out there, we, we try our best, we're all imperfect human beings, we do the best we can. And then whatever happens, happens. And, and, you know, more than that, you can't really ask for. But, but I tell people, if you want, if you want a written guarantee, forget it, life's not going to give you that. There's no such thing.

• 55:31David Puder?

  And then what about the, like, you know, this kind of idea of expecting discomfort? What if, how could you challenge their idea that they should be comfortable, or they should not have any anxiety, or?

• 55:44Speaker 01

  Well, I try to, I try to point out that there's this basic flaw in their, in their beliefs, basically, that they have this, you know, and I like Zen a lot, because it teaches good things. But one thing that it teaches is not to make demands, basically. And what these people, one of the things they're demanding, they're saying is that things that I don't like in life shouldn't exist, or things that I find disagreeable shouldn't happen to me. And I say, that's an illogical statement, because you can't control those things, and you can't guarantee them, you know, whatever happens, happens. And, you know, like it or not, you know, your, your goal is to be flexible enough and adaptable enough to be able to deal with whatever comes your way in life, because life is, is like that. The financier Malcolm Forbes, I always liked something he said,

• 56:28Speaker 01

  he said that just getting, and he was a big risk taker as an investor, but he, he had this saying, he said, just getting out of bed in the morning is taking a risk. So, so, you know, I think people just have to accept that everything is risky. If you start a relationship, you're risking that it may not work. Or if you take a new job, you're taking the risk that maybe you won't like it, or it won't sue you, or anything like that, basically, you know, it's, it's just the nature of life.

• 56:53David Puder?

  Have you seen people come in and have a fear of being sued? Is that?

• 57:00David Puder?

  Like in a new job or something, or a new situation, is that, is that ever part of the obsession?

• 57:05Speaker 01

  Not, not so much a big one, really. I haven't, I haven't encountered, I gotta be honest, I haven't encountered that one. That much, usually it's things that are much worse, like going to jail, or going to hell, or, or being murdered, or, you know, all kinds of things like that, like really severe things, not, in fact, even my attorney patients don't seem to worry about that.

• 57:26David Puder?

  I have, I have one attorney patient, and he has a frequent fear of, you know, being taken to court, or his board license being removed.

• 57:36Speaker 01

  Yeah, we say, well, yeah, you know what, sometimes that happens to people. And, and like we said, expect the unexpected. I mean, life, that is the nature of, of life. And in fact, I mean, you know, it is unpredictable. So we, we just go from day to day, moment to moment, and hope for the best, do the best we can, do our due diligence, and, you know, we hope things work out. If they don't, then okay, we try to, like I said, adapt and, and deal with it as best we can. But that, that's all we as human beings can do. There are limits.

• 58:08David Puder?

  Okay, so like, let's, let's talk a little bit about sitting in the doubt. Like, what, what are you, when they're sitting in the doubt, one thing that I've done to try to get them away from obsessing about the thoughts of how to sit in the doubt, is just sit in the bodily sensations of the doubt? And I'm wondering if this has been helpful for you as well?

• 58:26Speaker 01

  Well, people do get a lot of physical sensations that are often accompanied with anxiety, and we have them learn to tolerate those too. I have, in fact, I have a patient who gets like these dissociative episodes, and, and part of her treatment is to, to, just like we do in panic disorder, basically, we get the person to stay with the physical sensations and learn that, you know, I tell the person, I say, you're confusing. And you're confusing discomfort with danger, basically, like anxiety is uncomfortable, but it's not dangerous. It can only, it's adrenaline in your bloodstream, basically. And I try to explain the physiology of it to them and explain, you know, that's what's actually happening and, and, you know, that it's a normal, hardwired experience that

• 59:11Speaker 01

  evolution has equipped us with. They said, you know, you, you want to be able to get anxious about something because that evolution has equipped us with that to help keep us alive, you know, to run away from danger or to fight if need be at all, the, the fight or flight response. So, so we come equipped like that. There's no way, we can't shut that down, basically. But if you start getting anxious about being anxious, you're only going to make yourself more anxious. You're not going to get less anxious. So it's learning to accept anxiety along with other things that, that happen in your life, things that you can't, you can't eradicate that you're going to feel anxiety. So you have to learn to tolerate it. I mean, what choice do you have?

• 59:45David Puder?

  So let's say they start like obsessing about how their anxiety is going to eventually lead to them.

• 59:52Speaker 01

  Oh, so we, you know, dying. We say, yeah, that's what's going to happen. It's true.

• 1:00:00David Puder?

  But then they said, but you just told me that it, um, it didn't, it won't happen.

• 1:00:04Speaker 01

  Right. Now, now you're looking for reassurance. So don't do that. Just agree with the thought.

• 1:00:09David Puder?

  That's good. You're like, it's-

• 1:00:11Speaker 01

  This is not a democracy. You have to do what I say. And if I say you have to do that, that's what you have to do because that's what's going to get you better.

• 1:00:17David Puder?

  Okay. And they say, well, I doubt that you have the knowledge to get me better at this point.

• 1:00:24Speaker 01

  Right. And I say, well, I say, who, sometimes I, I will try to give them a little objectivity and say, well, who do you think's telling you that? And then often they'll say, yeah, it's my OCD, you know? I mean, it's, it's, you know, because as I say, I explained at the beginning of treatment that it's going to give them doubts about the therapy, about me, about their ability to get well. So, so it's, it's going to fight its own treatment. And in fact, for some people, that's the main part of their OCD.

• 1:00:50David Puder?

  So the one thing you don't have them say and assume that it's true is that you're incompetent? You don't allow them that obsession?

• 1:00:56Speaker 01

  Oh, no, they're obsessing about that. No, I'll say, yeah, right. Dr. Fenzel doesn't know what he's talking about. I'll have them do recordings about that. He's, he's informed. He doesn't, he, he, he's misdiagnosed me. I don't really have OCD. I'm getting the wrong treatment, et cetera.

• 1:01:10David Puder?

  Okay. That's good. I like that.

• 1:01:12Speaker 01

  The trick is you go toward the anxiety, never away from it. I always tell them what we're trying to achieve here is the opposite of avoidance.

• 1:01:20David Puder?

  So, so when a, when a patient under those circumstances writes down 25 times a day, Dr. Fred Penzel is an incompetent therapist.

• 1:01:29Speaker 01

  Right.

• 1:01:29David Puder?

  And they bring, and they bring you those sheets of hundreds of writings. You don't get offended?

• 1:01:34Speaker 01

  Uh, not at all. Number one, I know why I'm doing what I'm doing. So it's not like, it's not like a personal thing. But secondly, actually, I don't make them bring this stuff in. If they tell me they've done it, I, I trust them. Cause I say, if you don't do the homework, then the only one that's going to have a negative effect on is you, not me. So you're, you're not going to get well. So I, I trust everybody.

• 1:01:53David Puder?

  Let's talk about like comorbid issues and how that complicates it. Like, let's say they have like bipolar and OCD. I think there's a genetic link there. Have you seen a lot of patients with the combination of those things?

• 1:02:03Speaker 01

  I've seen some. Yeah. Usually I, I refer, if they're not under treatment for that, I'll refer them to a good psychiatrist to, to get the bipolar under control first, because if that's not under good control, that could really interfere with the therapy in a, in a major way. So, so, and, and most people who have bipolar who come to me have already been treated for it. And that, that part's doing okay, but it's the OCD now that's, that's really causing them problems.

• 1:02:32David Puder?

  How about like personality disorders and OCD? Do you, do you, is that something you're seeing often? Or is that something that you've?

• 1:02:40Speaker 01

  That's, that's a really, it's a really interesting topic, you know? I, I have my own views on that, which some people.

• 1:02:46David Puder?

  I want to hear your views. You can have different views. It's fine.

• 1:02:48Speaker 01

  Um, yeah. My, my view is that I believe, well, first of all, nobody can really truly define what a personality is. One of, one of my old professors used to say that personality is what personality tests measure. So, so.

• 1:03:01David Puder?

  Yeah. That's right.

• 1:03:03Speaker 01

  I, I, and again, I, I don't treat personality disorders, quote unquote. I, I have questions about some of them. For instance, uh, uh, obsessive, uh, or, you know, uh,

• 1:03:14David Puder?

  Obsessive compulsive personality disorder.

• 1:03:16Speaker 01

  Personality disorder, I do not believe is a real entity. I believe that it's something that they, they, they took people who were just kind of perfectionistic and pathologized them. Basically, they turned it into a disorder. And, and I think now there are some people who are very perfectionistic and, uh, very definite about the way they want things and, uh, they're, they're, they're not unhappy being the way they are. And, and they like, they get satisfaction from being it. So for us to, you know, like, you, you know, homosexuality used to be classified as a disorder and now not so. But I think that these people also have been tagged unfairly, uh, with a label that, that is really unjustified. And I, I, I think that, yeah, there are perfectionistic people in this world. There's like a whole

• 1:03:58Speaker 01

  spectrum of, of, of people from, uh, you know, people who are completely lackadaisical, who are over perfectionistic. But I, I don't think it's a pathology. I don't think it's a disorder and that we should be trying to cure them.

• 1:04:11David Puder?

  Right. How about, um, how about like borderline paralysis disorder and OCD? Is that?

• 1:04:17Speaker 01

  Well, you know, again, I, I, I think there's something there. I, you know, if, if I, generally speaking, if I have someone who's having trouble regulating their emotions, and I don't know if that by itself would, would constitute borderline personality disorder, but I will send them for DBT, uh, treatment. Because I, I don't, again, I don't specialize that. I know my limitations and I, I, I treat what I treat. But I, I would, I know people who are, you know, more expert in that and I would send, I would refer these people for DBT treatment.

• 1:04:49David Puder?

  Hmm. What about, um, like schizophrenia and OCD?

• 1:04:54Speaker 01

  Uh, I've treated people with schizophrenia and OCD, but as I say, like, like the bipolar people, generally their, their schizophrenia has to be under, you know, good control before I can really treat them. I mean, if somebody's sitting in my office actively hallucinating, we're not going to get very far in treatment. And I really feel for these people because they really suffer. Uh, but I, I, uh, I would, you know, again, make sure that their schizophrenia was being properly medicated and that, that, you know, the thoughts were, uh, under good control. And then we could certainly work on the OCD. And, and we do. And, and I've, I've had success with, with these folks.

• 1:05:30David Puder?

  Great, great. What about eating disorders and OCD? Is there any time where it's more OCD than eating disorder in your mind?

• 1:05:40Speaker 01

  I believe that eating disorder, well, first of all, you know, a related disorder to OCD, which may be sort of a variant on OCD is body dysmorphia or body dysmorphic disorder, BDD. And I believe that eating disorders, generally speaking, are a subgroup of body dysmorphic disorder. Basically, the person sees an overweight or fat person and no matter what, even if they're skin and bones, so it's like a, you know, it's like a misperception, basically. But I mean, it's such a severe misperception that they'll, they'll actually starve themselves to death. I mean, about 25% of anorexics die. So, so we see how severe this is. But it's, it's a very, they have a very high degree of belief in their thoughts.

• 1:06:25Speaker 01

  Like people with BDD often do, basically. So I do not consider myself an eating disorder specialist. I think some of these folks actually need more controlled environment, need to be more of an inpatient program where they can, they can relearn how to eat and at the same time get a treatment for, you know, medication and therapy as well. So, so, you know, I believe they're treatable, but the thing is you can't treat everything. And I leave that kind of treatment to people who are more special in order programs that that particularly focus on eating disorders. But as I do, as I say, I do see them as like a subgroup of body dysmorphic disorder.

• 1:07:06David Puder?

  Okay, so with the body dysmorphic disorder, like let's say their obsession is around that their, you know, nose is unattractive, that they're, you know, so are you, are you having them say to themselves that this is true?

• 1:07:20Speaker 01

  We work up to that, sure. And along with, you know, and I believe medication is very important with these people because their degree of belief can often be much higher than you even see in people with OCD, that it's, it's really... You know, it's really up there, uh, basically. It's near, near delusional in some people. Almost not quite, but, but, but way up there. So yeah, we do the same treatment, but with that kind of, of disorder, you're going to be in for a bit of a longer haul with that and, and going to have to be much more patient. And the person themselves is going to have to be much more patient. Uh, sometimes, uh, you know, they, they have to convince themselves first they've exhausted other remedies by trying to fix whatever the thing is themselves,

• 1:08:02Speaker 01

  or go for surgery, or dental work, or all kinds of things, and, and have not found any results. And then sometimes they'll, they'll go for therapy. Uh, but that's usually not their first choice. Their first choice is to fix whatever they think is wrong with their appearance.

• 1:08:16David Puder?

  Do you see it as a doubting disease of sorts? Is that?

• 1:08:19Speaker 01

  Um, yeah, but, but, but again, as I say, the degree of belief is so high that, that, uh, it's, it's almost at the outer edges of doubt, you might say.

• 1:08:31David Puder?

  Okay. So is it like a delusio- there's a delusional character?

• 1:08:35Speaker 01

  Almost, not quite. If it was delusional, then we're talking about, you know, again, a thought disorder. Uh, but, but this is more like OCD, but again, it's very, the very person very strongly believe they'll argue with you that, that they don't have what, uh, what they say they have. They, they have what they say they have and that you're wrong. And all they'll give you all kinds of evidence, uh, for why they're, they're pretty sure it's true. I, I would say, you know, they're, maybe they're like 95% certain that it's, it's so.

• 1:09:06David Puder?

  What about trichotillomania? Is that, I, I know you treat that. I know you've written about that, um, briefly. Like what, is that a doubting type of disease as well?

• 1:09:15Speaker 01

  Uh, no, not really. It's, it's, it's part of a group of what we call body-focused repetitive behaviors or BFRBs. And, and we think that these are more, um, There's a lot of inputs into them. There can be thought input, you know, that like a person say, well, certain kinds of hairs have to be pulled. There's like a kind of perfectionism to some people's pulling, like the hair is in the wrong place and has to be pulled out, or it has the wrong texture, or the wrong feel to it, or it's the wrong color, things like that. But then there's also a big, for many people, it's a big sensory component also. And it's really, you have to treat this very comprehensively, because there's many inputs. It's much, it's a

• 1:09:58Speaker 01

  much more complicated than they appear. There can be cognitive elements, there can be sensory elements, there can be emotional elements, environmental inputs. There's a whole range of things that you have to take into account when you're designing a treatment for someone. And these things can exist in different proportions to each other. Some people's more sensory, other people's more cognitive, you know, and so it's not a one size fits all treatment. It's a treatment that has to be tailored to each person, basically. And that's true of excoriation disorder, you know, what they call skin picking, you know, things like that. So, you know, it's a, it's a real specialty, and it really, it takes a really deep understanding

• 1:10:41Speaker 01

  of these problems, rather than saying, well, it's just a bad habit, you know. That's what a lot of, it gets tagged as that a lot, unfortunately. But it can, it can be quite excruciating.

• 1:10:52David Puder?

  Absolutely, yeah. How about skin picking? Is that kind of lumped in that same category?

• 1:10:56Speaker 01

  That sort of, yeah, same, same approach, same sort of categorization. And the interesting thing is, you see these behaviors in animals also.

• 1:11:05David Puder?

  Oh, yeah. My cat, my cat does that.

• 1:11:08Speaker 01

  Yeah, it's called feline alopecia. It's called where they, the skin, not skin, the fur off their backs. Basically, dogs have something called canine acrolick, where they lick the fur off their paws. Horses do, I ride horses, so I'm around horses quite a bit. Horses have repetitive behaviors like that. They call flank biting. They'll pull out, you know, their own fur, basically. So, so, yeah, these, it's, it's

• 1:11:39Speaker 01

  Animals obviously much simpler, there's not a really cognitive element to what animals are doing. But if they're usually kept from doing instinctive behaviors, like if they kept penned up or in restrictive circumstances, very often they're more likely to do that than if they they're allowed to, you know, more freedom and and the ability to carry out their their normal instinctive activities.

• 1:12:01David Puder?

  Hmm.

• 1:12:03David Puder?

  Okay, so coming back just once again to this, I want to get, make sure I get this idea correct in my mind about, so you have this, you have this obsession, like I could murder someone. And then the first sort of gradient of that is to maybe have them write it 25 days, 25 times a day, write that over and over again, but you're writing like a lesser degree of it, right?

• 1:12:25Speaker 01

  Yeah, that would only be, yeah, that would only be one assignment out of several.

• 1:12:30David Puder?

  There would be, yeah.

• 1:12:31Speaker 01

  We don't just give one assignment, we give like an array of things, so they're they're always working and and hitting it from different angles. Through different channels.

• 1:12:41David Puder?

  So the the um, the first, the first time when they're writing that out, many times, it's not, I could murder somebody, it would be less, less extreme, right?

• 1:12:52Speaker 01

  Yeah.

• 1:12:52David Puder?

  Like, there are some people that murder people?

• 1:12:54Speaker 01

  Yeah, yeah, we would start with something, you know, a little, a little bit provocative, but a little more on the neutral side. That doesn't, is not directly about them, more general.

• 1:13:05David Puder?

  Okay. And then the the story, the two-page composition, is that, let's say you start that, is that about them, or it's about in general, people murdering other?

• 1:13:16Speaker 01

  Uh, it would, again, it would probably be, we we work from the general to the specific.

• 1:13:21David Puder?

  Okay. Yeah, let's get general to specific, yeah. And then, so there's articles that you would have them read as well, and maybe videos?

• 1:13:29Speaker 01

  Absolutely.

• 1:13:31David Puder?

  And so you surround them from like all different sides with these different modalities. Are there other ones that you haven't talked about that you often do?

• 1:13:39Speaker 01

  Again, you know, as I say, we go, we go places, we do activities, we say things, we carry out actions, we, we write, we listen. Uh, you know, it could be, again, you know, there's, there's no one size fits all for OCD. So it has to be, you know, tailored to that person, basically, and, and their specific OCD and what they need. Uh, essentially, so, so like the, the same principles are at work in each people's treatment. But the balance of what they do might look different from one person to the next.

• 1:14:10David Puder?

  Yeah, very cool. That makes sense. Well, as you think about OCD and what we've talked about today, are there other things that you, we haven't touched upon that you feel like you'd wanna sort of impart to my audience before we wrap it up?

• 1:14:23Speaker 01

  Uh, no, I think we've hit a lot of the, the main points here of all this. Uh, you know, the, the, my, my main message always is just that OCD, as opposed to some other kinds of, of issues, is treatable. There's always hope for people if they're, you know, willing to do the work and, and get the right kind of, uh, treatment. And, and I think that that's, you know, always people want to know that because they need the hope, basically. And, and, uh, they need that to motivate themselves, the, the belief that, yes, I can do this, I can get better. And all, and I always try to make that clear, even from the first session with my patients. I say, you know, of all the things that you could have, this is something you really can recover from. So, and if you just, if you just do the work, you know, then you're gonna get the results.

• 1:15:07David Puder?

  So you're not, you're, you're not sitting in the doubt from session one with them like?

• 1:15:12Speaker 01

  Well, as I say, the first, we start with education.

• 1:15:14David Puder?

  A little bit of reassurance in the first one.

• 1:15:17Speaker 01

  Right, but it's more general, it's not about their specific topic.

• 1:15:21David Puder?

  Right, okay.

• 1:15:22Speaker 01

  It's just about, you know, why they're there at all and what we can do for them and what they can do for themselves. And all that, that, you know, that I do believe that people have it in them to recover. They just have to kind of find that within themselves and be at the right point where they say, you know what? I've had it, enough is enough, I'll, I'll do whatever I have to do, I don't care anymore. I have people come in and say, anything that you could ask me to do couldn't be any worse than what I go through on a daily basis. And I, I know these people are gonna recover with that kind of attitude.

• 1:15:54David Puder?

  Okay, that's good. So what's the main way to get ahold of you? Like, your website would be the best?

• 1:15:59Speaker 01

  Uh, yeah, that has all the information on it, how to contact us. It's got all my articles uh, from the past and all that. And uh, uh, oh, one other thing I just wanted to throw in there, just at this moment here, if I can. Uh, another thing we've been in OCD that we've been turning our attention to lately is working with people who are on the autism spectrum.

• 1:16:20David Puder?

  Hmm.

• 1:16:20Speaker 01

  Autistic people also can have OCD and there can be a fairly high percentage of people on the autism spectrum with OCD and that, you know, my message is that they are treatable and they're great to work with and there's a lot of help and hope for them. Unfortunately, there's a lot of therapists who believe they can't do it or that these folks can't be treated, but that's really not true that they're, you know, and I think there's a growing awareness in the autism community of OCD and the fact that, you know, it's the features of OCD are different from the features of autism.

• 1:16:56David Puder?

  Yeah, so give me like one example of like someone who has autism that also has OCD and is it?

• 1:17:04Speaker 01

  Well, they can have pretty much the same same topics as people with, uh, as, you know, people who have OCD who aren't autistic, uh, basically. So it's really, it doesn't look that much different. And, and, uh, you know, we can sort of sort that out because there's some things that are more part of the autism that the person wouldn't want to give up or isn't interested in giving up and it's really an essential part of them. And we don't try to, you know, force people to change that way. I don't believe in coercive therapy and everything, but if they say, you know, there's certain other things that bother me that I want to get under control, then I say, fine, let's, let's work on it. Let's do that.

• 1:17:44Speaker 01

  And all these other things that, you know, other people are telling you, you've got to change and I'll say, that's up to you. I mean, I can sometimes convince people why certain features of their autism may be getting in their way and leave it up to them to decide what they want to do about it. But I, you know, I respect everybody's right to, uh, Be themselves essentially in any way that they choose.

• 1:18:06David Puder?

  Hmm, very good. Well, thank you so much for coming on, Dr. Denzel. I appreciate you and really grateful for you sharing your expertise with the with the audience that listens to this. So appreciate you.

• 1:18:18Speaker 01

  My pleasure. My pleasure. I the more the more information we get out there and the more people we can get to, I think the more the more wellness is going to be in general.

• 1:18:29David Puder?

  Well, I'm sure this is going to help some people and there's going to be ripple effect as well, which is which is what I get excited about. So.

• 1:18:37Speaker 01

  No, it's good. It's a good thing you're doing. And I think educating people is of tremendous value. So I think I think that's great. Keep doing it.

• 1:18:45David Puder?

  All right. Thank you. Appreciate you. We'll leave it there.